How does this work ? (A&E question)

[JadeJewellery]

Just want to start off by saying I’m NOT criticising the treatment I had nor am I criticising the staff. I’m just curious of how it works thats all!

It happened 2 months ago but just sort of wondering now since I’m feeling better and reflecting on it all. I’m in England if that makes a difference.

i was in a&e recently with what was potentially quite serious. I have multiple conditions, knew it was my heart and told them at reception. I was violently vomiting, could barely stand up, and I just had this feeling that I was going to die in the waiting area. My heart felt completely wrong and I knew something was very bad. It turned out I was correct- I was in 3rd degree block and my heart was barely in the 20s.

The treatment I had was brilliant, but it took so long to be seen for triage. I was in the waiting area for around an hour and a half and they were taking people in order of who arrived first rather than severity. There were multiple people going in for things which were definitely not life threatening eg a sore finger from 3 weeks ago (and it wasn’t that they were going in for minor injuries, it was all A&e) and even they themselves were saying to reception that I should be seen quicker because I was visibly so unwell in the waiting area but the staff kept saying I’ll be seen when I’m seen and i basically had to wait my turn

maybe im completely wrong, but i thought people were seen in order of severity rather than order they arrived? Or is that only the case after triage?

i know I sound a bit melodramatic about it all but I was just so frightened because I seriously thought I was about to die in the waiting area. I felt dreadful- they said the vomitting was because my blood pressure was falling so low and my body was struggling to keep going because I’d been in the block for so long. It was just frightening realising how many people were in front of me and I assumed (probably wrongly) that you’d be taken immediately if something was wrong with your heart?

but yeah not criticising staff they were brilliant! Just wondering about if that wait is normal that’s all

Triage is seen in order but when I was an A&E receptionist we would alert the triage nurse to anyone with chest pains as soon as we'd booked them in. Ditto anyone else we were worried about. The nurse would see them next.

Glad you are sorted now but when people book into A&E they can literally list any reason so that finger injury may well have booked in as chest pain or something unrelated. Equally you may have been listed as presenting with vomiting. I will also say that just because people look ok that actually they may not be. 90% of people attending will state they feel like they are dying, at work I hear it on a constant loop, everybody wants triaging first and want to be seen by a dr straight away. I’m an experienced ED nurse and as much as we try to stick to the 15min target for triage it rarely happens now as the arrivals come through thick and fast and book in a lot quicker than the triage process takes hence the bottleneck. Triage is the process of sorting and prioritising so it would make sense no one can prioritise accurately until the triage is complete.

And you move on and read as well, op has kindly clarified 🙄

When I took my daughter a while ago, there were signs up advising people that patients were seen in order of urgency, not order of arrival and not to go to the desk to complain/query if you see this happen. Maybe different hospitals function differently, but I would have thought that this would have been the norm?

Incidentally we sat there that day and waited, and waited, and waited.....we saw people come and go. Then someone came across and asked if we'd been to xray yet. No, we hadn't. Oops, they said. We thought you had! We'd been forgotten 🙄

@gototogothis is not true. 111 do not alert ED to your pending arrival nor do they send over notes. They pretty much tell everyone to attend ED within the hour. I can vouch for this as both experienced ED nurse and as a patient/relative. you do not jump any queue because you called 111 first. Same as if you arrive by ambulance, you are still seen in order of priority by how sick you are. If you arrive by ambulance but can sit in the waiting room then you will go through the triage process via the waiting room.

Yes, it was nice of her to clarify what was already obvious for you.

And move on….

In my experience it often speeds things up if you can tell them specifics. I have a family member with chronic issues which put them at higher risk of sepsis and when we need A&E I do basic obs and lead with those. E.g. to reception "he has a 40.1 degree temperature, his heart rate is 162bpm at rest and his oxygen saturation is 86%, we are worried this is sepsis". We keep blood pressure monitor, thermoter and pulse oximeter handy for this purpose.

@socksandshoosI get what point you are making but even with this complaint how do you propose this could be changed? Triage is the point where the team find out more about why you are in ED, receptionists are not qualified to decide how gets triaged first. For instance, an abdo pain can actually be a heart attack and someone with dizziness can be having a stroke. The headache can be a brain bleed and a low blood pressure can be a dissecting aorta which requires immediate lifesaving surgery (within minutes). The elderly who tend to sit quietly and not make a fuss can be seriously unwell. Experience states younger people shout the loudest for the smallest of things. People do not always present as text book cases. Staff are doing their best in a completely broken NHS although soon it’ll be private!

