Who is a high-risk patient to keep close to you?

(Editor's Note: This is the second part of a two-part series on keeping patients safe during lengthy wait times. Last month, we gave practices to identify a patient's deterioration, enlist the help of others in visualizing patients, and instruct family members. This month, we report on identifying which patients are at high risk for deterioration, using safe triage practice, and avoiding blocked views of patients.)

Is there no room available for a patient who you suspect has an urgent illness, a patient at risk for falling, a patient on blood thinners, or a patient at risk of hurting self or others? If so, move these patients within your visual range, advises Karen Toulson, RN, MSN, CEN, NE-BC, an ED nurse manager at Christiana Care Health System in New Castle, DE.

"Patients that are a known risk for deterioration, or where the triage nurse has concerns, should not be sent to the waiting room," says Toulson. Instead, she says to perform a complete physical assessment of the patient related to the chief complaint, including current medications and past medical and surgical history.

"Accommodations for the patient to go to a treatment room should be discussed with the charge nurse," says Toulson. "The patient should remain with the triage nurse until moved."

At times, triage nurses at Huntsville (AL) Hospital place a certain patient on a monitor in an unused triage room or in a wheelchair by the front desk. The patient is checked frequently until a bed becomes available. "Any patient that the triage nurse is concerned about needs to be closely monitored while awaiting bed placement," says LaGina May, RN, an ED nurse and triage coordinator. She says that category includes patients with altered mental status, psychiatric patients, elderly patients, chest pain patients with or without a cardiac history, immunocompromised patients, and patients with shortness of breath, allergic reactions, weakness, seizures, or abnormal vital signs.

"The list could go on and on," says May. "If the triage nurse is concerned about a patient, the triage coordinator needs to be notified. We ensure the patient gets back as quickly as possible and treatment is initiated quickly." (See related stories on safe triage practices, below, and avoiding blocked views.)

For safety's sake, do not assume — or hurry

When you have a patient that needs to be seen "sooner than later" and you have to put them back in the waiting room, do the following, says Tarah Grooms, RN, ED director at Methodist Richardson (TX) Medical Center:

1. Inform the charge nurse of the presenting signs and symptoms of the patient and the risk for deterioration.

2. Document the patient's baseline vital signs.

"If or when they do deteriorate, the physicians and nurses have evidence to base their interventions on," says Grooms.

3. Place these patients within a visual field that gives you the ability to assess them as needed.

Grooms says the pediatric population is at high risk in the waiting area if they are experiencing any respiratory compromise. "They have to be watched closely due to the risk for rapid deterioration," she says. "Any elderly patient with vague complaints needs to be watched for worsening in presenting symptoms."

Listen to all info

The triage nurse should not allow any patient that is alone with any high-risk presentations to be out of his or her visual field, adds Grooms. "We always pay attention to the patients that sign in and go sit out of the triage nurse's visual field. They are usually the high-risk patients that will 'fall through the cracks,'" she says.

Always be aware of patients that have the potential to change, whether that means their level of consciousness, vital signs, pain severity, or behavior. LaGina May, RN, an ED nurse and triage coordinator at Huntsville (AL) Hospital, says, "Psychiatric patients, with or without a plan, may first appear calm but then later become a harm to themselves and to others."

"Triage nurses should also avoid getting in a hurry and not listening to all information that a patient or family may want to give," says May. "Sometimes the one clue you need is the one not heard."

Frequent ED patients are also high risk for a condition that goes undetected at triage, she says. "Just because Jane Doe is always here with a headache doesn't mean that this time she is not going to have a headache and a head bleed," says May.

A patient's sudden change in acuity might not even be related to the initial complaint. For example, a patient might come in with an ankle injury, but she forgot to eat after she took her daily insulin.

"She has been waiting for a while, when suddenly someone comes running to the desk hysterically about this patient," says May. "Upon recheck, the patient has a decreased level of consciousness due to drop in blood glucose."


Avoid blocked views of waiting patients

Does your waiting room's layout or design limit your view of patients? If so, you might need to make these changes:

1. Change the layout of the chairs.

"All chairs need to face the triage staff. You can't effectively visualize a patient if their back is turned," says LaGina May, RN, an ED nurse and triage coordinator at Huntsville (AL) Hospital.

2. Place the nurse charting area in the line of sight of the patients.

John Provost, an ED nurse at St. Joseph's Hospital and Medical Center in Phoenix, says, "In the facility I work in, all nurse charting stations were placed at the door of two patient rooms. This allows the nurse to view his or her patients while they are being treated, as well as waiting on disposition."

3. Use cameras to assist in visualizing areas of the waiting room.

At Methodist Richardson (TX) Medical Center's ED, the view of the cameras at the back nurse's desk was changed to cover the areas the triage nurse might not be able to see while in the room with a patient.

Tarah Grooms, RN, the hospital's ED director, says, "We have video cameras to view the entire waiting area and entrance from the back nursing station. This can help avoid the high-risk situations."

4. Place patients in busy staff areas.

"If the nurse is not able to watch constantly, then other team members will be able to assist," says Provost.

5. Put blinds in treatment and triage rooms.

Cassondra Richard, RN, CEN, an ED nurse at Oregon Health and Science University Hospital in Portland, says, "The waiting room must be visible to the registered nurse posted at triage. In our department, the triage rooms are private and secure rooms but have blinds that can be opened to allow visibility of the waiting patients."

6. Reposition the furniture.

Grooms says, "There is a beam in the middle of the ED waiting area that was obstructing the nurses' view. We moved the chairs in the waiting area to different locations, so the patients can be visualized at all times from all different angles."