Triage Bias in the Emergency Department

From “Triage Bias in Emergency Medicine: The Edith Rodriguez Tragedy” 
J. Gertsner, A. Harvey, B. Jones, B. Krasity, J. MacCallum , L. Naing, T. Pham, Victor Tseng
University of Wisconsin School of Medicine and Public Health

Please see a short presentation of this case here.
Edith Rodriguez died of a perforated bowel on May 9, 2007, after she lay untreated on the emergency room floor of Martin Luther King, Jr.-Harbor Hospital for 45 minutes.The troubled MLK-Harbor Hospital had been cited over 12 times in three years for inadequate care leading to patient injury or death and was closed in August 2007 after failing federal inspection. Rodriguez was captured on surveillance videotape writhing in pain and vomiting blood, as a janitor cleaned around her and hospital staff walked past. When hospital staff did not assist her, Rodriguez’s boyfriend, Jose Prado, called 911 in an attempt to secure medical assistance.

Rodriguez was known by hospital staff to be a drug addict and possibly homeless. Shehad been to the MLK-Harbor ER for severe abdominal pain three times in the three days prior to her death and was discharged repeatedly with a diagnosis of gallstones. When Rodriguez was brought into the ER May 9, triage nurse Linda Ruttlen said, “She’s a regular here. This is her third time here. She has already been seen and was discharged.” After a disturbance, hospital staff called the police, who arrested Rodriguez on an outstanding warrant. Rodriguez became unresponsive during her arrest and was rushed back into the ER, where she died minutes later. On June 2, 2007, Rodriguez’s death was ruled accidental. Soon after, MLK-Harbor Chief Medical Officer Robert Peeks and triage nurse Linda Ruttlen were placed on administrative leave (subsequently, both resigned). Prosecutors determined that neither the arresting police officers nor hospital staff would face criminal charges. On December 4, 2008, an official Los Angeles County assessment of the Rodriguez case inadvertently leaked to the press. The report concluded that Rodriguez could have been saved if she had been properly treated (1-8).

Triage occurs in emergency departments when multiple patients are prioritized with the limited resources and staffing available. In the example of Edith Rodriguez, who died at Martin Luther King Jr Hospital in Los Angeles awaiting medical care, triage bias resulted in the neglect of this patient and her death. Patients in the waiting room dialed 911 in order to try to generate a response to Mrs. Rodriguez’s emergency condition, but they were told the hospital staff was responsible for her care.Several factors may have played into Mrs. Rodriguez’s inability to get care in an Emergency room, and included in these may be that this was her third visit in three days (9) One bias that may have affected the quality of Mrs.Rodriguez’s care could be a‘frequent flyer bias’. “People who repeatedly visit the emergency room are called ‘frequent flyers’. Instead of a single page of a new patient sheet, the frequent flyer has a hefty chart with ample past history and testing that would seem to simplify things. Except, of course, when it complicates them.” (10)

Crowding in emergency departments can put a heavy strain on staff and may make them more vulnerable to hasty and stereotype-driven thinking. One important factor contributing to crowding is the phenomenon of patients visiting emergency departments for care that could be provided by a primary care physician. Many of the patients in emergency departments – perhaps even a majority – are there for such symptoms. Lack of access to primary care (either not having a primary care physician, or being unable to schedule an appointment promptly) helps cause this problem. It is important to note that people who use emergency departments as primary care clinics are not necessarily the same people who attend emergency departments frequently. Most frequent consumers of emergency care also consume other forms of health care often. Somewhat surprisingly, lack of insurance access is not itself predictive of more frequent emergency department use. (Potential confounding factors must be considered here: young adults are more likely than older people to be uninsured, etc). In any event, the number of non-emergency cases in emergency departments may make it less likely for physicians and other staff to take subtle emergencies seriously (16 – 19).

Physicians, as human beings, are subject to functional limits that are often pushed or exceeded in current Emergency Room conditions. Overcrowding, based on the unavailability of funding or distribution of services relative to need, causes possible workloads to be exceeded for individual physicians, and sacrifices must be made. These sacrifices are unfortunately often in patient care, either by deferring care, providing care out of standard of care protocols, or by simply overlooking necessary care as diagnosis is a function of time. Many of the limitations are placed on hospital emergency departments because lack of public funding, and can also be caused by inefficient management or workload distribution. By expressing the proven risks and results to patient safety and satisfaction to leverage higher funding, more development, and proper distribution of care resources physicians will be able to maximize safety and care relative to ability, not individual choices on where to transfer the discrepancies in resources to discrepancies in care. Also, by health care systems developing more efficient systems, the ability’s of physicians can be more appropriately distributed to patients, and not used by organizational diversions (11 – 13).

These triage bias result in unfortunate health outcomes considering the importance of prompt attention and treatment in medicine these days. Most highly prevalent medical conditions such as stroke, heart attack and hypoglycemia are extremely sensitive to timeliness. Bad medical outcomes such as coma and even death will result in a matter of minutes. More importantly, patient-doctor relationship can also be severely damaged due to the lack of confidence in our health care system. It is our best interest in medicine to protect the positive and respectful professional relationship in our society and to avoid negative reputation (Example: “Killer King”). When it comes to the closure of a hospitaldue to bad reputation, the overflow to neighboring hospitals might even worsen the patient wait time with the limited resources available.

