Christina Sereda (BSc, MSc, MD, CCFP, Mom)
“Why is that person going ahead of me in the emergency department when I was here first? It’s not fair.”
The above statement, or variations upon it, is a frequently repeated refrain in the local emergency department (ED). I hope to demystify the rationale behind the order patients are seen in the emergency departments in all Canadian hospitals.
First, imagine if you will, that you are returning home from an extended vacation (perhaps you put your humble abode up on a website that rhymes with Hair C&C and had some short-term residents occupying the premises). You notice three things when you first walk in. One, there is a huge red wine stain on the living room carpet, and it’s pretty dry by now. Two, you notice the toilet in the bathroom is plugged and actively overflowing. Finally, it hits you: that odour that you noticed when you first opened the door? It’s the unmistakable smell of natural gas. And you see that your companion is about to light up a cigarette that is already poised in his mouth. What do you do first?
Hopefully, you said something to the effect, “I’d knock the lighter out of my friend’s hand, get everyone to safety, and call the gas company’s emergency line.” Those of you that reached for the plunger or the carpet stain remover, please see me after class. Because when the whole place goes, “Kaboom!” there won’t be a carpet or water damage from an overflowing toilet to worry about anymore.
The above example illustrates that problems are associated with different degrees of urgency to which they need to be attended. In the ED, patients come in with a myriad of concerns from the gravely serious (patient lacks a pulse and CPR is actively being performed by EMS) to the moderately serious (a person has been having abdominal pain for a few hours) to the not so serious (My hip has been sore for 20 years and today I want to do something about it!). Indeed, everyone’s problem is important. As you can hopefully appreciate, the first patient is the patient who should be seen first, as they will die or suffer great harm if they don’t get immediate medical attention. The third patient has waited 20 years, and two more hours of waiting is likely not going to harm them.
Indeed, a system has been designed for use in all Canadian Hospital Emergency Departments to help sort out which patients are the natural gas leaks, which ones are the overflowing toilets, and which ones are the carpet stains (I mean that figuratively, so please, no angry calls to my office). The Canadian Triage and Acuity Scale (or CTAS) is a tool that allows EDs to prioritize patient care requirements. It ensures that the sickest and highest risk patients are seen first and it allows resources to be assigned to these patients.
How does this work? Simply put, when a patient enters an ED and registers, a nurse will then assess that patient. The “presenting complaint” is noted (for example, chest pain or shortness of breath) and vital signs are gathered (temperature, heart rate, blood pressure, etc.). When this is all put together, a score from one to five is obtained.
Level 1 is “Resuscitation” and applies to conditions that are threats to life and limb (or imminent risk of deterioration) and these patients require aggressive interventions. These are people who are in cardiac arrest, respiratory arrest, or who were involved in major trauma, as examples.
Level 2 in the scale is “Emergent”. These patients have conditions that are a potential threat to life, limb, or function, requiring rapid medical intervention. Examples cases are shortness of breath; chest pain with cardiac features; and some types of trauma.
CTAS Level 3 is deemed “Urgent”. These are conditions that could potentially progress to a serious problem requiring emergency intervention. Examples include high blood pressure; vomiting with mild dehydration; moderate abdominal pain; and moderate headache.
Level 4 is “Less Urgent”. These are conditions that are related to patient age, distress, or potential for deterioration that would benefit from intervention or reassurance within one or two hours. Examples here would be a urinary tract infection or constipation.
Finally, Level 5 is “Non-Urgent”. These are conditions that may be acute but non-urgent; or conditions that might be chronic, but are not showing evidence of deterioration. A medication request (prescription refill) or a dressing change would fit into this category.
Certainly, patients come to the ED at random and unpredictable times (sometimes one at a time and sometimes in a large group). Patients arriving at the ED are also what we call “undifferentiated”, which means they do not come with a diagnosis. We have to sort out patients and figure out the best care possible for each one, sometimes with limited information.
So, what does this mean for you, the patient in the ED?
1. Please be patient with us, the ED staff. We don’t like it when you have to wait, either. Staff are usually dealing with multiple patients at once. Sometimes there is a team of a up to a dozen people working on one critically ill patient for hours. Your local health care workers often work very long hours under stressful conditions.
2. Please be honest. Do not hide any crucial details, even if they are really embarrassing. We need
to know how much alcohol you drank or any recreational drugs you might have taken. Our job is not to judge you.
3. Bring your medication list with you and know your allergies. We don’t know what the “white round pill” that you take is, because half of the medications in existence are white and round. Contrary to common belief, all of your past health information is not gathered in some computer system that we have access to (yet).
4. Tell us if your condition changes. If your pain is getting worse, let us know. If you have a new symptom, let us know.
5. Consider alternatives for less urgent conditions. Can your pharmacist front you three pills of your regular medication so that you can make it to your family doctor’s office for your refill instead of coming to the ED?
My aim here is not to discourage people from coming to the ED, as there are numerous conditions that should be seen in this venue. It is my hope that this article illuminates for the general public some of the processes that go on in the ED.
Dr. Christina Sereda is a local doctor who hopes to shed some light on the medical system and patient education.