I used to work in A&E, and this is how it worked.

Unless someone arrived via a crash call (usually something very serious like a major car accident or cardiac arrest) everyone checked in at reception. When I worked there, it was a receptionist rather than a nurse. Patients where then triaged quickly by a nurse. Triage usually included things like observations, history taking, bloods/heart ECG if necessary. They were then streamed into three categories:

1. “Exam” / Minor injuries - things like sports injuries, suspected fractures, minor wounds, etc. these people were the ‘least sick’ in the department.
2. Intermediate care - issues such as abdominal pain, vomiting, dizziness, and similar concerns go there.
3. ‘Majors’ was for the most serious problems like chest pain, seizures, allergic reactions, or breathing difficulties.

What people in the waiting room often don’t realise is that after triage, patients are placed into one of these three streams. They are then seen based on both clinical priority and how busy that specific area is. If at triage, someone’s observations show they are safe to wait, they will be sent back out to the waiting room, this is usually because there’s no space in that area. If someone’s observations are not safe, they should be taken into the department regardless of space - often on a trolley in a corridor with monitoring. The sections function separately, so you might see someone go through to minor injuries while others are still waiting, that doesn’t mean they’ve ‘skipped the queue’ it’s just that they’re in a different stream (there are different staff members in these areas so they don’t ’share staff’ so to speak) You also may not realise that someone who looks like they’ve just walked in the door may have been triaged 3 hours before and were just getting called back in to be treated.

So yes, patients are absolutely seen and prioritised based on clinical need, but waiting times also depend on how many patients are being treated in that particular section. Someone above made a really good point, if clinical judgement wasn’t made and staff just listened to how sick people claimed to be it would be absolute chaos. I’m sorry you had to go through that! If you had presented only with nausea and vomiting they likely would have initially triaged you to intermediate care and sadly found your heart issue later… these things unfortunately happen. So many conditions present awkwardly, for example some of the patients with the worst headaches I’ve ever seen… have simply had migraines. Some of the sickest patients I’ve seen have walked through the door quite the thing…with a heart rate of 200!! It’s very hard to initially tell with presenting symptoms sometimes.

Hope that clears things up!

I see what you mean- that makes complete sense. I think the frustrating thing was we made it really clear it was my heart- I’ve had problems in the past and knew it was my heart again. My partner told them my history. The vomiting was secondary to it and actually a sign my body wasn’t coping with it. But I think you’re correct- I think they mistook my symptoms to just be nausea/vomiting. These things happen, it’s nobody’s fault. And it all turned out fine since I’m here posting this! Lol.

I once had an elderly patient who came in following a fall. His main concern was a foot injury, transpired he later admitted to having hip pain. Turns out he had a fractured neck of femur and had been walking round for two weeks post fall. You never can tell. We now have a nurse at the entrance to ask key probing questions and will do a set of obs if clinically needed right there and then. If found to be sick or look particularly sick they will ask triage to make a priority however this only works if the majority coming through are well enough to wait their turn. I have had shifts where it’s been endless queues of sick people who all need prioritising and escalating but then the problem is that not everyone can be triaged or seen straight away. Someone has to wait. No ED nurse wants to risk patients collapsing or dying in the waiting room, we are constrained by the system and resources provided.

Were you not triaged? I’ve been in A&E twice in the last two years or so - both after loss of consciousness episodes - first one my DH took me in - I was hooked up to an ecg within 5 minutes of arrival but then the wait was interminable (I was having focal seizures - all lead to an epilepsy diagnosis). I would’ve thought if you were vomiting and in severe distress they’d see you quickly but maybe that’s just in Casualty.
Second time I was brought in by ambulance because I was injured, so it was different, but 100% you get seen quicker even though the crew denied this! I was on a bed in the assessment area within 15 mins or so of arrival then I went to majors.

how could the staff have been brilliant if you had to wait so long ? i’m so sorry this happened to you and i’m sure someone could have been kinder to you. o don’t believe all nurses and doctors are ‘angels’ and when necessary we need to call this out.

