THE EMERGENCY ROOM is the place where most of us enter the health-care system. Many are there with undiagnosed life-threatening conditions when they first arrive. Their survival depends on how fast and accurately the staffers diagnose and treat their problems. Most emergency rooms can at times get so crammed full that they become unsafe. Even an anthill will implode if you put too many ants in it. Accordingly, there are three determining factors in getting -or preventing- a good result in the emergency department. These are triage, waiting time, and capacity. First, the overlying problem is that at most times in any emergency room there is only one physician for dozens of people. The nurse-to-patient ratio is usually about fifty to one, counting those in the waiting room. Thus it is not possible to take care of everyone without making people wait for several hours. That is why one of the registered nurses must provide triage services. Triage is a nursing assessment made to determine the level of urgency of the patients' need for medical intervention -who can wait and who is likely to die in the waiting-room.

How Triage Works

Emergency departments are places that have waves of people coming in by ambulance, by private car, on foot, and, in some cases, by helicopter. These people have all kinds of problems with all levels of severity. The nurses and doctors often endure unreasonable amounts of stress and suffer from exhaustion as there are usually more patients than they can safely handle at anyone time. As long as this continues, there will be casualties in terms of people dying

A Fatal Triage Error

A case in point is the premature death of a thirty-eight-year-old mother of three. One Friday morning during the summer of 2000, Mrs. K. was traveling with her husband via the subway on their usual commute to their respective jobs in Manhattan when she fell and hit the back of her head against a pole as the train jerked forward. She grappled with the intense pain for a moment and then regained her composure. Mr. K. asked his wife:

"Are you all right? Do you want me to bring you to the hospital?

• No, I'll be okay. Just walk me to my job."

Mr. K. accompanied her to the bank where she worked as a loan officer. Mrs. K. spent most of the day fighting headache and dizziness, unable to focus on her work. After she told her boss what had happened, he advised her to go home around 3 P.M. She called her husband and he brought her to their home in Queens. The rest of the weekend, Mrs. K. stayed in bed with a slight headache, but she was able to sleep after taking Tylenol.

When Monday came, Mrs. K. went to work again. She was still dizzy and unable to focus on her job. She called her husband again, and he took her to the emergency room in one of the several world-famous New York City medical centers.

When they arrived at the hospital, the waiting room was mostly full, with only a few vacant seats. They went into a small cubicle on the side to see the triage nurse. The nurse wrote in the triage notes, "Complains of headache since Friday. She claims she hit her head on subway." The nurse then took Mrs. K.'s vital signs (measurement of temperature, pulse rate, respiratory rate, blood pressure, and oxygen saturation). The readings were all within normal limits, and the nurse observed that Mrs. K. walked in with a steady gait. Thinking that the patient should have gone to her private physician instead of wasting the emergency department resources, the nurse assigned the lowest priority level and told Mr. K. to take his wife to the walk-in clinic down the hall, saying, "There's going to be a four-hour wait. They are crowded and we are short of help today."

When Mrs. K. tried to get up, her legs buckled. She was still conscious but was unable to get out of the chair. The nurse, convinced that her initial assessment was correct, believed that Mrs. K. was putting on a dramatic performance in order to get faster service. Therefore, she reluctantly offered a stretcher and helped Mrs. K. to climb on to it with the husband supporting her other arm.

Then the nurse rolled the stretcher out into the hallway and went back to her desk. She called the charge nurse in the main emergency treatment area to report the case and said:

"I've got a drama queen here who claimed that she is too weak to stand up after I told her she would have to go to walk-in and wait a few hours for a doctor. Her vitals are fine. She walked in with her husband and said she has a headache after allegedly hitting her head in the subway three days ago. Where do you want her?

"Did you put her on a stretcher?

"Yes, what else could I do?

"I have no space in here. It is a zoo. Where is she?

"I put her in corridor A, and I sent the husband to registration.

"Okay, we'll come and get her as soon as we have an opening, if no real emergencies show up between now and then. She'll probably end up waiting longer than she would in walk-in."

About thirty minutes later, Mr. K. came back from registration and could not find his wife. He had to wait five minutes for the triage nurse to finish with another patient before she would show him where to find corridor A. When he went up to his wife, she was lying on her back and not moving. He nudged her shoulders, and she opened her eyes and spoke with slurred speech, looking confused. He went back to triage and found the nurse with yet another patient. He blurted out:

"There is something wrong with my wife! She is difficult to arouse and she has slurred speech!" The nurse replied:

"I'll take a look at her in a few minutes.

