Just a question to understand the ER better

Home Health Columnist / Guide · Sep 19, 2012

Your father was experencing an urgent change in condition, not necesarily a critical sitution in which seconds count.

Critical seen immediately is chest pain, knife stabbing, gunshot wound, severe motor vehicle accident or trauma. A 15 min to 30 min wait in person not struggling to breathe with these symptoms to be seen by triage RN is about average --in larger jamm packed ER's wait may be longer.

hiddencatRN, BSN, RN · Sep 19, 2012

Without knowing what else was in the waiting room to be see, it's hard to say. There are plenty of chief complaints that would need to be seen first. Waiting 15 minutes to be triaged is not a long wait.

Anna Flaxis, BSN, RN · Sep 19, 2012

Based upon your description, I would have assigned him an ESI level of 2, because he is a high risk patient (ESRF on hemodialysis) experiencing cardiac symptoms (rapid heart rate [the throat discomfort, though not classic cardiac, would be concerning considering the rest of the picture]), which means he needs to be seen by a physician within 15 minutes.

The second nurse who seemed unconcerned may have interpreted the symptoms differently, as not necessarily emergent or urgent. That's the thing about triage, is that even though there are standards and attempts at objective measurement of data, there is a lot of subjective interpretation of data and individual experience that comes into play. Two different nurses could triage the same patient completely differently.

As others have pointed out, we don't really know what was going on in the back. They could have been in the middle of a resuscitation, a trauma, a STEMI, or a stroke, and all of those would trump your father's level of acuity.

Did he have a good outcome?

Esme12, ASN, BSN, RN · Sep 19, 2012

so a quick run down. just wanted opinions.
59 yr old male patient in ESRF comes into the ER. wife signs him in and describes that he is "finishing dialysis (home hemodialysis), rapid heart rate, feeling of fist in throat and constant burping." (that is exactly what she wrote down). two nurses are behind the window, one seems concerned and the other says, "well we will get to you we can". in a not so nice tone. there was about 3 other people waiting to be seen in the waiting room, 3 in peds waiting. and nobody was in the back being seen by triage. he waited for 15 minutes before being seen. I am still a student, and have not had experience in triage, but wouldn't they be a bit more urgent and concerned with him? again, i know it all depends on whatever else they have, but their attitude just really kind of sucked. (well the one nurse). anyhoo, turns out he was in afib. his HR was all over the place but seemed to be fond of the high 170s.
my father is the said patient.

I am sorry you had a bad experience. It is difficult to know what was going on in the department or on the radio in the back with EMS. There could have been patients that were being admitted to open rooms for the new patients. Triage is the most "difficult" are a in the ED. Being the traffic cop, monitoring who needs to be seen and who doesn't requires extensive knowledge and nerves of steel. Every patient/family that approaches that window feel that their problem should be seen first. We call triage the penalty box.......because everyone has to do their time there and they aren't happy.

Unfortunately, in everyday life you are going to experience people who have "bad attitudes". I am not condoning her attitude at all.......but you never know what her personal burdens are. Maybe they just experienced a particularly bad code with a pedi or neonate and needed a moment to recover their nerves of steel...... maybe they just had a phone call that a relative was ill or had passed away. You really have no idea what their personal burdens are so I always give the benefit of the doubt......and try to understand....and yes some people are just mean.

I hope your Dad is feeling better.

cec726 · Sep 19, 2012

I agree with what everyone else said, it all depends on what other critical patients came through the front or the back door. He would have been an urgent situation, but they may not have had a bed open for him immediately. With his vitals they were probably working on finding one for him. A fifteen minute wait isn't bad at all. With his vitals, he would have gotten back quickly in the ER I work in, but some people that aren't as urgent can wait 8-10 hours.

Hope your father is doing better now. Good luck with your nursing career.

NurseOnAMotorcycle, ASN, RN · Sep 19, 2012

The one thing that patients do not see is the triage nurse informing the charge that "This person needs a room now." The charge then needs to FIND a room appropriate (available suction, cardiac monitoring, whatever) and then get that patient back. If you take this into account, waiting in an ER for only 15 minutes IS immediate attention. I can guarantee someone was watching on the cameras in case they needed to run out and help him.

