Consider this situation: A detainee admitted two days ago was complaining of nausea and vomiting at 3 am. An officer called the medical unit requesting a nurse evaluation. The nurse, however, was busy getting meds ready for the 5 am court call. The officer called several times over the next 3 hours, and the nurse finally arrived at the housing unit at 6 am to assess the inmate. He was pale and diaphoretic and stated he also had been having chest pain over the last three hours. Vital signs are measured manually and include blood pressure: 90/60; heart rate: 120 beats per minute; respirations 30 breaths per minute; and oxygen saturation level of 92%. What should happen next?

Obviously, this inmate is in need of a higher level of care than can be provided at the facility. His vital signs are unstable. This situation is an example of the conflicting priorities that face many correctional nurses. While preparation for medication administration is important, assessing this inmate earlier may have significantly affected his deterioration and ultimate hospitalization. Using a rapid assessment and triage process could have helped this nurse to evaluate and treat this patient quickly, allowing both priorities to be met.

What is Rapid Assessment?

The rapid response process was developed in hospitals to positively affect patient care and outcomes. More than 15 years ago (2004) the Institute for Healthcare Improvement (IHI) began encouraging American hospitals to implement rapid response teams.  IHI found that nurses were failing to observe subtle changes in patient conditions.  The failed recognition led to poor outcomes and was identified as a “failure to rescue.”  Today a “rapid response” may be called based upon recognition of a patient’s changing condition or just having signs or symptoms consistent with a life threatening or other serious condition (confusion, tachycardia, tachypnea, fall and others).

Frequently correctional nurses practice with few other health care staff present. We must “keep an eye on” the health of many inmates. The rapid assessment process can help to identify patients needing immediate attention.

The RApid ASSESSMENT PROCESS

Basically, the rapid assessment process involves systematically implementing a uniform response to emergencies or unexpected events. The event or incident frequently takes healthcare staff out of their comfort zone and having a systematic planned response that can be used in most situations facilitates efficient and appropriate patient evaluation.   It may require that the normal routine stop or be delayed because of the need to respond, but responding is a priority.  It can range from a fall to an acute asthma attack or to an entire group of individuals that suddenly develop diarrhea. Rapid assessment encourages initiating nursing interventions based on a physical assessment of the patient or the situation.  It requires physical assessment skills and clinical decision-making.  It involves independent nursing interventions and creative thought (applying oxygen, obtaining an EKG, checking the blood sugar, administering nebulizer treatment), analyzing what is the best next step for the patient, and consulting with a Provider as the situation requires.

Pitfalls to Avoid

There are three common problems that can arise when assessing a potentially changing patient’s condition. Keep these in mind when managing emergency patients.

• Breakdown in communication: Communication is always a challenge in correctional health care. Frequently, a correctional officer first responds to a request for an urgent health evaluation. Thus, the patient must convince or convey a clear message that medical help is needed. Communication may not be clear or the officer may be distracted by other tasks. Once contacted, the nurse may need to prioritize his/her/their current workload to assess the patient; as in the situation described in the introduction of this post. Once completed, this assessment may need to be communicated to a medical practitioner. Communication can break down at any point in the process.
• Failure to recognize early signs of deterioration: Talking through bars and assessing the patient by looking briefly as he/she/they sit on the bed is not an adequate assessment. We know that in the correctional environment, sometimes it is difficult to make arrangements for a thorough assessment, but it is the nurse’s responsibility and obligation to the patient to do so. When an inadequate assessment is done, the signs of deterioration in condition can be missed. In settings where infirmary or observation cells are available, patients determined to need closer or more frequent monitoring can be moved to a location that facilitates this very important health need.
• Incomplete assessments: Distractions and physical barriers can lead to incomplete assessments, as can focusing on one area to the exclusion of others. This is called Anchoring. Because the patient in the situation described above was complaining of nausea and vomiting, a thorough assessment would have included abdominal, neurologic and cardiac evaluations (in addition to the usual basic evaluation).

Developing SkilL with Rapid Assessment

The best way to develop any skill is to practice, and Rapid Assessment is no exception. Training can be scenario based, or it can be a debriefing after a Rapid Response. Staff who respond to emergencies should have additional education in physical assessment, and the training should include review and practice, and require an appropriate return demonstration before the staff member can function as a rapid responder. Excellent assessment skills are important in the care of all of our patients, but especially those whose conditions are evolving and include subtle symptom changes. The nurse’s responsibility is to identify these abnormal or unexpected findings and bring them to the attention of a provider, who ultimately has to determine the treatment plan for that patient, and providing independent nursing interventions. It is a team effort!

Have you been involved in a situation requiring rapid assessment and response? Share your experience with us in the Comments section below.