• But my wife needs help now!

• Your wife is fine. I will be there in a short while. I have nine people waiting to be triaged. As soon as I have finished, I'll come and look."

Mr. K. threw up his hands in frustration and went back to his wife. She was still arousable but stuporous. He waited another twenty minutes and no one came. He went back to the triage nurse and told her he was very concerned and demanded immediate medical attention. The nurse gave him the same reply as if it were prerecorded. This back-and-forth continued every ten minutes for another hour until Mr. K. found a different nurse and asked:

"What happened to the other woman?

• She went on her dinner break," was the reply.

"Please come and look at my wife. I am having a hard time keeping her awake, and she has been in the hallway on a stretcher for almost two hours. Please!"

The relief nurse became alarmed at what she heard. She immediately went over to Mrs. K. and found her completely unresponsive. She sounded the alarm, and suddenly an array of doctors, nurses, and medical students appeared and rolled Mrs. K. into one of the code rooms (space designed for life support). Within a few minutes, Mrs. K. had an intravenous line and an endotracheal (breathing) tube. A transporter brought her to radiology, where a CAT (computerized axial tomography) scan revealed a large hematoma (blood clot) on the brain. Apparently, the head trauma on the subway train three days earlier had caused a slow hemorrhage in the back of her head that ultimately produced continuously increasing pressure within the skull. In less than thirty minutes, Mrs. K. was in the operating room undergoing neurosurgery for removal of the clot and cauterization of the bleeding vessels. She remained in a coma for eight months and died without ever regaining consciousness. Too much time had passed, causing irreversible brain damage.

In this case, there was no problem with the skill and efficiency of the emergency department staff in general. The quandary was one triage nurse with a bad attitude. When Mr. K. left his wife to take care of her paperwork, he, in effect, put the life of the mother of his children in that nurse's hands. When she said, "As soon as I have finished, I'll come and look," Mr. K. had to believe that once his wife was on a stretcher, she would get prompt medical attention. If he had not had that typical mistaken confidence in the health-care system, he might have been alarmed at the nurse's initial low-priority assignment, refused to leave his wife's presence, and vociferously demanded immediate medical attention from hospital management.

Triage Priority Levels

The general standard for emergency departments is to have five levels of priority: code, critical, urgent, nonurgent disabled, and ambulatory.

Code. The code level refers to someone who has suffered cardiac arrest outside of the hospital or someone whose vital signs crash within the emergency department. Resusdtation efforts are in progress. These cases do not go to triage. They go straight into the code or trauma room, where, usually, there is a team standing by. This category also includes people with gunshot or stab wounds with possible vital organ involvement and/or altered or absent vital signs.

Critical. The critical designation denotes a person with stable vital signs who is exhibiting symptoms or who gives a history that clearly delineates a life-threatening condition. This might be a patient with chest pain, shortness of breath, and profuse sweating (diaphoresis). This also would include people who have a history of vomiting blood, multiple traumas with head injury, or a gunshot or stab wound, as well as asthmatics, diabetics with low blood sugar or extremely high blood sugar, and the like. The triage nurse usually sees these people first and should hand them over immediately to the doctors. In some cases, the nurse can administer initial treatment under standing orders, such as oxygen or a dextrose (simple sugar) injection for the diabetic who is crashing from low blood sugar (hypoglycemia). No time should be wasted in treating these individuals.

Urgent. The urgent category, as usually described in hospital manuals, represents patients with serious conditions requiring medical intervention within two hours. More specifically, a doctor should see patients with an urgent need within one hour; these patients should never wait more than two hours. These are people with abdominal pain, high fever and/or productive cough, deep lacerations with bleeding under control, closed fractures with deformity, and so on. If the emergency department is so overwhelmed that the triage nurse can anticipate a longer wait, he or she has an obligation to monitor such a patient for changes in symptoms with vital sign measurement at least once every hour. Accepted standards of care also require that these persons be lying on a stretcher and not sitting in a chair.

