Ongoing industrial action by Victoria’s nurses has focused public attention on acute health-care services, and provided an opportunity to examine the way those services should best be supported, funded and delivered.
While the action and resulting public debate has exposed such workplace issues as nurse-patient ratios to greater scrutiny, there are still some areas of our health system that get little attention. These include the increasing number of patients and control of the unpredictable, and often overcrowded, emergency departments (EDs).
Ambulances can be directed to bypass some EDs when they reach capacity but the front doors always remain open to the public. When people arrive at that door, they’re greeted by the triage nurse who can, at times, be responsible for more patients in the waiting room than there are inside the entire emergency department.
Nurses in this role are usually dynamic, experienced and intelligent, and have excellent communication and time management skills. They don’t have super powers though. So how do they manage the care and safety of patients awaiting treatment?
To understand this issue, an outline of the triage system and the level of demand on our emergency departments, is necessary. Each patient within the triage system is assigned a score that determines their priority of care and acknowledges that they may be able to wait without detrimental effects. These guidelines also mandate how long a patient should wait, and are calculated based on the urgency of their condition.
Statistics show an increase in Victorian ED attendances of 6% in 2009 to 2010 over the previous two years. This increase resulted in greater waiting times for patients – including more ambulances parked at hospitals waiting to hand over to the triage nurse – and a greater chance of patients’ health getting worse while waiting.
Victorian government data also states that during 2009 and 2010, 30% of ED patients waited longer than the recommended maximum time. Many of these patients had the potential to deteriorate with negative outcomes. While not every patient who waits longer than they should gets worse due to delayed treatment, there are certainly many worrying examples. These include reports of women miscarrying in waiting rooms, and an elderly patient who died after waiting on a trolley for several hours, and was only noticed by a member of the public.
An alternative model
Australasian triage guidelines and the culture of most EDs dictate that the triage nurse is usually responsible for the care of any patient in the waiting room. But is this still realistic, with the ever increasing number of patients presenting at EDs?
In addition to the essential triage role of allocating a category to presenting patients, the triage nurse must also reassess patients who have reached the maximum waiting time to detect patient deterioration and alert staff to urgent medical assessment and commencement of treatment. They also attempt to provide basic comfort, analgesia, infection control and information to patients and their families in the waiting room.
After devastating outcomes from prolonged waiting times for treatment, some hospitals across the country have employed a nurse to be responsible solely for the waiting room. But this practice requires additional funding and so isn’t widespread.
An appropriately qualified nurse responsible only for the waiting room would improve patient care in many instances. This nurse could assist waiting ambulances hand over patients in crowded EDs, could improve communication and prevent frustrated patients leaving without treatment. He could even commence care, such as starting rehydration therapy for a dehydrated child.
Triage nurses do attempt to do these things now, but often aren’t able to, due to the constant stream of patients requiring help.
We need to question how well we care for people in hospital waiting rooms, as these patients are undiagnosed, untreated and vulnerable. We need to ask if anyone is really looking after the waiting room. Or should the question be, whose responsibility is the waiting room – the overloaded triage nurse’s or those who make decisions about funding?