Shortness of breath? Get treatment 40 minutes sooner

Start care at triage

When patients with shortness of breath received either a partial or a full standing order set, their median treatment time decreased by 40 minutes, according to a study done at Johns Hopkins Bayview Medical Center in Baltimore.1

Of 1706 patients who presented to the ED with a chief complaint of shortness of breath from January 2007 through August 2009, 304 did not receive any triage standing orders, and the remainder received diagnostic tests at triage to identify pulmonary or cardiac causes, with the results made available to the ED physician immediately, says Rodica Retezar, MD, the study's lead author and an ED physician at the hospital.

"Therefore, a disposition decision can be made for whether the patients needs more tests, can be admitted, or can be discharged," she says.

It's especially important to consider both cardiac and pulmonary causes for shortness of breath in elders with multiple comorbidities, adds Retazar. "Standing orders are of value when there is delay in being seen by a provider, which allows for the processing of these tests during this time," she says.

Rapid interventions

A nurse-initiated shortness-of-breath protocol, including peak flow measurements, is used by ED nurses at Tufts Medical Center in Boston. "This helps us determine the degree of compromise in a patient with shortness of breath," says Alexandra Penzias, RN, MEd, MSN, CEN, an ED clinical nurse educator.

For patients presenting with shortness of breath following a blunt or penetrating injury, the ED's trauma protocols require nurses to place a patient in a trauma bay and activate a pager system that alerts the trauma team, says Penzias.

For patients whose shortness of breath is not related to an injury, the protocols allow a triage nurse to place a patient in a room immediately and initiate care, says Penzias. "This includes, in select patients, the administration of nebulized medications," she says. "This reduces time to treatment, which is essential in this population of patients who are at high risk of morbidity."

Learn this immediately

Ask these questions during your initial assessment if your patient reports shortness of breath, advises Maria Miralles, RN, BSN, CEN, clinical nurse IV in the ED at NorthBay Medical Center in Fairfield, CA.

  • Was the onset sudden or gradual?
  • Did anything precipitate it?
  • Is it associated with a cough? If so, productive or non-productive?
  • Is there pain with it?
  • Is the patient orthopneic?
  • Does the patient have any adventitious breath sounds, or no breath sounds?
  • Is there fever?
  • Is there any lower extremity swelling?
  • Was there any trauma prior to the shortness of breath?
  • Are there symmetrical breath sounds?
  • Is there any associated history?
  • Is the patient speaking in short phrases or words, or able to speak in full sentences?
  • Are there any nasal or sternal retractions?

"Based on these questions, we can identify treatment that is appropriate for patients, such as some of our core measures for congestive heart failure and pneumonia," says Miralles. "We also determine if the shortness of breath is related to a trauma." (See clinical tip on questions to ask your patient, below.)

Reference

  1. Retezar R, Bessman E, Ding R, et al. The effect of triage diagnostic standing orders on emergency department treatment time. Ann Emerg Med 2011;57(2):89-99.

Sources

For more information on assessment of shortness of breath, contact:

  • Alexandra Penzias, RN, MEd, MSN, CEN, Clinical Nurse Educator, Department of Emergency Medicine, Tufts Medical Center, Boston, MA. Phone: (617) 636-5357. Fax: (617) 636-4723. E-mail: apenzias@tuftsmedicalcenter.org.
  • Maria Miralles, RN, BSN, CEN, Clinical Nurse IV, Emergency Department, NorthBay Medical Center, Fairfield, CA. Phone: (707) 646-5825. Fax: (707) 646-5801. E-mail: mmiralles@northbay.org.
  • Rodica Retezar, MD, Department of Emergency Medicine, Johns Hopkins Bayview Medical Center, Baltimore. Phone: (410) 550-7852. E-mail: rreteza1@jhmi.edu.

Clinical Tip

Will patient deteriorate? Ask these two questions

If your patient reports shortness of breath, Alexandra Penzias, RN, MEd, MSN, CEN, clinical nurse educator in the Department of Emergency Medicine at Tufts Medical Center in Boston, MA, says to ask these two questions: "Have you ever been hospitalized for your shortness of breath?" and "Have you ever been intubated or treated in an intensive care unit for your shortness of breath?"

"If answered in the affirmative, this indicates a patient with a history of serious disease and a tendency to deteriorate rapidly," says Penzias.