Non-urgent disabled. The nonurgent disabled individuals, unable to walk or remain in a chair, are those for whom the triage nurse determines that up to a four-hour wait is clinically acceptable. The acceptable standards require that the triage nurse place these people on a stretcher for comfort and safety. Sometimes the disability relates to the presenting problem, such as a herniated disc causing severe low back pain. With others, the disability does not seem related, as with nursing home residents who arrive because their feeding stomach tube or bladder urine-draining tube has become dislodged. This creates a problem because most of those transferees do not need to be in an emergency room. A physician could easily replace the tubes at the nursing home.

Notwithstanding the practical considerations, the health-care reimbursement system provides nursing home operators with financial incentives for transferring their residents to occupy space in the hospital emergency department. This is especially incomprehensible since it would be a great deal less traumatic to the frail elderly to remain in their quiet, peaceful, familiar beds rather than having strangers uproot them to' the noisy, overcrowded emergency room. Nonetheless, the government would rather waste an extra three thousand tax dollars for the ambulance and hospital charges and prevent patients with real crises from having access to the emergency room bed. This is a defect in the health-care bureaucracy that indirectly kills people and causes the elderly to suffer mental anguish.

Ambulatory. Lastly, the ambulatory patients are those who do not need emergency care but are there anyway with colds, toothaches, headaches, bumps, bruises, abrasions, small lacerations, skin rashes, and so on. This usually makes up the majority of the waiting room population. This is why emergency departments need triage. The more progressive hospitals have a twenty-four hour walk-in clinic to relieve the burden of the emergency areas. However, the principle standard of any triage nurse is to err on the side of caution. Thus many people who would do well with the clinic will remain in the emergency department.

To conclude with regard to triage, it is important to ask the triage nurse, "What level of priority did you assign?" Then ask for the rationale. If he or she sends you to the walk-in clinic with abdominal pain, nausea, diarrhea, fever, and/or a severe headache following head trauma, you have a problem. You are supposed to be on a stretcher with an intravenous line and with a blood specimen drawn, tagged, and bagged for the laboratory. The triage nurse need not have the last word. You have a right to ask for the charge nurse or supervisor to reassess the situation and countermand the initial decision.

Emergency Room Waiting Time

There is a relationship between how long patients have to wait to see a physician and the outcome. Injuries and illnesses that need medical and nursing intervention are time sensitive. The longer the wait, the more damage occurs because there is a loss and/or deprivation of basic needs for survival, such as oxygen, blood, electrolytes (potassium, sodium, etc.), sugar, water, immunity, skin integrity, and the like. Additionally, waiting time in the emergency department is determined, in part, by factors such as the ratio of physician and nurse to patient, laboratory turnaround time, x-ray turnaround time, and average length of stay.

These factors are obviously interdependent. Most urban emergency rooms are overwhelmed and overcrowded. For some it is occasional, but for most it is the norm. Health-care planners do not seem to be assessing community needs before pouring the cement. The planners are building the emergency rooms too small, and the number of doctors and nurses are too few to provide safe care for the overwhelming numbers that converge at the door. This is a bizarre phenomenon because it defies logic. It would seem that the faster they move the patients through the system, the more revenue there will be.

Upon closer examination, you would find some correctable contributing factors, such as waiting four hours for the results of a ten minute laboratory test, inadequate staffing of nurses and technicians, and/or lack of prompt response from on-call specialists.

Additionally, patients who have completed the diagnosis and stabilization process remain in the treatment area waiting for a bed or for transportation. Thus if a patient hangs around for two hours for the ambulance to bring him or her back to the nursing home, the next person then has to wait two hours for that space to become available.

Moreover, when such conditions exist with hundreds of people moving around in a frenzy, the state of affairs usually becomes chaotic and confusing. Charts are misplaced, specimens do not get to the laboratory, the doctors cannot find the x-rays, and sometimes the nurses have to go look for their patients. These situations further slow the process.Accordingly, the people who manage the emergency rooms need to develop a new model of patient-flow dynamics because the current design is simply not working.