Physicians must assume a central role in mitigating the adverse effects of triage bias in the Emergency Department setting. While diagnostic stereotyping and triage bias may be impossible to eliminate altogether, it will be critical to prevent them from negatively impacting patient care. The enactment of change can be thought of in terms of three different focus areas. Firstly, physicians must move to restructure the perceptions of ER staff on both patients themselves, and on the overall ethos of care in an ER. This can be done via education of nurses, physicians, and (nursing/medical) students. Education is a potent method of creating awareness about the existence of bias (13). In addition, steps should be taken to
keep this issue in the attention of the public; it should not require a fatal case, such as the present, in order to garner publicity. This can be done via the interaction of physicians with local media, health boards, and community meetings.

Secondly, it may be necessary to gradually restructure the way in which ERs screen patients and deliver care. Improvements to screening would include the standardization of triage protocols, perhaps via computerized scoring systems, and requiring the ER waitingarea to be surveyed routinely by an attending physician. During shifts in which the patient load exceeds the staff capacity, one solution would be to enlist auxiliary physicians (e.g. Triage Liaison Physicians, a feature of ERs in Canada) for a temporaryshift. This has been shown in randomized trials to decrease wait time, and increase the frequency of complete patient assessments (14). This case also demonstrates the need to coordinate medical transport services (i.e. dispatch) with ERs to allow patients with imminent need to care to be transferred to other hospitals.

Finally, bias must be counteracted by constant assessment of the Emergency Department. The Emergency Medical Treatment and Active Labor Act (EMTALA) requires that all patients must, at a minimum, receive a screening exam, but Edith Rodriquez was not examined. A system must be implemented in order to assure that the standards of EMTALA, and the more subjective guidelines of the Society for Academic Emergency Medicine (SAEM, 15), are met. Outcomes as a result of accurate or flawed triage should be used as an indicator of the quality of care in ERs. In addition, most hospital departments (e.g. surgery and internal medicine) have Mortality and Morbidity conferences in which ‘adverse events’ are discussed in a non-punitive way. Triage errors should be included more frequently in these discussions.


Sources Referenced

  1. Therolf G. “County faulted in death at King-Harbor,” Los Angeles Times. 4 Dec 2008. Available at:,0,7137499.story.
  2. Jablon R. “Pressure to shut LA’s King hospital after woman dies on ER floor,” Associated Press. 14 Jun 2007.
  3. Marquez J. “Troubled LA hospital could lose license after woman dies onemergency room floor,” Associated Press. 22 Jun 2007.
  4. Walton A. “DHS officials submit report on Rodriguez case,” City News Service.15 Jun 2007.
  5. “Officers cleared in death of woman who got delayed treatment at Los Angeleshospital,” Associated Press. 17 Jul 2007.
  6. Walton A. “King-Harbor closes emergency room after failing federal inspection,”City News Service. 10 Aug 2007.
  7. Ornstein C. “Tape of ignored King-Harbor patient goes online; Times postsexcerpts of the video, which the county had withheld,” Los Angeles Times. 2 July 2008.
  8. Jablon R. “LA hospital staff won’t be charged in death,” Associated Press. 9 July 2008.
  9. CBS News. Killer King L. A. Hospital in Peril Los Angeles, June 23, 2007. 5 Dec. 2008.
  10. Groopman, Jerome. How Doctors Think. New York: Houghton Mifflin Company, 2007.
  11. Scott Levin et. Al. Shifting Toward Balance: Measuring the Distribution of Workload Among Emergency Physician Teams, Annals of Emergency Medicine, Volume 50, Issue 4, October 2007, Pages 419-423
  12. Cowan RM, Trzeciak S. Clinical review: emergency department overcrowding and the potential impact on the critically ill. CritCare. 2005;9:291-295.
  13. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. IOM. March 2002.
  14. Impact of a triage liaison physician on emergency department overcrowding and throughput: a randomized controlled trial. Holroyd BR et al. Acad Emerg Med. 2007 Aug;14(8):702-8
  15. Ethics of emergency department triage: SAEM position statement. SAEM Ethics Committee (Society for Academic Emergency Medicine). Acad Emerg Med.1995 Nov;2(11):990-5.
  16. Byrne M, Murphy AW, Plunkett PK, McGee HM, Murray A and Bury G. Frequent attenders to an emergency department: A study of primary health care use, medical profile, and psychosocial characteristics. Annals of Emergency Medicine Volume 41, Issue 3, Pages 309-318. (March 2003)
  17. Grumbach K, Keane D and Bindman A. Primary care and public emergency department overcrowding. American Journal of Public Health, Vol. 83, Issue 3 372-378. (1993)
  18. Peppe EM, Mays JW, Chang HC, Becker E, DiJulio B. Characteristics of Frequent Emergency Department Users. Menlo Park, CA: Henry J. Kaiser Family Foundation. (2007)
  19. Richman IB, Clark S, Sullivan AF, Camargo CA Jr. National study of the relation of primary care shortages to emergency department utilization. Acad Emerg Med 14(3):279-82. (March 2007)

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