Wait times in the emergency room are a major contention point for patients. I usually introduce myself and tell them right away about wait times. "You're blood's been drawn, EKG is looking good, and Xray needs to be developed. I know it's going to feel like we are ignoring you but we really aren't. We are checking you every time we walk by and are watching your heart from the desk at the same time. So now it's all waiting until we get your results back. I know this is the worst part for patients so bear with us, it can take around 2 hours."

So far it's only failed me maybe 10% of the time. As long as people know why they're waiting and that we aren't ignoring them they're pretty ok with it. Patient personalities are a totally different ballgame.

Guest343211 · Sep 20, 2012

People with afib have a good chance of having a stroke, among other serious/critical problems. Some folks don't tolerate rapid Afib for very long.

Sorry guys. Unless there were mass casualties going on, I'd get that pt at the least on a monitor ASAP. Call me crazy.

brainkandy87 · Sep 20, 2012

I think Stargazer said it best: triage is an extremely subjective area. One man's emergency is another man's, well, non-emergency. There's a lot of variables we don't know.. the experience of both nurses, the other patients in the waiting room, what was going on in the ER at the time, your father's presentation, and so on. Don't take it as the ER not taking your father's complaint seriously. Fifteen minutes is not a long wait at all and at a high level ER, this would actually be considered a short wait time. Sometimes when you're the patient or with a patient, it's hard to step back and look at the big picture of the ER. Yes, you might be worried and yes, it might be an urgent problem that should be addressed by the ER, but as always, emergent complaints take priority.

Hope your Dad is ok though.

tami101481rn · Sep 20, 2012

I have to disagree with all of you saying 15 minutes is not a long wait time. If EMS brought in a patient from a dialysis clinic with these symptoms, he would be high priority. Dialysis can cause to quick of a shift in electrolyte imbalances, namely K+. That would be the best explanation for rapid heart rate, the feeling in his throat etc. A shift in k+ leads to cardiac problems, MI etc. I have an issue with any high level acuity patient going to triage, whether it be chest pain, difficulty breathing, or a patient with ESRFbwith a rapid heart rate. I understand busy, trust me, but there is always a stable patient who can be shuffled.

brainkandy87 · Sep 20, 2012

I have to disagree with all of you saying 15 minutes is not a long wait time. If EMS brought in a patient from a dialysis clinic with these symptoms, he would be high priority. Dialysis can cause to quick of a shift in electrolyte imbalances, namely K+. That would be the best explanation for rapid heart rate, the feeling in his throat etc. A shift in k+ leads to cardiac problems, MI etc. I have an issue with any high level acuity patient going to triage, whether it be chest pain, difficulty breathing, or a patient with ESRFbwith a rapid heart rate. I understand busy, trust me, but there is always a stable patient who can be shuffled.

Maybe the 15 minute wait was due to shuffling.

We have hall beds in our ER that get used when we are totally full (as was the case tonight). However, I'd rather have a pt hang out in triage/waiting room for 10 minutes while I move someone non-emergent from a room to a hall bed instead of putting an emergent pt in a hall bed immediately. My rationale is that it's much more unsafe to put an emergent pt in the hall where you don't have a monitor or supplies. I'll hold that pt for ten minutes while I shuffle a non-emergent out. Who knows, maybe that was the case. Like I said.. lots of variables we don't know.

Guest343211 · Sep 20, 2012

I have to disagree with all of you saying 15 minutes is not a long wait time. If EMS brought in a patient from a dialysis clinic with these symptoms, he would be high priority. Dialysis can cause to quick of a shift in electrolyte imbalances, namely K+. That would be the best explanation for rapid heart rate, the feeling in his throat etc. A shift in k+ leads to cardiac problems, MI etc. I have an issue with any high level acuity patient going to triage, whether it be chest pain, difficulty breathing, or a patient with ESRFbwith a rapid heart rate. I understand busy, trust me, but there is always a stable patient who can be shuffled.

Really, I have to agree with this. This is a pt who may very well be a ticking time bomb. So then the ED becomes like the casino. ????If EDs would stopped being used like clinics or urgent care centers so much, people like the student's father would get seen right away. Dude you know if he had been considered a VIP, he'd been seen in a few minutes flat or less with such symptoms.