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Triage—Evaluating and Prioritizing Patient Emergencies

By Julie Harp CPOT, ABO, NCLE

Release Date:

October 1, 2005

Expiration Date:

July 31, 2010

Learning Objectives:

  1. Describe the three levels of triage.
  2. Explain the process of screening and triage of patient complaints over the phone.
  3. List which priority cases should be seen within several days of their initial complaint.

Faculty/Editorial Board:

Julie Harp is a graduate of the Indiana University Optometric Technologies program. She manages the contact lens clinic at the IU Optometry School and teaches in the technician program. Current certifications include: CPOT,ABO, and NCLE.

Credit Statement:

This course is approved for one (1) hour of CE credit by the National Contact Lens Examiners Education Committee (NCLE). Course #: CWJP002-1
Please check with your state licensing board to see if this approval counts toward your CE requirement for relicensure.
This CE course is an abbreviated version of the complete article available from Transitions Optical.

In many optometric circles “red eye” has become a generic term applied to any of a wide variety of ocular emergencies. Symptoms can range from mild dryness to severe pain and lead to diagnosis from simple allergies to irreparable loss of ocular function. As varied as these eye complaints can be, the same holds true for how each patient chooses to attend to their particular situation. Some may beat your door down over a change in prescription, while others are content to wait despite devastating consequences. It is the responsibility of the technician to be vigilant, especially for those who may not adequately convey their needs. Communication breakdowns can occur at any level for a variety of reasons. It is important therefore, to maintain an investigative mindset. The patient will rarely understand the complete scope of what is wrong with them. Technicians must endeavor to educate and convey this information in a manner that will promote compliance. Evaluating and prioritizing patient emergencies according to the level of urgency is known as “triage.”

The three levels of triage can be described as follows:
The Emergent or Immediate Case: Needs to be seen within the hour.
The Urgent Case: Needs to be seen the same day.
The Priority Case: Needs to be seen within days.

THE EMERGENT CASE

The true emergencies are thankfully the rarest, including those situations where permanent vision loss is immanent danger. Among this category are:

  • Chemical burns
  • Retinal artery or vein occlusion
  • Penetrating injuries
  • Sudden vision loss

Sudden monocular vision loss without pain is most commonly diagnosed as an occluded blood vessel or a massive retinal detachment.
In a central retinal artery occlusion treatment must be initiated within 15 minutes or permanent vision loss will occur. If left untreated for longer than one hour blindness usually results. For this reason, perhaps more than any other, sudden vision loss should be treated as the greatest of emergencies. While the diagnosis could alternatively be a vitreous hemorrhage or retinal vein thrombosis, this symptom must always be treated as if it were a worst case scenario. One person’s vision saved, after all, is well worth the nine others who rushed in to less climactic ends.
Retinal detachments represent an immediate threat to the eye sight as well. They can be sudden and massive as a result of trauma to the head or slower and more insidious in their progression. When the retina pulls away from the inside surface of the eye the patient may report symptoms such as flashes of light, sudden increase in floaters or a curtain/veil over the vision. These symptoms, especially if reported together should be treated with greatest urgency.
Chemicals, especially ones with high or low ph, can cause sudden and devastating injury to the eye. In this situation the longer the substance is in contact with the eye the worse the resultant damage. The best treatment that can occur here is one initiated by the patients themselves. Irrigating the eye for 20 minutes immediately following exposure will go a long way toward halting the progression of the burn. Since length of exposure time will greatly affect the extent of the tissue damage it is of critical importance to irrigate quickly and thoroughly. Any patient reporting exposure to chemicals should then be instructed to bring the container along with the material safety data sheet if they are at work. As with the other true emergencies, these patients are not to be kept waiting. Treatment must be initiated immediately upon their arrival at the clinic.
Ocular trauma must also be considered at the highest level. While not all injuries produce permanent effects, most produce significant pain and rupture of the globe cannot be dismissed over the phone. The most common eye injury occurs as a result of foreign bodies. Everyone at some point manages to get something in their eye. Most of the time tearing and blinking reflexes manage to remove the particle before it causes any damage. It is when this system fails that emergency measures must be taken. Whether it is dust in the eye or any other environmental insult, triage of ocular trauma is relatively simple. The patient can usually relate to the technician a specific event contributing to the current symptoms and must instructed to come in as soon as possible.

