Improper Triaging

Editorial Team / Admin · Nov 6, 2005

Hi there,
I suppose this is a little bit of a venting session on my part but also something that I wish to learn from. I have only been working in emerg for 1 year and have been loving every moment of if. With that being said I did encounter a less the desirable situation last week. I was working in our ambularoty care area last night, where waiting time was approx 3 hrs between triage time and actually seeing a physician, which isn't that bad for our department.
Anyways....earlier that night I noticed a 5 yr old triaged with a presenting complaint of SOB, c-task 5...I kind of brought it to the attention of some of my coworkers but they told me not to worry that this pt had a long wait because of where they were triaged to, the complaint wasn't severe at all. 3 hrs later bring the pt into ambulatory area and they are in moderate respiratory distress, using accessory muscles, lower SaO2 for a child....Definately got the dr in there very quickly....
That certainly lessoned my faith in triage at times.... Any input on how this situation can be avoided in the future would be greatly appreciated.....

Hello, NurseNewbie,:balloons:

And, rightly so to vent.

Anytime an individual presents to the ER c/o SOB especially a child, they should be immediately triaged and be labeled for immediate attention. As you know a child can go to heck in a hand basket in a heart beat. And, if you cannot move air, everything else is a moot point. Why wasn't this child re-evaluated during the 3 hour wait?

To me and this is JMHO, the policy of a 3 hour wait in this situation is gross negligence. This child slipped through the cracks.

shadowflightnurse · Nov 6, 2005

Siri,

Apparently you haven't worked in an ED that is balls to the wall busy, people coming in faster than the triage nurse can keep up, short staffed in the back, no in-patient beds and getting bumped off diversion because every other ED in the region is having the same problems. In a perfect world, a person wouldn't have a 3 hr wait, but if they did they woulf be re-evaluated a couple of times. Just because a person has a chief complaint of "shortness of breath" doesn't mean they should be triaged as an immediate. I have had many people c/o SOB and talking to them it may be less than an emergency. Digging through the persons story, evaluating them for life-threatening issues and prioritizing them is what triage is about. Nobody would ever get seen if every patient that walked in and complained of SOB or CP or ABD pain was tagged as an emergent. I am not defending the issue int the OP, but just pointing out there is more than just making everyone an "immediate."

**canoehead, BSN, RN** · Nov 6, 2005

I would always eyeball people as you are walking around the area and do walking rounds with an O2 sat and stethoscope to up triage anyone who is worsening.

vaughanmk · Nov 8, 2005

We have known asthma kids with active wheezing wait 3+ hours daily. If they are moving good air and minimal accessory muscle use then the sickles and the "E" wheezers get marked to go ahead of them. I work in a childrens hsopital so kids with a CHI and vomiting can also wait 6 hours. Yes kids can and do go down hill quickly. You just have to be prepared and think ahead. Try to get in the habit of telling pt's families that if things get worse come up and let the triage nurse know.

hollykate · Nov 9, 2005

It is hard to reduce improper triaging. I think it is a problem occasionally everywhere. We recently triaged a guy who felt sick and was vomiting. Classified as non urgent- turned out he was in new onset rapid a.fib- the triage nurse did not palpate a pulse and the auto bp cuff gave her an inaccurate pulse.

Our nurses go through an ESI triage class, its a week long! They are good, but patients can always surprise us. Triage when there are several areas- fast tracks, non urgents, urgents to triage to can get to be really scarey.

The situation of occasional bad triage can not be avoided. It is usually reported and kept track of and if it is consistent then that nurse needs a refresher in triage.

CEN35 · Nov 10, 2005

Bottom line..........

too many people view it as a complete H&P rather than a true triage, while others wait who might be worse off.........

It will never change that has always been a problem.......

ClaireMacl · Nov 13, 2005

With us, any asthmatic or DIB has a chest assessment by a doc or enp (emergency nurse practitioner) before being downgraded to waiting for their turn.... esp with kids, asthma can be fatal.

ER-RN2 · Nov 14, 2005

I triage all of the time. The main problem that I see is that some patients don't tell you their history, meds, etc. Sometimes the story changes after they are put in a room. It is very hard to place those type of patients.

allnurses Guide · Nov 14, 2005

I work in a rural 3 bed ER . . . . I'm with Siri . . that child would have been in the ER quickly.

Even though I do realize that my experience in a small ER is different that those in the big city.

steph

KatieBell · Nov 14, 2005

In the rural ER I am in now, there is always a bed open.

When I worked in an Urban setting, it was a frequent thing to set kids (and adults) up for a treatment in triage. We have 2 triage areas one that is large enough to put a person in a chair, on a monitor and start a treatment. We occasionally also did labs and xrays from triage, sped things up for twisted ankles etc.

Mistakes in triage are going to happen for a variety of reason, the number one being that people are human.

MADDOG70, BSN · Nov 14, 2005

Just wanted to share with you what I do to prevent this. Our ER is extrememly busy. We see 170-210 pts a day. Average wait is bet 8-10 hrs. When I think someone should be watched closely while they are waiting I always tell the patient or family to bring the patient back in 1 hour or if they feel worse before then to come back sooner. I find that people watch the clock for that one hour and always bring their loved one or themselves back on the minute to be re-evaluated. We have a policy to re-evalutate pts every 2 hours. It NEVER gets done because of how busy we are. But by telling them to come back they ALWAYS DO! Pt's and their families can take some of the responsibilty here and come back when told. It truly helps. I also explain to them that there is no room in the ER right now but I want to keep a close eye on them. I rarely have anyone call me names or yell about this. It works quite well. Good Luck.

Hi there,
I suppose this is a little bit of a venting session on my part but also something that I wish to learn from. I have only been working in emerg for 1 year and have been loving every moment of if. With that being said I did encounter a less the desirable situation last week. I was working in our ambularoty care area last night, where waiting time was approx 3 hrs between triage time and actually seeing a physician, which isn't that bad for our department.
Anyways....earlier that night I noticed a 5 yr old triaged with a presenting complaint of SOB, c-task 5...I kind of brought it to the attention of some of my coworkers but they told me not to worry that this pt had a long wait because of where they were triaged to, the complaint wasn't severe at all. 3 hrs later bring the pt into ambulatory area and they are in moderate respiratory distress, using accessory muscles, lower SaO2 for a child....Definately got the dr in there very quickly....
That certainly lessoned my faith in triage at times.... Any input on how this situation can be avoided in the future would be greatly appreciated.....