What's more, on the subject of overcrowding in the emergency department, the lack of available beds in the respective intensive care units and/or floor exacerbates the overloading. Hospital managers in many instances are loath to divert incoming patients to other facilities because it translates to a loss of revenue. Frequently, under such management, doctors admit patients and hold them in the emergency department until a bed opens up, which could take days. This deplorable policy has been common practice for the entire twentyseven years that I have been a nurse, and it continues to this day. I have experienced this predicament as both a nurse and a patient. I once stayed at Montefiore Medical Center in 1986 on an emergency room stretcher for two days. It was pure torture. The stretcher was too narrow and too hard. I was lying on a metal platform with a thin foam rubber slab between it and my backside. The resultant pressure was painful. The reason given for this torment was that there were no beds available. The management should have offered me an opportunity to transfer to another hospital in the area, but that was not an available option because the system was not set up for true customer service. Considerations like safety, comfort, and dignity are not a part of the policy-making process.

Finally, the emergency room is not equipped to house patients for more than four hours at a time. If waiting for a bed causes the patient to remain longer than that, the quality of care falls below standard. The emergency room nurses cannot reasonably provide for the needs of new arrivals and give the time and attention required for a proper nursing assessment and management of the admitted patient's condition.

The solution to the universal emergency department debacle is complex. Certainly, if you have been waiting several hours, you would feel restless, frustrated, and angry. You might even worry that something bad will happen if you do not get to see a doctor in the next few seconds. The situation can get very ugly at this point. Once, an emergency department administrator got an inspiration to bring in a magic show to entertain the people in the waiting room and ease the tension. It had the opposite effect, and the magician had to disappear. Although he was good at his craft, he was playing to the wrong audience. One man told him where to shove his rabbit, and a woman shouted, "Why don't you conjure me up a doctor so that I can get treated for this lousy migraine!" When the performer pulled out his rope trick, another man told him to go hang himself with the rope.

But it is important to know that loud complaints are counterproductive. The last thing you need is to cause the nurses and doctors to want to avoid you. Once it becomes apparent that you have waited too long, you need to understand that the triage nurse has decided that the patients going ahead of you would have a higher risk than you of dying without prompt attention. This does not mean you have no risk. This is a comparison of your risk against that of others, and you came out on the bottom. Remember that the triage nurse is simply choosing between two or more people to fill one vacant slot.

While being careful not to displace another person who would need medical attention sooner than you might, you can take a few actions that might reduce your waiting time:

Ask the triage nurse to give the rationale for your low priority.

If you feel your symptoms have gotten worse, report it and say that you feel your condition is deteriorating.

If you believe that the decision to make you wait is not correct, call the nursing supervisor..

Remain truthful about your symptoms and don't exaggerate..

Do not lie on the floor pretending to have passed out. You will not likely be able to fool the nurses and doctors, and if you do, you could get the wrong treatment.

Once you are inside you will likely experience more waiting for blood and urine tests and/or x-rays. This will take another four to six hours. The best way to approach this is to let the charge nurse or supervisor know that you are aware that a lab test takes no more than a few minutes and that an x-ray takes ninety seconds. At this point, you can ask a staff member to call the laboratory or x-ray department to find out what is going on. However, it is important to realize that this situation is not going to improve instantaneously. The most common reason for such delays is simply that the laboratory and x-ray facilities and the personnel are inadequate in meeting demand. Increasing such resources would require an act from top level executives committed to improving emergency services.

Furthermore, the hospital administrators have the option of going on diversion. This is simply calling the 911 dispatch office to report that the hospital is over capacity and that ambulances need to divert patients to alternative facilities. There are capacity ordinances in every municipality governing all public places, like theaters, restaurants, and houses of worship. Why do the local governments allow hospital executives to cram in more people than they can safely handle? In this situation it is not a matter of being unsafe in case of fire - it is unsafe as it is. Thus if you find yourself sitting in the emergency waiting room for several hours and the place is jam-packed with people, ask the nursing supervisor if the emergency room has been placed on diversion. If it has not, then ask, "Why not?" I do not know what answer you will get, but it is the question that matters. The question, if repeated often enough by many different people, will make decision makers realize that the public is mistrustful of their management policies.

To offer some additional solutions, there are some emergency centers that are managed better than others. It is important to be able to choose one that will give you and your family a better chance for the most effective care possible should you ever need it. You will need to make such a choice as soon as possible, because you would not have time to make a selection during an emergency. You should know where each emergency room is located in your area and the shortest route to get there. It would also be advisable to make an appointment with the emergency department administrator to inquire about the quality of care in his or her emergency room. Here is a list of questions to ask:

How many attending doctors are on duty at anyone time and is that number consistent with established policy?

