From Triage to the Courtroom: Legal Risks in ED Practice

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Christine Macaulay MSN RN CEN
A certified emergency department nurse, Christine is currently the nursing practice specialist for the Children’s Hospital of Philadelphia. She has over 20 years of experience as an emergency department nursing expert witness. Chris has held management and clinical specialist positions at a variety of Philadelphia area hospitals. She earned a certificate from Villanova University’s Nurse Executive Program and is a National League for Nursing Accrediting Commission program evaluator.

Christine answered these questions:

• Why is the triage seat the hottest one in the ED?
• What is the main responsibility of the nurse who triages a patient?
• What is the difference between the Triage Nurse screening and the Medical Screening?
• Do all ERs use the same system for assigning a triage code?
• How can I figure out the triage category that was assigned to the patient?
• How is triage documentation organized?
• What kinds of systems are in place for following protocols for treatment?
• Can any nurse do triage?
• What are some patient symptoms that should immediately raise a concern and result in the patient being taken into the treatment room?
• How long should a person be expected to wait in the waiting room before being treated?
• How often should the patient be reassessed in the waiting room?
• What if the patient in the waiting room starts to feel worse? Does this change the triage category?
• When a patient decides to leave because the wait has been too long, what is the nurse’s responsibility when informed the patient is leaving?
• What documents should be reviewed when a case involving triage is being evaluated?
• If an attorney is handling a case involving improper triage, what documents would be important to request from the hospital?
• Where can we find the standards to evaluate the medical records documentation?
• What are some common allegations you’ve seen in cases you have reviewed involving triage issues?
• What if the nurse just did not have time to document, isn’t taking care of the patient the first priority?
• What if a nurse uses the defense that she is only required to “document by exception”?

From: "Emergency Nursing Malpractice", by Christine B. Macaulay, Donna Hunter-Adkins, Mary Kathryn Saville, Ellen Barker in Nursing Malpractice, Third Edition, edited by Patricia Iyer and Barbara Levin:

The emergency department nurse is usually the first healthcare professional to see the patient when he or she arrives. Triage is the process by which the nurse makes a professional judgment about the severity of the patient’s condition based on critical thinking and knowledge. The nurse determines where the patient is placed in the treatment area and how quickly the ED physician ranks the patient severity of symptoms to expedite the care of the sickest patients.

Preparations are made for treatment, once the emergency facility receives notification of a patient's arrival. ED personnel are expected to document communication that occurred with the first responders. This should show that accurate information was relayed from the first responders (often referred to as "the field") to the receiving institution so that they may prepare for the patient.

"Triage" is a French word that means "to sort." It is a process of rapidly sorting or classifying patients according to the need for emergency treatment and potential for further injury. Some hospitals use three levels, emergent (first priority) urgent (second priority) and non-urgent (lowest priority.) Most use a four level system to identify the sicker urgent patients sooner. Based on the services available, the ED nurse may use five triage categories.

The legal nurse consultant involved in an emergency department medical malpractice case may advise the attorney to ask for the hospital's triage policy and triage guidelines used in the ED. Ask for the policy regarding the qualifications of the triage nurse and compare with the credentials of the nurse who performed the triage.

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