Part 4 The Lewis Family
4.5 Lewis family case study 4: John is transferred to the emergency department
Nicola Whiteing and Elicia Kunst
Introduction to case study
Learning Objectives
By the end of this case study you should be able to:
- Understand how care is prioritised through the process of triage.
- Outline an A to G assessment.
Scenario
John is transported to the nearest tertiary hospital emergency department (ED). While en route from the accident scene to the ED, the paramedics notify the ED of the details of the accident and their assessment and ask if the hospital is able to accept care of John. This ensures there is capacity and resources available to provide good patient care. The paramedics continue to monitor John’s pain and assess his condition during transport. On arrival at the ED, the paramedics provide further details to the triage nurse about John’s condition and the treatment they provided. The triage nurse conducts their own rapid assessment. Based on the Australasian triage scale (ATS), the nurse allocates John to category 3, based on the adult physiological predictors scale. While maintaining spinal precautions, John is transferred from the ambulance stretcher to the ED bed.
Function of triage
Triage is an essential function that underpins the delivery of care in all EDs. The triage process allows a number of people with a range of conditions to present to the ED at the same time. Triage requires a reliable and consistent process to ensure the available resources are used to minimise the risk of clinical deterioration from delayed care. Although triage systems may function in slightly different ways depending on local factors, effective triage systems share the following important features:
- A single-entry point for all incoming patients (ambulant and non-ambulant), to ensure all patients go through the same assessment process.
- A physical environment that is suitable for undertaking a brief assessment. This should include easy access to patients that balances clinical, security and administrative requirements, as well as the availability of first aid equipment and handwashing facilities.
- A systematic patient process that facilitates the flow of patient information from point of triage through to ED assessment, treatment and discharge.
- Responsive data for activity in the ED, including systems for alerting the department of incoming patients from emergency services to facilitate efficient resource allocation.
John’s triage
The nurse assesses John as he presents to the ED. An initial quick assessment involves assessing for safety and checking John is physiologically stable enough to allow for assessment. Once he is assessed as stable, the nurse takes him through the systematic ‘A to G’ assessment framework:
- Airway: checking for John’s patency and potential for obstruction.
- Breathing: looking at his respiratory rate and effort, assessing his pulse oximetry, considering the potential for oxygen or ventilatory support.
- Circulation: assessing central perfusion, his blood pressure and heart rate, assessing risk to circulation due to blood loss, vasodilation or constriction, or other haemodynamic instability.
- As time permits, this includes looking at factors that affect cardiac output, including cardiac rhythm. Initially, cardiac output and rhythm can be assessed using a basic assessment like palpating a pulse for regularity and strength, then subsequently assessing the cardiac rhythm using continuous cardiac monitoring. A 12 lead ECG provides a static picture of the electrical activity across a wider section of the myocardium, or cardiac muscle.
- Disability: considering factors that limit or affect John’s normal function, like injury, pain or other physical limitations.
- Exposure: observing him for other injury, skin integrity, and considering issues that affect his temperature; assessing him for hypothermia, hyperthermia, and fever.
- Fluids: considering John’s risk of fluid deficit or overload and the potential need for intravenous access (including peripherally inserted venous cannulation (PIVC) or other central venous access device (CVAD) such as a portacath or peripherally inserted central catheter (PICC).
- Glucose (and other electrolyte disturbance): assessing his blood glucose level if this is a risk factor and considering the potential for other metabolic disorders.
John’s airway remains patent without any signs of wheeze or distress that might indicate partial obstruction. His breathing is regular and even, with no signs of respiratory distress. The respiratory rate is 18 and pulse oximetry shows an SpO2 of 96% on room air. Blood pressure is 112/ 72, his heart rate is 92 and the cardiac monitoring shows a normal sinus rhythm. At rest, John appears comfortable as he lies on the bed; he is not grimacing or wincing or holding an affected part of his body. John says his pain is currently 6 out of 10 at rest when he is asked for his pain score. However, when he is moved to the other bed, John does cry out in pain, reporting his pain score as 10 out of 10. John states the pain is on his right side, throughout his lower back, radiating laterally to the hip and down into the right leg. The triage nurse notes the paramedics administered intravenous fentanyl pre-hospital as well as inhaled methoxyflurane (Penthrox).
On examination, the nurse notes bruising and some swelling over John’s right hip and lower flank. There is also swelling over the right clavicle. The cervical collar remains in place and the team, made up of medical and nursing staff, continue with spinal precautions. Nursing staff remove John’s remaining clothing and he is dressed in a hospital garment to allow for a more thorough physical examination. John’s privacy is maintained as much as possible by drawing curtains around the cubicle and using garments and blankets to cover him.