How many nurses are on duty during each shift and how many are supposed to be on duty?

How many patients can you fit in the treatment areas at any one time?

Are the attending physicians board certified in emergency medicine?

Do your nurses and doctors have the certification to provide advanced adult and pediatric life support?

Do you have a trauma team?

May I see your list of specialists on call?

If I need a specialist that is not on your list, where will you transfer me and how long will that take?

What is your policy on leaving patients in other areas such as the x-ray department?

To begin with, getting answers to the first three questions will enable you to calculate how many people each doctor and nurse can take care of at any moment in time. If the ratio is greater than ten patients for everyone doctor or five patients for everyone nurse, that emergency department is understaffed and unsafe. You should tell the administrator that this is unacceptable. Expressing your concern and encouraging others to do the same begins a process of cumulative feedback that will ultimately have a positive effect.

Secondly, aside from making sure that the staff members have the right credentials, the issue of available specialists is a crucial matter. Not every hospital has the ability to handle critical emergencies such as brain hemorrhage or stab and gunshot wounds. You should find out what specialties are available and the usual response time once the emergency attending makes the call. I once triaged a twenty-five-year-old woman who came in looking extremely pale with low blood pressure and abdominal pain. I treated her for shock and called in a request for immediate attention. The emergency attending physician came out, made a fast assessment, and decided that we were dealing with an ectopic pregnancy (the embryo attached itself inside the fallopian tube), which is life-threatening. She called the gynecologist, who got there in five minutes, and the patient was in the operating room within thirty minutes of her arrival and ultimately recovered. In this case, the successful outcome was almost entirely dependent on the prompt response of the specialist.

Finally, one of the most common mistakes made in emergency nursing care is leaving patients in areas outside of the emergency department. This happens most frequently in the x-ray department corridor. The patient is either waiting for the x-ray technician or waiting to be brought back to the emergency room. Too often such people experience a potentially life-threatening crisis with no one in attendance, such as a semiconscious sixty-eight-year-old woman who vomited and choked while lying supine on an emergency room stretcher. The nurse decided to leave the patient alone for a few minutes to avoid exposure to the x-rays. Within the time it took to shoot an abdominal film, the woman's stomach contents went into her lungs. The result was extensive brain damage and death two days later. If the nurse had donned a lead apron and remained with the patient while the x-rays were being taken, she could have turned the woman's head to one side and prevented the choking. Thus since such occurrences are unpredictable, there should be a nurse in attendance at all times with patients who have an altered level of consciousness.

In summary, the emergency department is a place to which many people owe their lives. When properly run, it is the only safe haven for many hurting and frightened folks. Unfortunately, if you have ever been to one, you know that virtually every emergency room in existence is too small and has too few nurses and doctors to provide timely treatment to all who turn up. It usually looks like there has been a disaster causing massive casualties. There seems to be a universal belief among those who plan and manage that an overcrowded emergency room serves the financial needs of the institution. Otherwise, the spaces would be larger, there would be more staff, and, unless there is a real calamity, waiting time of more than one hour would be astonishing.

As you make your rounds to evaluate the safety of the emergency departments in your area, use the following comparative tool.

Comparing a Safe Emergency Room with a Dangerous One

Reasonably Safe Emergency Department Dangerous Emergency Department

Average doctor-to-patient ratio of one to ten Average doctor-to-patient ratio of one to more than ten

Average nurse-to-patient ratio of one to five Average nurse-to-patient ratio of one to more than five

Keeps statistics on waiting time and has as goal to average one hour or less Does not follow waiting time and/or has no formal program to reduce it

Allows nursing supervisor to call for ambulance diversion when filled to capacity Has unwritten policy against going on diversion to avoid losing revenue

Maintains strict policy on assigning only nurses with proper credentials and orientation Uses temp-agency nurses without adequate orientation

Has a written protocol for stabilizing and transferring patients with problems requiring treatment at another hospital No such protocol in place or not reviewed and updated every three months

Keeps a list of on-call specialists and contacts each daily to confirm availability and response time No calls made to specialists each day to confirm availability

Has strict policy on keeping patients under close observation until medically cleared No such policy in place

Does not keep new admissions in emergency department for more than four hours; transfers admitted patients without beds to other hospitals Will keep admitted patients indefinitely in the emergency department until bed opens up; transfers admitted patients only upon demand