Frequent checks can spot patients at risk

The recent case in which a woman died while awaiting care in a hospital emergency department (ED), while others called 911 for help, could be a reminder of the need for staff to check for updates on patients waiting for emergency treatment, says Grena Porto, RN, MS, ARM, CPHRM, senior vice president with Marsh, a consulting firm in Philadelphia, and past president of the American Society for Healthcare Risk Management (ASHRM) in Chicago.

There has to be a mechanism for a regular rounding on patients, Porto says. Sometimes ED staff rely on phases of care to be triggered by some action, such as getting lab results back on the patient, she says. "Until that lab result comes back, the patient waits, and no one checks on him until the lab result triggers the next step," Porto says. "You assume he's in the same condition as the last time you saw him."

That assumption can be a recipe for disaster, Porto cautions. When lab results take a while, radiology is backed up, or a doctor takes longer than expected to arrive, the patient can fall by the wayside. The patient and family members may not recognize the signs of a worsening condition, or if they grow worried, they may not know the right words that would get a nurse's attention. Complaints that the patient is "still really sick" or "feeling worse" may not prompt much response if the care team is waiting for the next phase of care to be triggered.

"But if you have a better system in which you check back on that patient in a prescribed way, at routine intervals, there is less chance of the patient crashing without anyone noticing," she says.

Specific nurse can check on patients

The problem is addressed at the University of Michigan's ED by assigning a specific nurse to check back with patients who are waiting. A "waiting room" nurse reassesses all patients on an hourly basis, which includes checking lab results and standing orders, says Lori Pelham, RN, ED clinical nurse manager at University of Michigan in Ann Arbor. Experience is required: Nurses cannot be assigned to this role until they have been in the ED for six months and have completed a triage course.

Part of the waiting room nurse's job is to expedite care when necessary. If the patient's condition has changed such that he or she should be in a treatment room, the nurse works with the charge nurse to find a room. Abnormal blood work or lab results may spur intervention and expedited care, for example.

Because patients have ongoing contact with the waiting room nurse during reassessments, they are less likely to leave without treatment, Pelham says. The nurse's frequent contact also can help detect changes in more stoic patients, especially the elderly, who may be reluctant to volunteer that their symptoms are getting worse.

In many cases, the decision to change a patient's triage status is the result of not just one finding but a combination, Pelham says. Having a specific nurse assigned to this task helps ensure that the significance of those changes is not missed, she says. "This nurse is putting all the pieces together and seeing that the patient's condition has changed," she says. "It can help to have one person whose job is to make sure we don't miss how some of these facts come together."


For more information on monitoring patients waiting in the ED, contact:

  • Lori Pelham, RN, Clinical Nursing Supervisor, Emergency Department, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI 48109. Phone: (734) 936-6222. E-mail: