Another ED waiting room death: Don't let it happen on your watch

Assumptions can harm or kill your patient

(Editor's note: This story is part one of a two-part series on care of psychiatric patients in the ED. This month, we give tips for identifying underlying medical conditions. Next month, we'll share the best ED nursing practices for reassessment during long waits.)

A woman you've seen many times in your ED comes in again, confused, agitated, and unable to follow directions. Many times before, she had the exact same symptoms, always because of noncompliance with antipsychotic medications. Would you assume the same was true this time?

Luckily, the ED triage nurse who cared for this patient didn't make that assumption. Instead, she discovered that the woman had a very high potassium level and was in acute renal failure.

"The nurse really made a difference for that patient," says Barbara Morgan, RN, director of emergency services at the Cleveland Clinic. "If the nurse had based a triage assessment of this patient on past visits, the results could have been disastrous." The woman was at risk for organ failure and lethal heart arrhythmias.

At Vanderbilt University Medical Center in Nashville, the ED is seeing an ever-increasing number of psychiatric patients, with an average of more than 10 per day. Until all other causes of altered mental status are ruled out, you can never assume the patient has a psychiatric problem, says Corey Slovis, MD, professor of emergency medicine at Vanderbilt University and chairman of the Department of Emergency Medicine at the medical center. "Some patients who are acting 'crazy' may have markedly altered electrolytes, be in renal failure, be suffering a stroke, or be in shock from gastrointestinal bleeding," he says.

Don't get too 'comfortable'

Recently, Americans were shocked at yet another videotaped ED "horror story" involving a woman collapsing on the floor of a waiting room in a New York City ED and dying as staff failed to help her. She had a history of psychiatric issues, but she died of blood clots after waiting almost 24 hours for treatment. The hospital has been sued for $25 million, and six employees were fired or suspended, including two emergency nurses.

Morgan cautions that the cause of a patient's cognitive impairment might not be psychological. It could be head trauma, a brain tumor or intracranial bleed, low blood sugar, a drug overdose, high potassium, hyperthermia, low oxygenation, infection, malnutrition, liver or renal disease. "Also, elderly patients can become confused or develop psychosis from pneumonia, urinary tract infections, and dehydration," says Morgan.

Freda Lyon, RN, BSN, MHA, service line administrator at Bixler Emergency Center in Tallahassee, FL, says, "The patient that scares me the most personally is the patient that darkens our doors frequently with a multitude of complaints. We get to know them and are comfortable with them. My fear is that we will miss the subtle sign or symptom of an impending crisis."

Lyon has cared for many patients brought to the ED for psychiatric evaluation who actually had serious medical problems. Confused, aggressive, or agitated patients have had low oxygen saturation due to pneumonia, low blood sugar, stroke, and brain aneurysms. "It is extremely important to assess the entire patient," says Lyon. "Vital signs, bedside blood sugar, electrolytes, and oxygen saturation will identify any life-threatening medical emergencies that may be causing symptoms that can be mistaken as having a psychiatric ideology."

For example, a 22-year-old male with aggressive behavior and altered mental status was recently brought to the ED by law enforcement for a psychiatric evaluation. During the initial assessment, the ED nurse discovered that the patient had an oxygen saturation of 55%. "The patient was intubated within 30 minutes of his arrival and was discovered to have a lung abscess," says Lyon.

Although all the facts aren't available involving the New York case, it seems that ED nurses wrongly assumed their patient didn't have a medical emergency. "When we make assumptions that aren't based on data, we run a very high risk of not doing right by the patient. That's when we run into trouble," says Morgan.


For more information on assessment of psychiatric patients, contact:

  • Freda Lyon, RN, BSN, MHA, Service Line Administrator, Bixler Emergency Center, Tallahassee, FL. Phone: (850) 431-4184. E-mail:
  • Barbara Morgan, RN, Director of Emergency Services, Cleveland Clinic. Phone: (216) 444-9262. E-mail:
  • Dan Nadworny, RN, BSN, CEN, Clinical Advisor, Emergency Department, Beth Israel Deaconess Medical Center, Boston. Phone: (617) 754-2316. E-mail:
  • Scott Phillips, RN, Clinical Nurse Leader, Emergency Center, All Children's Hospital, St. Petersburg, FL. E-mail:
  • Mickey White, RN, BSN, MBA, Director, Emergency Department, Emory Johns Creek (GA) Hospital. E-mail: