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While patients wait, triage nurses do interventions
Triage nurses at Memorial Hermann Memorial City Medical Center in Houston ordered a chest X-ray for a patient who reported chest pain but had stable vitals and a normal EKG. As a result, the patient's pneumothorax was identified quickly.
"If that patient had waited in the waiting room for four hours and was then brought back to his room, only to have to wait for the doctor to see him and order the X-ray, it could have been a bad outcome," says ED nurse Marilyn Garcia, RN.
Because the chest X-ray was done from triage and the pneumothorax was seen right away, the patient was brought back quickly and a chest tube was inserted by the ED physician. "The patient had a very good outcome," she says.
Other interventions done while patients are waiting to be seen include blood tests that can identify infections or gallbladder conditions, and urinalyses, done to identify a urinary tract infection. "And last, but not least, with appropriate assessment of a possible kidney stone, we can relieve pain and give fluids while the patient is waiting," says Garcia.
According to Garcia, "the most impact comes from protocols that we can typically start while the patient is waiting. These include X-rays, blood work, urine tests, and EKGs."
Will this psych patient harm someone in your ED?
Patients may report vague symptoms
Lack of eye contact with nursing staff, poor interactions with staff or family members, aggressive behavior, appearing withdrawn, and speaking with a flat affect. These are all possible warning signs that patients intend to harm themselves or others, says Daniel Register, RN, interim manager for adult emergency services at WakeMed Health & Hospitals — Raleigh (NC) Campus.
"These patients may also present to the ED with poor hygiene, increased irritability, decreased appetite, known ingestion, drug or alcohol abuse," he says.
According to a new report from the Agency for Healthcare Research and Quality (AHRQ), 1.4 million hospitalizations a year are for mental illness.1 According to AHRQ's data, 49% of those admissions come from the ED.
At triage, it can be difficult to detect the severity of a patient's psychiatric complaints, says Register. Patient might say he or she is a little depressed when he or she really intends suicide, or a family member might tell you a patient is acting agitated when he or she plans a violent act. For this reason, he says to be alert for patients who report vague symptoms —abdominal pain, nausea, vomiting, headache, and/or fatigue — instead of their true complaint.
"These are symptoms that any ordinary person would not associate with a psychiatric disorder," acknowledges Register. "But it is these patients that are of the utmost concern for underlying illness."
"Patients with underlying psychiatric issues can present to the ED for a variety of reasons," he says. While some might verbalize suicidal or homicidal ideation, others may present as an intentional overdose or ingestion, or with violent or aggressive behavior.
"The most challenging are those patients who are suicidal and have a plan in place," he says. "These patients are at the most risk for being successful with the suicide because they have come to terms with it."
Be suspicious when there is no correlation between the subjective history and the objective findings, says Register. "The astute nurse will assess further until he or she is able to find the truth," he says.
The most difficult patient to distinguish suicidal or homicidal ideation at triage is the patient who intentionally overdoses or ingests poisons, says Register. "This patient may not fully disclose their actions or behavior and may present with any variety of symptoms relative to the medication or drug ingested," he says.
At WakeMed's ED, triage nurses do a risk assessment screen at triage and perform a safety assessment. "This allows the triage nurse to implement a behavioral health counselor consult or social work consult based on their patient's situation, as well as implement safety measures for the patient and/or staff based on the patient's behavior," says Register.
At York (PA) Hospital, nurses ask patients to fill out a "crisis form" that asks questions about use of alcohol or other substances, physical complaints and suicidal/homicidal thoughts or attempts. [The Emergency Department/Behavioral Health Triage Form used by ED nurses is included.]
"This form is just a quick self-assessment for the patient to fill out," says Wendy Kilstein, RN, CEN, nurse manager of emergency services. "Once they have completed the form, they bring it to the nurse for a full triage assessment. If the nurse feels that patient would benefit from a medical evaluation, the patient is then registered as an ED patient, not just crisis."
Even if a patient insists that he or she has no intent to harm him or herself or others, the ED nurse still might be uncomfortable with the patient in the waiting room. "Our nurses have the authority, if they do not feel the patient is being up front, to place a patient in a seclusion room," she says. "Once in seclusion, the ED nurse notifies the physician, who then has one hour to determine if seclusion is warranted or if the patient can be removed."
Remember these easy-to-miss red flags
A young woman told an ED triage nurse that she "just wasn't feeling right" but gave only nonspecific medical complaints, such as headache and stomachache. She appeared to have a flat affect, was answering in a soft voice, and was giving one-word answers.
