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Question: A friend recently went to a hospital emergency department with abdominal pain. She waited for a long time and eventually began to vomit. At that point, they finally paid attention to her. It turns out her appendix burst. How could something like that happen in a hospital waiting room? Shouldn’t she have been seen sooner?
Answer: It’s unfortunate that your friend’s appendix burst under those circumstances.
The front-line triage nurses try to accurately assess the seriousness of each person’s condition to determine the order in which patients are to be seen by a doctor.
As your friend discovered, the system isn’t perfect. Many unpredictable factors can affect how promptly patients are treated, including the number of other people seeking medical assistance, and the severity of their injuries and ailments.
All Canadian hospitals follow the same general procedures for processing patients who show up at the emergency department. They are assessed by specially-trained triage nurses who rank each patient based on the Canadian Emergency Department Triage and Acuity Scale.
“The triage nurse is trying to identify the patients that if not dealt with immediately, or as soon as possible, there is a risk of death or that their condition could deteriorate quite quickly,” says Ray Howald, a clinical nurse educator for the emergency department at Sunnybrook Health Sciences Centre.
Ideally, patients should talk to a triage nurse within 10 minutes of their arrival. By asking a series of questions and taking some vital signs, the nurse ranks patients on a scale of 1 to 5 – with 1 being the most serious and 5 the least.
“We are basically deciding how long the patient can safely wait to see the ED physician,” says Mr. Howald.
Take, for example, the case of a broken leg. Not all breaks require the same response time. “If there is no pulse and the foot is cold, this may indicate injury to the veins or arteries and this needs to be treated very quickly because the patient could lose their foot,” explains Mr. Howald. “If the patient comes in with a simple broken leg which shows no signs of symptoms of vascular damage – the patient can wiggle the toes, there is a pulse, the foot is warm – then this patient could wait longer than the patient with a similar injury and possible vascular damage.”
Here is a basic breakdown of the triage levels:
Level 1: The patients should be examined immediately by a physician and requires aggressive interventions. Patients in this category include those suffering from cardiac arrest, severe respiratory distress, major trauma or those in a state of shock.
Level 2: The patients should be assessed by a physician within 15 minutes or less from their arrival. Symptoms may include chest pains, head injury, gastrointestinal bleeding.
Level 3: Patients have a condition that could potentially progress to a more serious problem, such as mild to moderate asthma or shortness of breath. A physician should see these patients within 30 minutes.
Level 4: Patients with less urgent injuries such as minor fractures, abrasions, back pain, abdominal pain, vomiting but no signs of dehydration. Under ideal circumstances, they should be examined within an hour.
Level 5: Patients with non-urgent symptoms such as minor lacerations (not requiring stitches), sprains, sore throat and abdominal pain. They can safely wait up to two hours or more before a physician examines them. In fact, treatment could be delayed or referred to other areas of the hospital or the health-care system.
The triage nurse rates each patient in just five to eight minutes. “It is a very rapid assessment because the nurse is trying to get to every patient as quickly as possible,” says Mr. Howald.
Although the ratings are based on well-researched guidelines, the nurses also rely on their intuition of how they think the patient looks.
“These are experienced nurses and they just have a feeling when something is wrong,” he explains. “It is not very scientific by any means, but it is very relevant in the medical profession. You trust your instinct and go with it.”
Once this initial rating process is completed, there is a possibility a patient’s condition could change – either for the better or for the worse.
The nurses are required to keep an eye on the patients in the waiting area. But this can sometimes be difficult to do in a thorough manner, especially at those times when there is a constant influx of new cases.
“We always instruct patients, if their condition gets worse, if their pain is worse, or if they feel like they are getting worse, to let us know,” says Mr. Howald.
A family member, or an accompanying friend, could also inform the triage nurses that the patient’s condition appears to be deteriorating.
“We can re-prioritize who will come in next,” says Mr. Howald.
Still, it can be difficult to always get the order right. And, in the case of your friend whose appendix burst, she was clearly not seen soon enough.
