Preparing your team for patient emergencies: How it takes a team to triage effectively and efficiently

Emergencies happen every day and at any given time. As primary care practitioners, our days are often occupied with preventive care appointments, scheduled surgeries and minor to moderate illness. True emergency cases are rare but can be a significant challenge when they arrive during already fully booked and hectic days. Unfortunately, some of these cases are not recognized immediately as emergencies upon arrival or during the initial phone call (if a call occurred), which can result in worsening or loss of a patient. Even if properly identified as an emergency, if teams aren’t properly prepared on how to handle them, efficiency in managing a successful outcome as well as the rest of the day is compromised.

The call

Identifying an emergency

Early identification is one of the most important parts of successfully managing emergency patients. The sooner the better; delay in recognition can result in worsening of the patient and even prove fatal in moderate to severe cases.

Some calls are easily identified as a true emergency:

• Hit by a car (HBC)
• Snakebite
• Attacked by an animal
• Drowning
• Housefire
• Abnormal/trouble breathing
• Blue tongue or gums (cyanosis)
• Very pale, white, or gray mucous membrane
• Fall from a height
• Seizures
• Collapse
• Toxin ingestion

Others are not as clearly defined. Use of a telephone triage sheet (Figure 1), often employed at emergency room facilities, can help teams focus on the right questions to ask clients. To best accomplish this, you would also need to create a list of “red flag” statements from pet owners that may indicate a severe problem.

As your team interacts with the pet owner, they should be actively listening for these red flags that would indicate an emergency exists. For example, the pet owner may say their pet:

• Keeps trying to defecate or urinate
• Is pacing and coughing or trying to vomit
• Is not breathing right or breathing abnormally
• Is falling over or can’t get up
• Has a larger belly or their belly hurts
• Has very red gums

Because of the inability to directly evaluate the patient via phone call, lack of medical training for our front staff, and unreliability of pet owner observations, we need to limit our classification of calls to immediate, same day, and scheduled. These are not medical classifications but rather designed to help our front staff and technicians decide how quickly these patients should be seen. It also acts as a guide, where appropriate and available, to decide when it’s more appropriate to refer directly to a local emergency or specialty hospital. The first step is to define with your teams (local specialists or ER can help) what are clear IMMEDIATE, SAME DAY, and/or SCHEDULED emergencies. Generate a list of conditions, laminate, and keep near all phones.

Call classifications

Immediate

When the patient is in crisis, delay in treatment could significantly worsen the condition, impair ability to treat (severe lacerations), result in infection (wounds), or lead to death, or there is any doubt in severity of condition. All eye injuries and blunt force trauma cases should be considered an immediate emergency regardless of how good or bad the patient looks. The patient should come in immediately or go to the closest ER.

Immediate Triage Situations

• Respiratory and cardiac distress, saddle thrombus, asthma, smoke inhalation
• DOA trauma
• HBCs (ALWAYS, no matter how stable they may appear)
• Injuries-actively bleeding, severe blood loss, animal attacks
• Distended abdomen - large-breed animals attempting to vomit
• Actively seizing patients
• Toxin ingestion
• Eye-related complaints
• Allergic reactions such as facial swelling, respiratory distress, upper airway stridor restless behavior, urticaria
• Straining to urinate, inability to urinate or defecate, tenesmus
• Sick kittens or puppies - young animals should never be weak or lethargic
• Acute onset of collapse, paresis or paralysis or loss of consciousness
• Elevated temperature
• Vomiting or diarrhea - especially when accompanied by anorexia, lethargy, hematochezia, melena or hematemesis
• Dystocia - actively contracting for >20 minutes or no fetus >4 hours
• Diabetic patients - +/- vomiting and anorexia

Same day

Patients who have been ill for a couple of days and appear to be worsening but are still relatively active and alert with no sudden decline. Patients with ongoing medical conditions (diabetes, Cushing’s, congestive heart failure (CHF), chronic renal failure (CRF), etc.) are at risk for acute-on-chronic illness. Delaying to the next day could result in severe crisis or infection. Fit the patient into an ER slot or any open appointment. They should not wait until the next day.

Scheduled

Nonlife-threatening, minor conditions that would not be adversely affected by a delay. The patient is acting/eating/drinking normally otherwise or slightly quieter. Examples are minor skin infections, mild to moderate lameness, sneezing, occasional vomiting, and diarrhea, etc. Schedule for the next available appointment within the next 1-3 days, but if the patient worsens then escalate to same day or immediate.