The woman also told the ED nurse that she was taking medications for anxiety and depression, seeing her doctor regularly, and denied that she had any current thoughts of suicidal or homicidal ideations. "However, her behavior and her stated words did not match," says Shawn Green, RN, evening clinical coordinator for the emergency department at Advocate Christ Medical Center in Oak Lawn, IL. "I sent her directly into the treatment room to be seen. Later, I found out she had a plan to overdose on pills the following week on a specific day at a specific time if she did not feel better by then. I feel that may have been the last time she reached out for help."
This incident underscores that your role in the psychiatric patient's experience in the ED is "very important," says Green. "The triage nurse only has a small window in which to assess whether a patient is a harm to themselves or others, or whether it is safe for them to wait for a short period of time in the reception area."
Here are four red flags that could easily missed in a busy ED, says Green:
1. Your patient's body language doesn't match what they are verbalizing.
Your patient might tell you that he or she feels calm, but he or she is clearly agitated, anxious, and restless. "This usually means that something more is going on with the patient. They are either minimizing their feelings, or are having difficulty recognizing and connecting their feelings to body language," says Green.
2. Family members accompanying the patient communicate something different than what the patient is saying.
This point could mean that either the family member or the patient might be minimizing or maximizing the situation. "You cannot determine the root of the truth in the time it takes to triage a patient," says Green. "But mismatching stories between family members or dysfunctional family dynamics sends a red flag that the patient needs to be seen sooner, rather than later."
3. Your patient is inappropriately silent or stares off for short periods before speaking. These responses can indicate many things from visual or auditory hallucinations to extreme anxiety, says Green.
"Sometimes, if a patient has been through the ED process before, or has attempted suicide before and wants to receive help for anxiety or depression, they are very cautious in saying whether or not they have had suicidal or homicidal thoughts or ideation," says Green. "They are afraid they will be involuntarily committed."
In this case, it will be your job, along with that of the ED physician and social worker, to decide whether your patients are at risk of harming themselves or others, and whether that will necessitate inpatient stays. "These patients pose a special challenge for the triage nurse, because just coming to the ED means they are recognizing that they need immediate help," says Green. "It is recommended that these patients are taken straight back into the treatment room."
Green says in order to get patients to tell you what is really going on, ask them directly if they have thought about hurting themselves or others and, if so, whether they have a plan. "Another line of questioning I have had success with is asking about past experiences when seeking help, or with past suicide or homicide attempts," says Green. "Once they have told me about it, I ask them to compare it to now. Do you feel the same as you did then? What was something that helped or didn't help from your last visit?"
4. The patient's medication list includes different or multiple medications used in the treatment of anxiety or depression, or the patient's list of allergies include antipsychotics, antidepressants, or anxiolytics.
"These, of course, may not indicate a psychiatric issue, but usually may require a follow-up question or two," says Green.
Ask psych patients open-ended questions
When a psychiatric patient offers only vague complaints, consider asking open-ended questions, says Daniel Register, RN, interim manager for adult emergency services at WakeMed Health & Hospitals-Raleigh (NC) Campus.
"While this method of communication should be utilized with a significant number of your patients, it is imperative to use these types of questions with anyone you suspect may have some underlying psychiatric issues," he says. For example, ask patients "Have you had any stressors at home?"
Follow up by encouraging patients to elaborate on their situation and any concerns they might have. "This allows them to verbalize why they have sought your facility out for help," says Register. "When you finally get to the root of the problem, it may have nothing to do with what they told the front desk nurse they would like to be seen for."
Suspect DT if your patient is a daily drinker
A psychiatric patient tells you he typically drinks a case of beer a day, but he has not had any alcohol for a day or so. If this is the case, your patient is at risk for life-threatening delirium tremens (DT), warns Wendy Kilstein, RN, CEN, nurse manager of emergency services at York (PA) Hospital.
"There are many reasons why these patients may have stopped drinking. They include, but are not limited to, lack of money, family, work, or the patient recognizing the harmful effects of alcohol," she explains.
If it is determined the patient is at risk for DT due to alcohol withdrawal, he or she is assigned an ED exam room to be examined by a physician, says Kilstein. Medications may be ordered, including benzodiazpenes, haloperidol, clonidine, and magnesium sulfate IV, to diminish the severity of withdrawal symptoms. "Thiamine should be administered before any solutions of D5W are started, to prevent Wernicke's encephalopathy," she says.