Literature & Research


Fasten Your Seatbelts!
There is little question that emergency department visits are increasing and that we are busier than ever. There is a plethora of information in the literature that examines possible causes for this continuing increase in visits, accompanied by the recognition that the overcrowding many departments face is a complex and multifaceted problem. A recent study published in the Annals of Emergency Medicine (June, 2008) identifies a further crisis looming on the horizon, which if not addressed may make it appear that these were the days of Easy Street. A frightening thought, indeed.

The Crisis? The Elderly
We are an aging population in America, and therefore we should not be surprised that visits to the ED by the elderly are also increasing. (Elderly is defined here as those 65 years of age and older.) Elders do not generally utilize the ED in a frivolous manner - they are more ill and experience more "true" emergencies than younger patients. Elderly patients often present with complex medical problems and histories complicated by multiple comorbidities and poly pharmacy. They require more diagnostic testing, are more likely to have emergent or urgent presentations, are more likely to be admitted to critical-care beds, have longer lengths of stays in the ED, and may present with subtle signs or symptoms that belie a catastrophic illness (Hwang, 2007).

And the News Gets Worse
According to the AEM study, "Increasing Rates of Emergency Department Visits for Elderly Patients in the United States, 1993 to 2003" (Roberts, 2008), not only are visits by the elderly increasing, but they are increasing significantly faster than any other age group. The study also predicts that if the current trend continues the annual ED visits for those aged 65 to 74 will nearly double in the next five years from 6.4 to 11.7 million visits yearly. "If trends continue, the effects on ED and hospital crowding could be catastrophic, and planning should begin now" (Roberts, 2008).

Roberts, D. C., McKay, M. P., & Shaffer, A. (2008). Increasing Rates of Emergency Department Visits for Elderly Patients in the United States, 1993 to 2003. Annals of Emergency Medicine, 51(6), 769-774.
Hwang, U. & Morrison R. S. (2007). The Geriatric Emergency Department. Journal of the American Geriatric Society, 55(11), 1873-1876

Evidence-Based Protocols at Triage
The use of evidence-based protocols which have been developed and implemented according to best practice and meet the requirements of each individual state's Nurse Practice Act can improve the efficiency of the physician. Furthermore, the appropriate use of protocols at triage can improve patient satisfaction, improve time to intervention for patients who meet predetermined criteria, and potentially decrease overall length of stay. Two recent articles describe evidence-based, nurse-driven protocols for obtaining chest x-rays on patients who meet the predetermined criteria consistent with community acquired pneumonia (CAP). The impetus for the development of these protocols, not surprisingly, was the challenges of meeting the quality of care standard set by the Department of Health and Human Services for patients with CAP in reference to timely administration of antibiotics.

Both articles provide the reader with important statistics and information about CAP, however at least part of the value of this literature lies in the process used to develop the protocols.

Process Used To Develop Protocol
Briefly, the process used included:

• Identification of a specific problem in meeting best practice
• Development of a hypothesis for how to improve the likelihood of meeting best practice
• Retrospective study of problem
• Development of the protocol
• Training of staff
• Implementation
• Intervention study following implementation (Cooper, 2008)

Also included in the article are the chief complaints assigned by the triage nurse for the patients who did have CAP but were unidentified as such at triage and subsequently did not have the protocol initiated.

Cooper, J.J., Datner, E.M., & Pines, J.M. (2008). Effect of Automated Chest Radiograph at Triage Protocol on Time to Antibiotics in Patients Admitted with Pneumonia. American Journal of Emergency Medicine 26, 264-269.
Kyriacou, D. N., Yarnold, P. R., Soltysik, R. C., Self, W. H., Wunderink, R. G., & et al. (2008). Derivation of a Triage Algorithm for Chest Radiography of Community-Acquired Pneumonia Patients in the Emergency Department. Academic Emergency Medicine, 15(1), 40-44.

Copyright 2008 Triage First, Inc.