Patients with physical disability or learning difficulties
Apart from the extremes of age, there will be patients who have particular difficulties. These include those with special needs, poor sight, poor hearing, etc. Persons who can cope quite well in the community under controlled circumstances may have great difficulties in the strange environment of the Emergency Department. Communications again become particularly important, and it may be appropriate for such patients to be seen relatively quickly.
Abusive/aggressive patients
There are levy things worse than having a full waiting room, with one or more patients (or more often relatives or friends of patients) constantly demanding attention. Although the guiding principle must be that these patients are not given priority just because they shout louder, the distress they cause to others must be taken into consideration. An initial attempt to communicate departmental policy may be followed by a number of actions. The patient may be placed in an individual cubicle to wait in order to minimise the disruption to the waiting room. Alternatively such patients can be seen, treated and discharged rapidly for the benefit of others. If all else fails the patient (or the patient’s relatives) may be asked to leave, assisted as necessary by security or police.
Patients under the influence of alcohol
These patients are difficult to assess because of the effect of alcohol on conscious level and on pain perception. They need frequent assessment to check that they are not deteriorating or developing a problem not immediately apparent at triage. Disruptive drunk patients should be treated as outlined above.
The regular
Most departments have a number of patients who are frequent attenders. It is undoubtedly tempting to place these patients in the non-urgent category without proper assessment. Beware, even the regulars develop organic pathology, injure themselves or have a serious complication of their disease. These patients (even those with predominantly social problems) are in fact more likely to develop illnesses or sustain injuries than the general population. Each attendance should be treated as a new visit and proper assessment should be undertaken; this avoids underestimation of possible serious causes for attending.
Patients who re-attend
There are occasions when patients return to the department, usually because their original presenting complaint has not resolved or they have developed a complication. Sometimes the patients’ expectations of the natural progress of an injury or illness are unrealistic. The patient may also return having failed to wait for definitive treatment on a prior occasion. The patient should be allocated a triage category according to the symptoms presenting at the time of triage, and not according to the original triage category. Some departments may have polices recommending that such patients are reviewed by a senior doctor if available. It may also be appropriate to offer some tit these patients a review clinic appointment for assessment by a senior doctor it the problem does not seem to need immediate treatment.
Clinic patients
Most Emergency Departments hold review ditties. Some services hold clinics in an area away from the department, and although they may see Emergency Department staff these patients would not impinge on the triage nurse role. If the clinic is held within the Emergency Department then it is usual for these patients to have a different priority and/or route through the department. It is important that the triage nurse explains to the new patients that there are clinic patients who may be called out of turn.
Patients referred by other agencies
Many departments allow their facilities to be used by other teams for assessment of the patients. These patients are usually pre-arranged or accepted patients from primary care physicians. They are often patients who are accepted for possible admission and many have a relatively high clinical priority. These patients must be triaged in the same way as Emergency Department patients. If the patient is triaged as first priority it would be usual for the Emergency Department team to initiate resuscitation, unless the referral team is in the department. The triage nurse should inform the referral team of the triage category of the patients in order to try and ensure that these patients are treated with a similar degree of urgency as Emergency Department patients. It may also be appropriate for the triage nurse m ask departmental clinical staff to provide analgesia or initiate immediate investigations, in order to smooth the patients’ stay in the department.
Some patients may have been brought in by the police (for instance tinder mental health legislation), by social services or by other professional services. Triage practitioners should be aware of the pressures on staff from other agencies and consider this when deciding on the management of such patients.
Departmental factors
Any department that deals with emergencies may at times be overwhelmed by the influx of patients. Sometimes it only takes one seriously ill patient, or an absent member of staff to produce standstill. Each department needs to develop means of coping with this. An accurate triage assessment is an essential first step in good departmental management.
Both the workload and the staffing of the department will vary according to the time of day. Frequently overnight there is reduced clinical staffing. This may cause increased waiting times and difficulties in the waiting room, particularly if there are patient who are aggressive or under the influence of alcohol. It may be appropriate for the clinician to see a few ‘quick’ cases before spending a long time with a patient of a higher triage category. Some departments may wish children to be seen more rapidly late at night.
Fast tracking, streaming and matching resources to demand
Streaming is a term used to describe the splitting of patients into different groups who are then seen by staff dedicated to their particular stream. Once within a particular stream the patient is not affected by pressures elsewhere in the system. This is similar to the concept of ‘fast-tracking’ where particular groups of patients (usually those with relatively minor injuries and illnesses) are identified and seen by dedicated staff to improve the flow. The main difference is that streaming is delivered as a planned intervention rather than as a reactive one.
The Manchester Triage System can be used to facilitate streaming. This is discussed in detail in chapter 8.
The quiet days
Even when the department is quiet it is important to maintain die momentum of work in order to ensure that patients are seen promptly within their triage category, and to stop unnecessary delays.
Comments