A crowded emergency department waiting room

While I was coming home from Miami last week, I saw a billboard on the highway. It advertised the name of a Miami hospital’s emergency department. There was a counter on the sign that declared, “11 minutes wait”. It got me to thinking about waits in emergency departments. It was not clear if the 11 minutes was the time a patient would wait to be seen or wait to be treated.

• Is waiting time the only criteria for quality of an emergency department visit?
• Is it the most important parameter?

The amount of time a patient has to wait to be triaged, or assigned a severity of illness score, depends on a lot of factors. Who is doing triage? How many patients are waiting to be seen? Nurses are typically the healthcare professionals who do triage. But there can be delays in emergency department wait time. First, the nurse who performs the initial assessment of patients can get overloaded. The work intensity can suddenly spike in the ED.

• A patient is in cardiac arrest and needs to be resuscitated.
• A patient suffers a major trauma after falling through a roof.
• An infant is gasping for breath because of croup.

What happens if all of these patients arrive simultaneously?

The triage nurse has to be very assertive, knowledgeable and comfortable with the role of expediting patient care. The triage nurse also has to be able to say, “I need help,” or “We’re overwhelmed and something may happen because we can’t get to these patients who are in need of triage.” All hospitals have to have a backup plan; the plan applies not only to triage but also whenever there are more patients than can be comfortably managed. For example, there may be one or two ED doctors. Is there a plan for when the doctor becomes overwhelmed? Can the doctor call another doctor in? The ED may need to notify rescue squads to stop transporting patients to the ED and divert them to other locations.

The first problem leads to the second problem: When the triage nurse gets overwhelmed, he or she cannot get to patients in a timely fashion. A critically ill patient can die without getting attention.

When a nurse friend of mine developed laryngeal spasms, her friends took her to a large Philadelphia inner city emergency department, where there was a glass window and metal tray for collecting slips of paper recording the patient’s chief complaints. My friend wrote that her chief problem was “can’t breathe”. She waited 15 minutes and no one ever approached the window. A patient standing outside told her the name of a different ED where she would get faster attention. When she got in a cab, she found out the cab driver did not know where the other hospital’s ED was located. After he dropped her off at the wrong corner, he drove around the block and came back to take her to the ED entrance. There she was promptly triaged and treated. Fortunately, the spasms stopped without ill effect. If the triage nurse is with a patient or is not at the triage area, the patient should ask the first hospital employee he sees for assistance. If there is a phone present in the reception/waiting area and no one is available, the patient can pick up the phone and dial the operator and advise her he or she is in the emergency department and needs medical assistance.

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