Pterygium

THE URGENT CASE

The urgent cases should be seen the same day or no later than the next. The actual red eyes fall into this category along with:

  • Swollen lids
  • Double vision
  • Drooping lids
  • Halos
  • Photophobia

Any monocular patient with vision complaints should be considered an urgent case as well. Every effort must be made to maintain the sight in this patients’ good eye.
Red eyes are most commonly diagnosed as viral or bacterial conjunctivitis. Symptoms include: tearing, discharge, itching, burning, photophobia,halos and blurred vision. If the patient wears contact lenses, red eyes and blurred vision can result from sleeping in or over wearing lenses. Such a patient complaining of terrible pain may also have a corneal tear. Dehydration can cause the lens to adhere to the corneal epithelium and tear it away upon removal. This individual may present with the inability to open the affected eye. Seeing halos around lights is frequently associated with the previously mentioned conditions. Mucous deposits forming on the surface of the cornea will split up light rays in much the same manner as a rainbow after a storm. Cataracts or cysts in the lens can cause this symptom as well but it is perhaps of greatest significance as a warning sign of impending acute angle closure glaucoma.
Acute angle closure glaucoma can be easily diagnosed. Onset occurs within an hour and has a fairly unique sequence of symptoms. Attacks are usually precipitated by some environmental stimulus that resulted in pupil dilation. Strong emotional states, darkness and certain medications are the most common triggers. Many allergy medications contain epinephrine- related ingredients that are contraindicated for glaucoma suspects. This patient may report a feeling of pressure or discomfort around the eye in mild cases. The more severe cases might include severe, incapacitating pain, nausea, vomiting and light perception visual acuity. They will present in the office with dilated pupils that do not respond to light. If a patient calls the office reporting the latter symptoms it should be treated as an emergency and treated as soon as possible. The former should be seen the same day, preferably within a couple hours. Symptoms like double vision and lid drooping indicate a muscle weakness. They must be treated with urgency because they occur as a result of systemic conditions. Disease of the brain, muscle nerves or muscles themselves can manifest in this manner. The patient presenting with complaints of double vision or lid drooping could possibly be facing a diagnosis as serious as: Myasthenia gravis, brain tumor, aneurysm or even stroke. Lid swelling can be the result of an infection of the sweat or oil glands in the lid margins, an insect bite or an allergic reaction. In any case, patients may tend to over react to this condition because of its disfiguring nature. In reality this is something that needs to be tended the same or next day but it’s hardly the dire emergency that might be proposed. In many cases the swelling resolves itself with little to no formal treatment.

THE PRIORITY CASE

The priority cases should be seen within several days of their initial complaint. These include:

  • Slow onset blurring of vision. This is usually a prescription change. It is important however to make sure that there are no other accompanying symptoms.
  • Seasonal allergy complaints. Some of these patients will call to request a refill on a previous medication prescription. They will often have a history of such occurrences and can occasionally be assisted without a visit.
  • Red eyes associated with contact lens wear. Always make sure the patient understands they are not to wear their contacts until they come in for their visit. The lens could be damaged or fitting improperly. Wearing it could cause the cornea to be compromised.
  • Lost contact or glasses.
  • Ocular migraines and headaches.

Ocular migraines are not a true emergency. They often involve symptoms such as flashes of light and other visual disturbances though, so it is difficult to distinguish them from retinal detachments. As always, it is safer to err on the side of caution. Even if the patient states that a headache followed the episode, it is well advised that they be seen as an emergency. Headaches are rarely ocular in origin. Most commonly they are associated with surrounding structures such as the sinuses or the teeth. They can also occur as a result of stress, tension and diseases such as hypertension and brain tumor. Ocular headaches are frequently the result of extended sessions of intense visual concentration. They can occur anywhere in the brain and should be suspected in individuals who have had a recent increase in visual demands. This type of headache is usually relieved by rest and is not associated with any other symptoms. Patients with complaints that fall into the priority category must often be treated with a certain degree of diplomacy. Prescription changes and lost glasses may certainly incapacitate someone, especially a high myope. Their problems are static though, as easily corrected tomorrow or the next day as they would be today. It is important to accommodate them to the best of the clinics’ ability but there are any numbers of ocular emergencies that must take precedence. The same holds true for the contact lens wearer that is experiencing irritation when wearing their lenses. Unfortunately they cannot wear lenses pending an appointment. The situation is controlled though, as long as the patient complies with instructions.

ON THE PHONE

The screen and triage of patient complaints over the phone can be a daunting task, to say the least. In a matter of a minute or two a patient must be interviewed, their symptoms reviewed and the correct level of urgency gauged. Consider for a moment the idea that 20 patients might call with the same problem, yet no two of them describe their symptoms in the same words. The true nature of such difficulty becomes apparent. How then can it be possible to accurately screen every person that calls? The answer is clearly that it isn’t. Even with all of the doctor’s knowledge it would be impossible to diagnose red eyes over the phone.

