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Based on review of clinical records, staff interview and policy review, it was determined that the ED nursing staff did not follow the Emergency Department Triage policy for 1( #1) of 10 patients reviewed.

Findings include:


A review of patient #1's clinical record revealed the patient presented to the Emergency Department on 7/28/11 at approximately 4:00 p.m. by ambulance. The patient was triaged at 4:03 p.m. with the chief complaint of "constipation." The patient's vitals were blood pressure 95/49, heart rate 112, respirations 22, temperature 96.8, and oxygen saturations of 100% on room air. The patient was assigned an acuity level of 3. The patient stated her pain level was 8 out of 10 on a pain scale of 0 to 10. The next nursing assessment was completed at 5:57 PM when the patient was noted to be apneic and pulseless, one hour and 54 minutes later.
An interview was conducted with the ED Medical Director on 11/21/11 at approximately 3:30 PM. The ED Medical Director was given the patient's triage scenario and was questioned as to what acuity level should be assigned to this patient. The Physician replied she " would have liked the patient to be assigned a level "2" But could not definitely have decided between a "3" or "2" without seeing the patient."

Based on the "Emergency Severity Index, (ESI)," Triage Algorithm (AHRQ, 2004), used by the facility's emergency department as reference, the patient would have been assigned an acuity level "2" using the algorithm. The patient expressed a pain level of 8 out of 10. According to the algorithm, a level "2" should be considered. Severe pain/distress is determined by clinical observation and/or patient rating of greater than or equal to 7 on 0-10 pain scale. According to the "danger zone" diagram provided, if the patient's heart rate is greater than 100 and respirations are greater than 20 the patient should be considered for an acuity level "2." The patient's heart rate was 112 and respirations were 22.

A review of the facility's policy, "Triage: Initial Emergency Department Assessment," policy# T-025, revised 11/2008, revealed an acuity level 2 required a patient to be assessed every hour or more often as indicated.

A review of the patient's clinical record revealed, then, determined the patient had an initial assessment at 4:03 p.m. and was inaccurately assigned a level "3" acuity. The patient was not reassessed until the patient "coded" at 5:57 PM almost 2 hours later.

The initial patient contact, per the "Physician - Clinical Report was at 18:02 (6:02 p.m.). The report goes on to add that "chest compressions performed by ER staff pulses abnormal. Good massage pulse. 8.0 endotracheal tube in good position (placed by ED physician). Good chest movement." The clinical impression was "Cardiac arrest, Abdominal Aortic Dissection (Highly suggestive as a result of presentation). Sepsis (secondary to toxic colon). Discussed case with Dr._____ will take to surgery." Disposition: "Admitted condition critical."

On 7/28/11 at 23:32, the surgeon informed the ED physician of the surgical findings. "He says the patient had a toxic colon and that he had to remove her entire colon."