The next step is to clarify within your hospital what type of cases you are not equipped to treat and need to refer to or redirect to a local ER or specialty hospital. To help avoid confusion and better identify true emergencies it’s recommended training your staff to ask pet owners what they are seeing, not what they think the problem is. Too often we are sent in the wrong direction by a pet owner’s “diagnosis” which could lead to a delay in treatment, or inappropriate, or harmful procedures or treatments. The use of a decision tree (Figure 2) that can be kept by all phones is a useful tool to help train our team and ensure consistency in identifying emergencies.

Figure 2: Telephone Triage Decision Tree

Telephone triage

• When in doubt, always escalate to the next highest level of concern.
• Direct pet owners to bring all medications the pet is currently receiving with the pet.
• Direct pet owners to bring any/all potential toxins the pet may have ingested.
• Notify the medical team of any immediate emergencies that are on the way to the hospital/clinic.
• When possible, assign the incoming case to a specific doctor or team.
• Be prepared to reschedule or reassign appointments to other days or doctors. Communicate, communicate, communicate!
• If referring the patient to a local ER, notify the facility and send any pertinent medical records.

The emergency patient is at your hospital, now what?

Arrival at the hospital

Upon arrival at the hospital or clinic, all declared emergencies or severely sick patients should be triaged/evaluated by a technician or doctor within 90 seconds for a medical classification of severity.This will enable your medical team to immediately intervene where appropriate and develop a treatment plan for the patient.

Classification

STAT: Patient is limp and non-responsive, arrest is imminent, or presents DOA.(However, dead is not dead, yet. Teams may have a chance to revive if arrest was just prior to or upon arrival.)

Critical: Patient vital signs are unstable and not within normal limits. The patient may be severely obtunded. Indicators are unfavorable.
Serious: Patient vital signs may be unstable and not within normal limits. The patient is acutely ill. Indicators are questionable.
Stable: Patient vital signs are stable and within normal limits. Patient is conscious but may be uncomfortable. Indicators are favorable to excellent.

Questions or actions that can help identify severity and progression

• Has the pet’s status changed since calling (or since starting to come to the hospital if they didn’t call)?
• When was the pet last normal? What changed?
• Confirm previous telephone triage questions with the owner. For unannounced cases, review the triage questions.
• The triage telephone tree can be adapted to “immediate treatment” and “can be squeezed in.”

A physical exam assessment is the main determination of severity coupled with a history. For example, a clinically stable patient but ingested a very dangerous and/or rapidly absorbed toxin vs. unstable HBC. Once a full assessment has been performed, teams can then decide on the best course of action. If the decision is made to transfer a critical or serious case, stabilize prior to transfer. Unstable patients are at high risk of death during the time it takes to reach a new facility.

If true emergencies are relatively uncommon in your hospital, your teams may be unprepared to handle these cases when they do arrive. To avoid this, it’s best to have a plan in place for how to handle them. This would involve preparing your team and hospital.

Preparing your team

Plan to reassign or reschedule patients

Since our days are filled with appointments, when an emergency comes in, there can be confusion as to who will be taking the case. Often, it happens to be whoever is available at that point in time. While that can work well, it doesn’t solve for when all the doctors are actively engaged in exam rooms or performing procedures.

Designating a doctor each day to be the go-to doctor for emergencies helps provide clarity for the team on who to go to when an emergency presents itself. In these cases, it is common to have 2-3 appointment times blocked off throughout the day to account for these. If no emergencies come in, the front staff can proactively call pet owners who are waiting for a future appointment and see if they want to come in early. If an emergency does come in but not at the time blocked off, this will allow a buffer of time that will allow the doctor to catch up with delayed appointments.

Assign a daily emergency team

In addition to having a doctor assigned to be the “emergency” doctor of the day, it is also ideal to also identify and assign daily “emergency team” to support that doctor. This usually comprises 2-3 technicians and/or assistants who are familiar with the location of all the equipment and supplies in the hospital. When an emergency arrives, they are the team activated to minimize disruption of the other doctors and technicians caring for the scheduled appointments. From this team, you will want to assign one to be the triage technician for emergency patients.

Triage Protocol

Emergency patients should be assessed within 90 seconds of their arrival. A triage technician assigned at the beginning of the shift performs the initial assessment and makes the important decision to bring the patient to the treatment area or leave the patient with the owner if it's stable.

