One morning, an 88-year-old man presented to the emergency department complaining of feeling weak. This was his second visit to the same ED within 24 hours—he had been discharged 3 hours earlier after receiving treatment for epistaxis (packing inserted).  His past history included CABG x3, MI, chronic lymphocytic leukemia, and HTN. His current medications were: Detrol, Metoprolol, Isosorbide, Lasix, Zocor, and aspirin. Vital signs as documented at triage: BP sitting: 103/41, standing: 104/44; HR sitting: 83, standing: 87; temp 100.8 (tympanic); RR 20; pulse oximeter 96% on room air. His objective assessment at triage revealed respirations unlabored, skin dry and pale, abdomen soft with bowel sounds present, mental status not documented. He was assigned a level 3 nonurgent triage acuity using a 3-level acuity scale.

Case Progression

The patient was placed in a treatment room within 10 minutes of arrival to the ED. Partially repeated vital signs 5 minutes later revealed HR 76, RR 22, and pulse oximeter 88% on room air. No repeat BPs or further vital signs were documented. The patient was placed on the cardiac monitor shortly after placement in a room; however was not placed on supplemental O2 until 45 minutes after the pulse oximeter reading of 88%. The patient was ultimately admitted with the diagnosis of pneumonia, hypoxia, and anemia.

What Went Wrong?

The most obvious issue with this patient presentation is the incorrect acuity assigned. Although there is a shift in the United States toward a valid and reliable five-level acuity scale there are a number of hospitals using three- or four- level acuity scales. Regardless of what scale is used, the patient presented above clearly is not a nonurgent patient. He has multiple factors that would cause his acuity to be higher, including consideration of his earlier visit, his age, his past medical history, and his vital signs. When triaging elderly patients we must always consider the effect of medications on vital signs; namely his inability to compensate for volume loss by increasing his heart rate. This can lead the triage nurse to believe that the absence of orthostatic vital changes indicates a more stable physiological status than what actually exists. Further, in a patient with HTN his blood pressure is concerning. (Also note the wide pulse pressure.)