Case Number: 1829 / 02 Case Precis Author: A. Charles A previously well 18-year-old male presented to a peripheral suburban ED in the early hours of the morning with a 24 hour history of being generally unwell with lethargy, headache and vomiting. He was triaged as a category 4. After waiting for approximately four hours later he‘ felt a bit better’ so he left the ED without being assessed by a medical practitioner. He had, however, been reviewed by the triage nurse on three separate occasions. Five hours after arriving home he was found by his family to be agitated with an altered conscious state and to be developing a purpuric rash. He was returned to the same emergency department by ambulance where advanced life support was commenced, including endotracheal intubation and
The Challenge of Triage
ventilation. He was thereafter transferred to a tertiary hospital Intensive Care Unit. Meningococcal septicaemia was diagnosed and despite aggressive treatment he deteriorated and died 4 days later.
Coronial Investigation The issues raised by the patient’ s family were:( 1) a perceived deficiency in the triage process and
( 2) the delay in being seen by a doctor during the first presentation.
Coronial Findings The Coroner found that the emergency department was particularly busy on the evening that the patient first presented. The triage nurse’ s assessment of the patient indicated non-specific flu like symptoms and therefore an appropriate triage category allocation had been given. Neck stiffness and photophobia had been examined for. The delay in the patient being seen could not be definitively connected to his death.
Recommendation The Coroner recommended that consideration be given to formalising a process where a patient is always reassessed by the triage nurse once the triage time has expired. In this case that would mean a formal nurse review one hour after initial assessment, it was noted that this was in fact performed informally on three occasions in this case.
Hospital Response The hospital reviewed its triage processes and procedures and concluded that any patient who presented with similar symptoms should be triaged as a ATS Category 3( to be seen within 30 minutes of presentation).
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Note: Triage category allocation is independent of local policies dictating activation of response teams, such as trauma team activation.
Prioritisation of multiple patients at triage
Although there is no research relating to triage of multiple patients who present simultaneously, a primary-survey approach theoretically prioritises patients in order of life threat. This approach means that patients with airway problems should take precedence over patients with breathing problems, who take precedence over patients with circulation problems. Table 4.1 outlines such a primary survey approach to prioritising patients.
Department of Health and Ageing – Emergency Triage Education Kit