When performing a triage, technicians or doctors should always assess the standards:

• Airway and breathing
  • Normal vs. abnormal lung sounds
  • Is the patent airway obstructed?
  • Pattern, rate, and effort
  • Inspiratory or expiratory sounds
  • Is there cyanosis?
• Circulation
  • Pulse quality. Is it?
    • Normal
    • Bounding
    • Weak
    • Thready
    • Synchronous
  • MM color
  • Heart rate and rhythm
• Level of consciousness (LOC)
  • Alert and responsive
  • Obtunded or dull
  • Hyperexcitable
  • Unconscious
• Body posture
  • Are they hunched or in pain?
  • Abducted forelimbs (can indicate increased respiratory effort)
  • How is their gait?
• Obvious injuries or bleeding

If the patient has arrested, or imminent arrest is suspected, pre-assigned roles (each shift) for CPR take effect.

CPR training and role assignments

In emergency hospitals, CPR is performed relatively frequently. The teams there are comfortable, trained, and participate in refresher training frequently. A smoothly run CPR code greatly increases the chance of successful resuscitation. Conversely, a poorly run, inefficient code greatly decreases the chance of successful resuscitation, which, of course, results in death. Any delay in initiating CPR, including time spent duplicating efforts, searching for supplies, and other inefficiencies, significantly decreases the potential for a successful recovery.

If a primary care hospital rarely needs to administer CPR to a patient, teams may be uncomfortable or unfamiliar in performing CPR. Because of this, it is strongly recommended that all hospitals or clinics invest in RECOVER or other forms of CPR training (RECOVER 2.0 is coming), a crash cart, and wall charts for CPR algorithms and CPR emergency drugs.¹ Another training option is to contact your local ER facility. They may be willing to have one of their team members train your staff.

Once your staff is trained, you’ll want to have your team ready to go by assigning roles in advance and then running practice runs on a consistent schedule (monthly or quarterly).These roles can be divided up among the doctor, technicians, and/or technician assistants.

• Team leader – usually a doctor who directs the actions during CPR.
• Compressor – the individual who performs actual chest compressions. Due to the rapid onset of fatigue in this role, there should be 2-3 team members ready to rotate through this role.
• Ventilator - the individual responsible for “bagging” or ventilating the patient.
• Record keeper and timer – keeps a record of drugs administered by dose, time, and route, time of CPR, time since last drugs administered, etc.
• Equipment/medications – makes sure all monitoring equipment is connected to the patient, pulls up all medications, and places catheter(s).

Preparing your hospital

Your hospital is optimized for your day-to-day operations. Emergencies can significantly disrupt your hospital flow.Designating a dedicated emergency area for all emergencies will help minimize disruptions and improve odds of successfully managing the emergency patient. Ideally, your emergency area will be the closest and easiest to access from the lobby or entrance to the hospital. This area should always be kept fully stocked. Using the space for non-emergency patients and procedures should be avoided or minimized as much as possible.

Equipment

Crash cart

Figure 4: Tape Secured Crash Cart. (image courtesy ofJennifer Warren, Madison Lenkiewisz)

Figure 5: Crash Cart Breakaway Lock. (image courtesy of Kris Ramdass, DVM)

A fully stocked crash cart (Figure 3) should be maintained and always secured. A crash cart should never be used except in a CPR situation. This is to avoid delays in treatment during CPR due to missing or expired drugs and/or missing or non-functional equipment.

Once the crash cart is fully stocked, all equipment verified as working and charged should be secured with a piece of tape across all drawers with the date last secured and initialed by the individual who secured the cart (Figure 4). Alternatively, plastic breakaway locks (Figure 5) can be used to secure the cart.

Additional equipment

• Gurney (Figure 6)
• Multiparameter Monitor
• O2 (Figure 7)
• Fluids and pumps
• Charts

Figure 8: Gurney. (image courtesy of Jennifer Warren and Madison Lenkiewisz)

Figure 9: O2 Line with Bubbler Setup. (image courtesy of Jennifer Warren, and Madison Lenkiewisz

Emergencies don’t have to be scary! With proper preparation, training, and equipment your team can handle almost any emergency.

Coronado is a seasoned veterinarian with a passion for helping animals during critical moments. A graduate of the University of Illinois College of Veterinary Medicine, he began his career in general practice before transitioning to emergency medicine after five years. Driven by the desire to “always find a way to make it work,” Coronado has dedicated the last 25 years to building and managing specialty and emergency facilities. He currently serves as the Vice President of Emergency Medicine for Thrive Pet Healthcare.

Reference

1. RECOVER. Veterinary Emergency and Critical Care Society. Accessed May 6, 2024. https://veccs.org/product-category/recover/