But it’s important to keep in mind that how quickly patients are treated partly depends on the availability of acute-care beds in the hospital. If there’s a shortage of free beds in the wards, then you can get a backlog of cases in the emergency department. “Access block can contribute to the increased length of stay in the waiting room,” explains Mr. Howald.
He also points out that people suffering from appendicitis don’t always display the same symptoms, or their cases may have advanced to a higher level of urgency.
“Patient A might have waited two days before deciding to come into the emergency department. Patient B might have come in right away,” he says. “Depending on how long they have had their symptoms, that can dictate what their outcome will be.”
Appendicitis isn’t the only diagnostic challenge in the emergency department.
Numerous studies have found that men and women may have different symptoms when they are experiencing a heart attack – and those variations can affect how quickly they are treated in the emergency department. For instance, men usually suffer severe chest pain – a well-recognized sign of a heart attack – and that means they tend to get prompt attention. Some women and also some men, on the other hand, have more diffuse pain and it may take longer for their problem to be identified.
A recent study published in the Canadian Medical Association Journal found that men suffering a heart attack tended to be treated somewhat faster than women. The researchers looked at a group of about 1,100 cardiac patients between the relatively young ages of 18 and 55. A total of 24 Canadian hospitals, plus one medical centre in Switzerland and one in the United States, took part in the study.
Patients suspected of having a heart attack should receive an electrocardiogram – which measures the heart’s electrical activity – within 10 minutes of their arrival at an emergency department. If a heart attack is confirmed, they sometimes require drugs to unblock clogged coronary arteries, and the drugs should be given within 30 minutes of arrival.
The study revealed that the average wait for an electrocardiogram was 15 minutes for men and 21 minutes for women. The men were also administered the clot-busting drugs at a faster rate: an average of 28 minutes versus 36 minutes.
As part of the study, the patients later completed a questionnaire that is used by psychologists to measure masculine and feminine personality traits. The results of this survey provides further insight into why some patients are treated sooner than others, says the study’s lead author, Dr. Roxanne Pelletier, a clinical psychologist at McGill University Health Centre in Montreal.
Indeed, both women and men with higher “femininity” scores waited longer for care. But more “masculine” traits increased the likelihood of getting quicker treatment.
This suggests that sex alone – being either male or female – isn’t the sole factor that’s determining promptness of care. Instead, certain personality characteristics – like being more or less assertive – play a role, too.
Dr. Pelletier believes her study provides valuable lessons for patients who end up in the emergency department.
“People need to know that when the come to the ER they need to be precise, concise and assertive,” she says.
Dr. Pelletier points out that the triage nurse has a relatively brief period of time – roughly 8 to 10 minutes – to question each newly arrived patient. So patients who aren’t concise in their answers may end up delaying their own care.
“If they feel chest pain, this must be the first symptom they report and they must put the emphasis on this symptom to expedite their treatment.”
This discussion of heart attack patients may seem like a digression from your original question about a burst appendix. But I hope it illustrates that patients can do things to increase their chances of getting timely and effective medical care.
And, in particular, it’s critical to be clear and concise about your symptoms.
Once you’ve been assessed, it’s extremely important to notify the triage nurses if there’s a change in how you’re feeling. They need to know if you have taken a turn for the worse.
There are other things that you can also do to speed up your initial processing.
For instance, Mr. Howald says be sure to come prepared with the following:
- Your health card,
- Your family doctor’s name,
- A list of your current medications, and
- A list of any allergies and diagnosed medical conditions.
Having these items on hand can help make your time with the triage nurse more efficient.
Paul Taylor, Sunnybrook’s Patient Navigation Advisor, provides advice and answers questions from patients and their families, relying heavily on medical and health experts. His blog Personal Health Navigator is reprinted on Healthy Debate with the kind permission of Sunnybrook Health Sciences Centre. Email your questions to AskPaul@sunnybrook.ca and follow Paul on Twitter @epaultaylor