Ah I see. In that case yes maybe there was a bit of a miscommunication between reception and triage nurse. Anything heart related they really should take seriously/quickly! Yes thank goodness you are here to tell the tale!

This is the core point. In your case you thought you were very ill and you were right but many people who think they are very ill are wrong. A feeling of impending doom is also a cardinal symptom of a panic attack. Vomiting and looking ill and sweaty could easily be alcohol withdrawal. Some people sitting quietly are in fact very ill. Until triage no one really knows.

The key is that the triage really needs to happen within those first 15 mins or the risk remains unaddressed. It was the overwhelmed triage queue that was the problem not the order of being seen. The only way that I know of to jump the queue is if the ambulance crew call ahead for a patient to go straight to majors.

I agree. I can imagine there are people possibly drunk etc who are very loud and would seem quite unwell but actually are not, and then they would be seen ahead of quietly deteriorating people which wouldn’t be fair.

ultimately as unwell as I was, and as miserable as it was, I clearly could wait (because I did) but it just felt so frightening in the moment because it felt like no matter what happened or how unwell anyone was, it was going to be a lengthy wait to be seen

Ironically, they initially thought I was having a panic attack until they saw my heart take a big 6 second pause on the screen and then they did the ecg and saw the block. Thankfully they did!

Actually in some hospitals where there is an interface between the 111 IT system and the ED system, a pre arrival for the patient does appear automatically on the ED system, with a document attached which contains details of what 111 recorded on their system (I work in NHS IT and have tested this functionality).

Agree. I skipped triage. The paramedics said they liked patients like me because they could take me straight through to resus instead of hanging around for hours. It was only then I realised just how ill I was.

Patients bought into ED by ambulance are triaged at handover from the ambulance crew, so in essence they "miss" the triage that walk-in patients get but they are actually still triaged. What they don't necessarily miss is a wait, after triage, to see medics.

DD2 has skipped the triage queue twice, but both have been triggered by medical staff, not reception (who is not a senior nurse or similar at our local hospital). Once she was brought in by ambulance, waiting in a corridor with the paramedics, senior paramedic suddenly said 'triage now, she can't wait', and triage sent us straight to resus. The second was more happenstance, I checked in a one year old with hives and swelling, the paed on duty had his door open, heard the check in, and pulled her in.

If a place is generally triaging within 15 minutes, seen in order is probably fine for all but the 'straight to majors' patients. I think it gets tricky when the time stretches out, because it's hard to reliably identify who needs to be triaged faster and who can wait an hour for their first observations.

That's awful, OP, I'm glad you got through it.

It just sounds so overwhelmed and poor patient care as a result. When MIL went to a and e with v worrying symptoms, she was seen very fast at triage and then they brought her straight through. Which is how it should be...but if they are completely overwhelmed can't always happen.

An 90 minute wait for triage is very poor.

I'm a paramedic, absolutely would have pre-alerted into resus so once you're at hospital you'd be seen straight away with 3rd block/hr20.
Difficulty is that from calling 999 she would have likely coded cat2. I've just responded to a cat2 call that was nearly 4 hrs old (47yr male chest pain sob). He didn't get a pre-alert and ECG was normal so just went in the regular waiting room as if he'd made own way. It's a tricky one, you don't really know how long an ambulance will take anymore and several hours is fairly normal.

Personally I'd make my own way if I was well enough, if I thought I was having a life threatening emergency I wouldn't risk waiting for an ambulance.

Getting this less and less now - most of our patients are dropped off without handover now- result of all the coverage of ambulances queuing for hours outside! Currently in our area anyone walking and talking is straight to waiting room no handover. If they're unwell on a stretcher we can only wait 45minutes to give a handover - any longer and PT is transferred to hospital trolley/chair without a handover and there are no exceptions to this - can be ?meningitis/sepsis, can have severe dementia no idea where you are - we have to leave.

It's only running in certain areas and it's a band aid to stop response times ticking upto 10hrs average (in real terms, the averages are reported lower since every time someone calls back on 999 to ask where the ambulance is the clock can be reset and response time looks better...)

@richardmarxisinnocentthis is not the case in the West Midlands and there are no plans to introduce such a system.