Advice from Triage Nurses on Early Health Warning Signs for Adults

In July, we presented data from our nurse triage call center evaluating the disposition given to adult callers when they called a nurse triage line (read original). Surprisingly, we found that 1 in every 3 adults who called a nurse line presented such serious symptoms that they required urgent care, as illustrated in Graph 1. In this article, we expand the study by explaining why the symptoms are serious. You can download these tips to give to your patients.

All patients should feel comfortable and unburdened to call a triage nurse with any health concerns. The more informed the patient is about how to call the nurse triage line, the less the likelihood that the patient will wait too long and end up being sent to the emergency room. Using the Schmitt-Thompson Protocols, a nurse will be able to assess the symptoms and determine the care needed.

Disposition given by Triage Nurses to 9,200 Patients

Graph 1: Data from our Call Center for April, May and June 2016

0 to 16 Weeks Disposition


TOP 5 reasons ADULTS are sent to the ER by a Triage Nurse

There are many elements that a triage nurse must take into consideration when choosing whether the emergency room is the most appropriate place for that patient. Each patient should be viewed as an individual and all risk factors, such as age, chronic illnesses, recent surgeries, medications, and lifestyle should be considered. Influences like age, culture, and economic factors may keep patients from calling a triage nurse until symptoms have progressed to the severe stage. In Graph 1, we listed the top 5 reasons an adult was sent to the ER by a triage nurse. Below, we go into detail why those symptoms are serious and early warning signs, as well as attached a leaflet with the information that can be given to patients.

1. Chest Pain: Chest pain is a symptom that can range from benign, or very mild, to a life-threatening cause. When a triage nurse hears the patient say they have chest pain, she will first rule out the “ABC’s”- making sure the patient is not having problems with their “Airway, Breathing or Circulation.” Using the protocols, a triage nurse will direct a patient to the ER if any of the following symptoms are present :

  • Pain radiating to arm, shoulder or jaw
  • Pain lasting more than 5 minutes and feels like crushing, pressure, or heavy
  • Chest pain not relieved by nitroglycerin (call 911)
  • Major surgery in last month

2. Abdominal Pain – Female: There can be many causes of abdominal pain in females. The triage nurse must be extremely cautious and thorough when obtaining the patient’s assessment. Abdominal pain is a very common symptom and can be related to something as simple as overeating to something life-threatening such as a ruptured abdominal aortic aneurysm. The location of the pain may give the nurse an indication of what could be causing the symptom(s.) For example, pain in the right upper quadrant may be associated with the liver or gallbladder, while pain in the right lower quadrant may be coming from the appendix, ovary or kidney. The following symptoms may require a trip to the ER :

  • Severe pain at an 8, 9, 10 on a scale of 1-10 and over the age of 60
  • Severe, excruciating pain and present more than one hour
  • Abdominal pain with vomiting that contains red blood or material appearing like coffee grounds
  • Black or tarry bowel movements

3. Back Pain Adult: Over 80 percent of people experience lower back pain at some point in their lives. Luckily, most back pain is not serious and will subside within a few months. However, it could be as serious as an aortic aneurysm, compression fracture, kidney stones, or nerve root impingement. Because it is so common and so many people experience back pain, the nurse should take extra time to determine the cause and severity of the pain. Below are some symptoms that would lead to the ER :

  • Severe, excruciating pain, sudden onset, and age over the age of 60
  • Back pain with urinary or bowel incontinence, new onset
  • Severe pain that is not relieved two hours after pain medicine is given

4. Breathing Difficulty: While it is always alarming to hear a patient that is short of breath or wheezing, the triage nurse must remember to remain calm; sometimes this can be the patient’s normal breathing pattern. The triage nurse must determine the severity of the patient’s breathing and ask, what is their baseline and how is tonight different. If any of the following incidences are relevant for the patient, the nurse will direct them to the ER :

  • Moderate shortness of breath, new onset and/or worse than normal
  • Accompanied with symptoms such as chest pain, extreme and unexplained fatigue
  • Co-morbidities, such as COPD, CHF, and breathing is worse than normal
  • History of blood clots in legs or lungs, or symptoms that would put the patient at risk for blood clots such as recent illness requiring prolonged bed rest, recent major surgery, recent long-distance travel by car or plane where patient sat for long period of time
  • Bleeding or clotting issues
  • Associated with irregular heart rate/heartbeat

5. Post-Op: Patients calling with post-op concerns can vary from anesthetic reactions, such as nausea, vomiting or drowsiness, to blood clots or bleeding, constipation, or more serious issues such as infections and dehiscence (opening of the incision). Symptoms that would alert the nurse that the patient needed to be seen in an emergency room might include:

  • Bleeding from the incision that won’t stop after attempting home care advice
  • Fever and incision looks infected and the office does not open in 4 hours
  • Severe pain in the incision, an 8, 9, or 10 on a scale of 1-10
  • Widespread bright red sunburn-like rash

If medical facilities implement proper education in the office and access to high-quality nurse triage or another form of telemedicine after-hours, patients are able to access a trained medical professional and get directed to the appropriate level of care. In addition, providing a triage nurse line when the office is closed allows the patients to stay with their providers and receive continuity of care at any time.

Did you find this article helpful? You can download tips for your patients from our triage nurses here.