One morning at 0850 an 80 year-old male, accompanied by his sister, presented to the emergency department via private auto with the chief complaint of altered mental status. He was comprehensively triaged at 0859. The patient's sister stated that the patient woke up the day before very forgetful and that "it got better for awhile." She also related that the patient developed numbness to the jaw the evening prior to arrival. She further told the triage nurse that the patient had been "feeling down" that morning and that he has been very depressed since the death of a family member in the past year. The patient denied experiencing pain. The patient's history included cataracts, hypertension, elevated cholesterol, and gastritis. His current medications were listed as Benicar, Crestor, and Nexium. The documented objective assessment on this patient was limited to A&O x2. Triage vitals signs: B/P 138/78, HR 66, RR 16, temperature 97.8F (36.5C), pulse oximeter 97%. His weight was documented as 180 lbs (81.8 kg) - it was not documented whether this was a stated or actual weight. Using a 5-level triage acuity scale he was assigned a Level 3 - Urgent triage acuity.

Case Progression
The patient was placed in a treatment bed at 0910 and was first seen by a physician at 1050. The treatment nurse noted on her initial assessment at 0910 that the patient was A&O x3 and without neuro deficits. At that time a hep lock was inserted and blood drawn. Diagnostics obtained on this patient included the following lab studies: CBC, PT/PTT, chem profile, cardiac profile, and a UA. All results were essentially within normal limits. A CT of the head was obtained which revealed no active bleed. An EKG revealed no acute changes. The history obtained by the physician noted that the episode for which the patient sought care was accompanied by aphasia and that the episode had lasted 5 minutes. No repeat vital signs were documented while the patient was in the treatment area, nor is there documentation that he was placed on a cardiac monitor. At 1200 the physician wrote orders to admit the patient to a telemetry bed with a diagnosis of TIA. At 1323, the patient left against medical advice.

What Went Wrong?
There are three key issues with the triage of this patient that warrant further discussion and are outlined below:

1. The subjective data was obtained almost exclusively from the patient's sister. The only documentation that indicates that the patient was actually asked any questions was that he denied having pain and that he was A&O x2. While family members and significant others can and do often provide us with valuable information, this information should supplement what the patient tells us, not replace it. The interview process not only allows us to ask and obtain specific pertinent information, it simultaneously provides a valuable means of obtaining critical objective data.
2. The objective data obtained was inadequate. Let's start with the only objective data outside of vital signs that was obtained - A&O x2. When a patient is not alert and oriented x4 (person, place, time, and purpose), a description should automatically follow in the form of A&O x2 - person and place, disoriented to time and purpose. Furthermore, a patient who presents with a chief complaint of altered mental status and who is A&O x2 should minimally have a brief neuro exam performed, as appropriate to the triage arena, including facial symmetry, presence or absence of tongue deviation, pupillary assessment, presence or absence of palmar drift, quality of speech (clear, slurred, garbled), and ability to move lower extremities. Of course, ability to move lower extremities could have been assessed had there been documentation on the patient's ability to ambulate, which there was not. Unless immediately bedded, all patients who present to triage regardless of the chief complaint should minimally have their ability to ambulate, mental status, respiratory status, circulatory status (including skin color and temperature), and any other abnormal findings assessed and documented. With rapid triage only and immediate bedding of the patient, this information should be documented quickly by the primary ED nurse or licensed independent practitioner. This is, in essence, the assessment of the ABCDs, which should be performed on all patients, and does not necessarily imply a full history and physical.
3. Wrong acuity: This patient, based on the minimal information provided in the triage assessment, should have been assigned a Level 2 (Emergent) triage acuity according to the criteria for ESI (Emergency Severity Index) or CTAS (Canadian Triage and Acuity Scale). Let's explore this a bit further - ESI defines the criteria for Level 2 as a high-risk situation or new onset mental-status changes (confusion, disorientation, or lethargy), or severe pain or distress. The Emergency Severity Index, Version 4: Implementation Handbook provides even further definition of mental status changes for us - "confused: inappropriate response to stimuli, decrease in attention span and memory, lethargic: drowsy, sleeping more than usual, [this and] disorientation: the patient is unable to answer questions correctly about time, place, or person" (Gilboy, 2005).

CTAS defines Level 2 - Emergent as those conditions that are a threat to life, limb, or function, requiring rapid medical intervention or delegated acts including altered mental state (Beveridge, 1998). Under the criteria for Level 2 - Emergent: altered mental state, CTAS notes that "Even subtle changes can be associated with serious life-threatening and treatable problems" (Beveridge, 1998).

In determining the triage acuity for this patient, his advanced age should also have been considered.

It is important to note that both of these 5-level acuity scales have been determined to be valid and reliable according to the joint Emergency Nurses Association / American College of Emergency Physician Task Force.

Further Discussion
As you read through the scenario, perhaps you noticed that the triage nurse made a point of documenting the sister's comments that the patient was "feeling down" that morning and that he had been depressed for a period of time following the death of a family member. Perhaps this influenced the nurse to assume that the issue was a mental health one instead of being physiological or organic in nature.

Final Thought
As we face an exploding population of elders in our emergency departments (see the Literature Review in this issue), it is imperative that we as a profession focus efforts on increasing our expertise in the care of this vulnerable patient population.

Gilboy, N., Tanabe, P., Travers, D. A., Rosenau, A. M., & Eitel, D. R. (2005). Emergency Severity Index, Version 4: Implementation Handbook. AHRQ Publication No. 05-0046-2. Rockville, MD: Agency for Healthcare Research and Quality.
Beveridge, R., Clarke, B., Janes, L., Savage, N., Thompson, J., & et al. (1998). Implementation Guidelines for The Canadian Emergency Department Triage & Acuity Scale.