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Though the patient may want and even expect this when their time is short, nothing is sure until they are sitting in the chair. All things being considered, it is not surprising that most techs are reluctant to turn people away. This is as it should be. It is in this mindset that most healthcare professionals tend to focus on individual symptoms rather than the whole picture. If a patient is having flashes of light, for example, most of the time the diagnosis is ocular migraine. It is more often than not, though, treated as if it were a retinal detachment. Why? The office can’t be a 100 percent sure of the reason without the doctor taking a look inside the eye. No one can be blamed for being over cautious. We are talking about the possibility of saving someone’s vision. Many optometric and contact lens practices have an established protocol for handling triage calls. The first and most important thing to keep in mind is how the patient perceives their symptoms. Despite the reality of where each case falls in the levels of urgency, the patient is experiencing an emergency situation. They would not be calling otherwise. A little sympathy goes a long way toward inspiring patience in one who may be faced with wait- ing for that prescription check. Alternatively, a measure of firmness might be appropriate for bringing in that patient who hasn’t realized the true severity of their symptoms. The caller suspected of retinal detachment, for example, should be discouraged from waiting until after an approaching exam to come in. The best way to accomplish this is to present the possible consequences. Don’t be scary, just be truthful. Present all the possibilities and why compliance is important. Such a conversation might go as follows: “We realize that you have a busy schedule right now but we need to strongly recommend that you come in as soon as possible. Your symptoms may be nothing more than an ocular migraine but they could also be something much more serious called a retinal detachment. This condition requires immediate intervention to prevent permanent vision loss. Since it is impossible to tell for sure the difference between these two conditions over the phone, we urge you to come in now to be evaluated.” If the patient still resists complying with requests to come in immediately it is always wise to call the doctor to the phone. Sometimes a patient will heed advice more readily when it comes from the doctor.

During the phone interview with the patient the technician should establish a detailed picture of the situation. As each question is answered it will assist in steering the tech toward the appropriate conclusion. Always keep in mind that not everyone will even volunteer they have a problem. They just call wanting an appointment, preferring it be sooner than later. Anyone scheduling a routine exam that is impatient to get in should be screened for possible emergency situations. It is as simple as asking if there is a reason why they need to be seen quickly. So what are the questions that need to be asked?
Pinguecula

The best place to start is by asking an open ended question such as: What symptoms are you having today? Most patients will happily volunteer enough information to form a basic conclusion. If they began the exchange with a specific complaint ask if they’re having any other symptoms. The primary complaint may not always be the one with the red flag attached. Furthermore, even if they deny the presence of other symptoms it is important to continue on. What the patient thinks qualifies as a symptom may not match the technicians’ list. Following are listed some of the more important questions to be asked. Remember, in answering the phone it is important not to sound like any type of diagnosis or treatment is suggested. The goal is to assess the seriousness and whether they need to be seen now, today, or this week.

  • What is the chief complaint or problem?
  • When did the problem start or how did it happen?
  • Is the problem in just one eye or both? Then ask some more specific questions to best assess action.
  • Are there any flashes of light, floaters or what might appear as a curtain or shade over the vision?
  • Was it a sudden or gradual onset?
  • Has there been vision loss or change?
  • Is it constant or intermittent in manifestation? If intermittent, how often?
  • Rate the severity of discomfort on a scale of 0 to 10.
  • Does the problem seem stable or is it getting better/worse?
  • Have you attempted self treatment? If yes, please describe.
  • Is the discomfort severe enough to describe it as pain?
  • Is there any redness?
  • Is there light sensitivity?
  • Do you have any discharge, debris or matting of the lashes?

CONCLUSION

It is not necessary or appropriate for the technician to be able to diagnose the patient at first contact though it may seem like that is what is being demanded. Remember there are two simple rules that will help facilitate the triage process.

  • Red Flags. Red flags preclude further questioning. If you encounter complaints of flashes, sudden appearance of lots of floaters, sudden vision loss, chemical contact or trauma there is no need to proceed with further questioning. They need to be seen as soon as possible. This patient is top priority regardless of other symptoms.
  • Communication. Always suspect there is something the patient has not volunteered in the initial exchange. Never assume they have told you everything.

Remember that it is the technician’s job to facilitate communication. The patient usually does not know what is important any more than they know how to fix it. Keeping this always in mind proceed with great patience and care. One grateful patient whose vision has been saved is well worth the effort.

Photos courtesy, Charlie Goldberg M.D., Univ. of California, San Diego School of Medicine, medicine.ucsd.edu


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