One afternoon, a 29-year-old female presented to an emergency department complaining of bilateral ear pain, cough, and sore throat. She had been seen by her PMD earlier that day and had been told that she was pregnant. She arrived at the ED at 1600 and was triaged at 1630. Her past history included hypertension and a cholecystectomy. Current medications were prenatal vitamins, and she admitted to taking “leftover” antibiotics over the previous 3 days. Vital signs at triage: B/P 100/64, HR 129, RR 28, T 97.5F (36.3C) (O), O2Sat 100% on room air. Her objective assessment at triage was “unremarkable” and she was assigned a level 3 (non-urgent) acuity using a 3-level acuity scale and she was sent to the waiting room. She was finally placed in a treatment bed at 1730 and seen shortly thereafter by a mid-level provider.

Case Progression

After assessment by the mid-level provider, a diagnosis of sinusitis was made and a discharge order written, along with a prescription for an antibiotic. The treatment nurse recognized that the patient continued to experience unexplained tachycardia and tachypnea and insisted that a re-evaluation of the patient take place. Further diagnostics were ordered and the patient was admitted to the hospital with a pulmonary embolus.

What Went Wrong?

By concentrating solely on the presenting complaint—one of the most common mistakes at triage—the nurse failed to recognize the high-risk nature of this patient’s presentation. While the presenting complaint itself was not particularly alarming, the patient’s unstable vital signs and recent diagnosis of pregnancy should have alarmed the triage nurse. Failure to use a consistent systematic approach in the decision-making process at triage contributes to the mistriage of patients that occurs in emergency departments every day in this country.

It is not possible to tell from the information available from this case exactly what was meant by an “unremarkable” objective assessment; however, the tachypnea and tachycardia alone make the objective assessment “remarkable.” Unexplained tachycardia and tachypnea is not a benign finding, and when it occurs during pregnancy, pulmonary embolism must be considered as a worst-case scenario.