After further assessment, the team notes that John has an 18g PIVC in the left arm antecubital fossa. This appears to be intact with no signs of redness or swelling. At this point, John says he needs to go to the toilet to pass urine. However, as the team suspects there may be potential for cervical spine injury, which has not yet been comprehensively assessed, they assist him to use a urinal bottle. As John is embarrassed and uncomfortable to pass urine in this way, the nurse provides reassurance. Then the team takes a venous collection of bloods to gather a baseline of haematology, including haemoglobin, biochemistry, renal function indicators and electrolytes.
John is assessed by the emergency doctors. Further investigation includes a radiograph or x-ray of the pelvis and both hips, the right clavicle and shoulder, and a chest x-ray to check for undetected trauma to the cardiac structures, airway structures and bony structures. The radiography also takes images of his cervical and thoracic spine because of the risk associated with how the injury occurred (the mechanism of injury) (State Insurance Regulatory Authority NSW, 2014, p. 17). The urine collected by the nurse is tested using ward urinalysis that looks for the presence of blood, which can be an indicator of renal system trauma.
John is found to have sustained a closed pelvic fracture as a result of a vertical shear injury. The x-ray shows a fracture through the superior pubic ramus. John is cleared of underlying gastrointestinal or vascular system trauma through a computer assisted tomography (CT) scan of the abdomen. The x-ray also shows he has a fractured right clavicle. When John is cleared for cervical spine injury, which means the cervical spine has not sustained any injury, the team removes the cervical collar. While John is allowed to raise the head of the bed so he can sit in a slightly inclined position, raising the bed head above 30 degrees creates pain in his pelvis. John is given further analgesia and is referred to the orthopaedic team for management of his injuries.
Nigel arrives at the emergency department
On arrival at the ED, Nigel speaks with a receptionist who tells him to take a seat in the waiting area. Nigel has not had any information regarding how John is, with Mark just telling him that he “has a collar on his neck and is in a lot of pain”. Nigel is worrying about how they will all cope if John has a spinal injury. After half an hour, a member of the medical team comes out to speak with Nigel. He discusses with him John’s injuries and what will now happen. Nigel is feeling great relief that John is going to be OK and goes to sit by his bedside to wait with John until the orthopaedic team arrive.
Planning for discharge
In conjunction with John, the orthopaedic team plan for conservative management of his injuries. This means that they support function and encourage rest to allow the bones to heal without surgical intervention. John will need support with mobility, activities of daily living, and managing pain. Nigel and Sally have suggested that John moves in with them while he is recovering from his accident. John is reluctant to do so, however acknowledges that he is going to need help from someone and agrees to move in with Nigel ‘just for a short time’. Nigel, Sally and John arrange to meet with the interprofessional team so they can ensure everything is organised for his discharge.
Case study questions
- John has a closed fracture. How does this terminology describe the nature of the fracture and damage to surrounding tissues? How does a closed fracture differ from an open or compound fracture? Consider the risk of further injury through secondary complications, management and implications for recovery from the injury.
- After a short stay in hospital and a week in a rehabilitation centre, John is discharged back to Nigel and Sally’s house. He uses a single crutch on his left arm to support his mobility due to his fractured right clavicle. Consider John’s social factors: how can he be supported on discharge to return to normal function?
- John was reluctant to move in with Nigel and Sally. Could he have been safely discharged to his own home? If so, who is able to support him with things like transport, meal preparation, shopping, laundry, cleaning? Job insecurity and financial stress can often occur after serious injury or illness – consider what support we can provide or recommend for John
Thinking points
The Australasian triage scale (ATS) is one of many triage processes in use worldwide. While this uses a 5-point scale to objectively prioritise patient care, some other scales use a 3 or 4-point scale. Have a look at some of the other triage processes that are used, and compare this to the ATS. List the strengths of a few different systems from countries that have a comparable healthcare system to Australia’s, for example, the United Kingdom, the United States, Germany, France or Canada.
John’s brother Nigel was called and he waited in the ED waiting room while John was triaged. Nigel asks the receptionist about the triage process and questions why John is not immediately seen by a medical doctor on arrival to the ED. Explain the process of triaging or prioritising patients to Nigel, and why it is important in providing efficient and effective emergency care.
Case study 4 summary
This case study has given you the opportunity to learn more about the use of systems that aid the triage of patients. You have also seen how the A-G assessment is applied to John’s presentation. John did not require surgery and was able to be discharged with conservative treatment. Patients that live alone may experience significant obstacles in their recovery, not only their physical recovery but also in social, emotional and financial aspects of their life.
References
State Insurance Regulatory Authority NSW. (2014). Guidelines for the management of acute whiplash-associated disorders for health professionals (3rd ed.). https://www.sira.nsw.gov.au/resources-library/motor-accident-resources/publications/for-professionals/whiplash-resources/SIRA08104-Whiplash-Guidelines-1117-396479.pdf