Poor Communication Between Triage and EP Can Result in Lawsuits
A toddler is triaged as a level 3 on the Emergency Severity Index scale, and the nurse entered vomiting as the chief complaint, but this did not tell the whole story. "Her documentation clearly pointed toward possible diabetes, based on a family history of diabetes related by the concerned mother," says Jeanie Taylor, RN, BSN, MS, vice president of risk services for Emergency Physicians Insurance Company (EPIC) in Auburn, CA.
The emergency physician (EP) didn't become aware of the possibility of new-onset diabetes until she saw the child an hour later. "Since all the EP saw was the data on the tracking board: 'Level 3; vomiting for the past day,'" the child was not seen as timely as was indicated by their condition and history," says Taylor. "Fortunately, the child did well in spite of a diagnosis of diabetic ketoacidosis."
Patients are put at risk when EPs are not given key pieces of information. "EMRs are sometimes a barrier if it limits the information that is readily and easily available to the physician," notes Taylor.
Information Varies Greatly
Triage nurses can easily become overwhelmed trying to keep up with incoming patients. The amount of information gathered in triage varies greatly by facility. "Some do only a brief rapid assessment, which doesn't always include vital signs," says Taylor. Others gather more data than is needed for triage, such as starting the medication reconciliation process or documenting the regulatory-required data such as screening for domestic abuse.
"In EPIC's review of medical records, we have noted a trend of under-triaging patients; but rarely are patients triaged to a higher category than warranted," says Taylor. "When patients are under-triaged, risk is created."
Another problem is that some EPs do not consider someone to be "their" patient until the patient is in an ED bed and assigned to them.
"Add in the chaotic and busy environment in the ED, conflicting priorities, and the list of tasks needed to care for patients already in ED beds, and you've got a real problem," says Taylor.
In one case, a 26-year-old intoxicated male was brought to an ED by emergency medical services. He was belligerent, combative, and had difficulty speaking and walking — none of which promoted accurate triage.1
"The patient was placed in 'bypass' — an area thought to be a hallway. No vital signs were taken," says Taylor. Nursing documentation indicated only that he was uncooperative and had no apparent trauma.
"An hour later, he was noted to be cyanotic and pulseless and could not be resuscitated," says Taylor. "He was not seen by the physician on duty before he arrested."
The court found that the EP on duty was negligent in failing to examine the patient, and that it was his responsibility to know who was waiting for care and how critical the need for care was.
"This case carries a valuable lesson for EPs, related to their responsibility to be aware of patients waiting for care," says Taylor. Strategies for EDs to reduce legal risks involving communication between triage nurses and EPs include:
Ensure that the triage process is efficient and does not create a bottleneck, yet gathers sufficient detail so that key data on patients presenting for care can be communicated to the EP.
"This is especially important when patients are backed up and waiting for care," says Taylor. "Analyze the triage information readily available to the EP to be sure it provides them with adequate detail."
Ensure that triage staff is highly skilled at triage assignment and recognizing sick people.
"Physicians should feel the triage staff is saving their hide by directing them to the high-risk patients, versus worrying that triage assignments are not accurate," says Taylor.
Reassess patients at reasonable intervals of 15 minutes to one hour, depending on acuity.
"Two hours is too long for all but urgent care patients," says Taylor. "Ensure that physicians are kept abreast of the results of the reassessments."
Ensure that EPs keep an eye on the tracking board and know who is waiting for care.
If they notice a patient who might be high risk — an elderly patient with abdominal pain or an infant with a fever — physicians should speak to the charge nurse about bringing the patient back for an exam, or consider going to the waiting room to look at the patient. "While we know that most ED physicians are very, very hesitant to venture into a waiting room of unhappy patients, sometimes it is the right thing to do," says Taylor.
While triage is a nursing and facility responsibility, says Taylor, it behooves EPs to occasionally insert themselves into the process.
"In high-volume EDs staffed with more than one physician, consider assigning a physician each shift to keep abreast of who is in the waiting room," she suggests. "Lay eyes on patients with complaints that could be high risk — or have them brought back to an ED bed."
Consider a process in which patients are assigned to an EP, or a team that includes an EP, right after the triage evaluation.
This can promote greater responsibility for getting patients back to the ED. "Even when the patient cannot be brought back to the ED, treatment may begin in the waiting room when an assigned physician feels responsible," says Taylor.
Ensure that patients are brought back to the ED as soon as possible.
Use wheelchairs, hallway carts, rotating exam rooms, and any other means at your disposal to get patients out of the waiting room and under the physician's care, urges Taylor.
Remember that triage does not meet the Emergency Medical Treatment and Labor Act's requirement for a medical screening examination.
"Long delays can be interpreted as a 'constructive denial' of a patient's right to treatment under federal law," says Taylor.
Remember that EPs are responsible for a patient from the minute the patient enters the department, not from the time the patient is assigned to a bed.
"If your facility has issues with wait times, be part of the solution," says Taylor.
Address discrepancies in nursing notes.
When reviewing ED charts, William J. Naber, MD, JD, frequently sees statements such as "nursing notes reviewed and agreed with unless discussed in my note."
"This is very dangerous if the provider fails to document a disagreement with something in the triage nurse's note, says Naber, associate medical director of the Center for Emergency Care at University of Cincinnati Medical Center and associate professor in the Department of Emergency Medicine at University of Cincinnati's College of Medicine.
A classic example is when the triage nurse documents a child is "lethargic" but the EP does nothing to address this. "If the child does not do well, and the provider has no documentation to dispute the lethargy, it makes for a very difficult case to defend," says Naber.
- Joseph R. Feeney, administrator vs. New England Medical Center, Inc. Retrieved May 31, 2013 from http://law.justia.com/cases/massachusetts/court-of-appeals/volumes/34/34massappct957.html
For more information, contact:
- William J. Naber, MD, JD, Associate Professor, Department of Emergency Medicine, University of Cincinnati (OH) College of Medicine. Phone: (513) 558-8086. E-mail: William J. Naber,.
- Jeanie Taylor, RN, BSN, MS, Vice President, Risk Services, Emergency Physicians Insurance Company, Auburn, CA. Phone: (530) 401-8103. E-mail: William J. Naber,.