What the heck is going on in this Emergency Department?

How come I have been waiting to be seen in the Emergency Department for 2 hours, and that lady walks in and goes straight through? That is just not fair.

Everybody understands what a queue is. And it seems like a fair and reasonable way to be seen. After all, it works for banks, and GP surgeries, and football games.

But the problem in an Emergency Department (ED), is that people who arrive after you may have a much more urgent medical problem. Problems where even small delays in reaching treatment can result in serious or even life threatening outcomes.

Sometimes this is obvious. For example when a patient arrives by ambulance and it looks like they must have been in a really serious accident. Or CPR is being administered by the paramedics.

Sometimes this is not obvious. Patients can walk in through the doors of the ED and actually be having a stroke, or a heart attack, or after having taken an overdose… and it can be pretty frustrating to see these well looking people ushered in to see a doctor before you.

OK then, how do you know that lady is sicker than I am?

It is the role of the Triage nurse to sort through everyone arriving and determine both their clinical urgency and the most appropriate area of the ED for them to be seen. This is a huge responsibility.
For example, that patient from the accident may need to be seen immediately, and moved to the resuscitation room. The person having a heart attack will go straight through to the acute care area. The person with abdominal pain will need to go in as soon as possible, but even so, will have to wait a while because the acute care area is now full.

Triage nurses are usually senior staff with many years of clinical experience and have undertaken specific additional training in this specialty. After performing a rapid history taking and assessment they will assign each patient a category between 1 and 5 (known as the Australasian Triage Scale or ATS). See the diagram above.

So even if you have been waiting a considerable time (and Emergency Departments are one of the busiest environments in the health system), a patient who just now arrives may be assessed with a higher ATS and be seen before you.

But I was given a score of 3 and I have been waiting 2 hours. What’s with that?

The reality is that in Australian ED’s most patients will not be seen within their maximum clinically appropriate time on any given day. This is due to many issues including hospital overcrowding, the number of really sick patients present, and staff to patient ratios.
So the reality is, if you have been Triaged as an ATS category 3, you will probably wait longer than 30 minutes.

But this is an emergency, what are you going to do?

Yes. This can be extremely frustrating, especially if you are feeling unwell, or in discomfort or you are the parent of someone else who is, and the waiting times are lengthy.

Hospital staff are well aware of this, and believe me, they give the utmost priority to trying to optimise the flow of everyone through the ED at all times.
Despite how it may feel, staff are working as hard as they can to get you seen and treated as soon as is appropriate.

To help with this, an ED may have different areas that specialise in managing particular types of problems (known as streaming), or have other strategies to try and lessen the waiting times. Most larger ED’s have nurses working in the waiting area to check on your condition and arrange for analgesia if you need it.

But why can’t the triage nurse just tell me how long the wait is when I arrive?

ED’s waiting times are in a constant state of flux, continually altered by:

  • The total number of patients
  • How unwell they are.
  • How complex (and time consuming) each individuals treatment is.
  • The number of empty beds available in the hospital to admit patients to from the ED.
  • Workloads and staffing levels.

But really, it seems pretty quiet!

Sometimes the waiting room does not look full, and it seems pretty quiet. But this can be misleading. Just down the corridor there may be critically unwell patients or medical emergencies in progress. These events require teams of doctors and nurses to attend which will significantly impact the flow of patients in the rest of the department.

Right. So what should I do then?

If you can see that it is very busy and you think your problem might not be all that serious, there are other options available such as nurse-led medical clinics, Medical centres, and even pharmacies (if all you need is a medical certificate for example). It is best to discuss this with one of the Traige nurses for further advice.

For many conditions, the ED is the right place to seek treatment. And most people are really pretty good at knowing when this is. So a long waiting time may be unavoidable.

The important thing is that staff should continue to communicate with you whilst you are waiting. And you should be re-assessed at regular intervals.
ED staff know that if you are kept informed and supported in the waiting room it minimises any anxiety and anger that might understandably arise.

You should immediately let the waiting room nurse or the Triage nurse know if:

  • There is a change in the condition of the person awaiting treatment.
  • If you develop increasing pain.
  • If you are having difficulty breathing.
  • If you decide you are going to leave before you are treated.
  • You have any other concerns or problems.

Ian Miller is a retired nurse with 35 years experience working in a major Australian emergency department.

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