Just a question to understand the ER better

[sheilahdee]

so a quick run down. just wanted opinions.

59 yr old male patient in ESRF comes into the ER. wife signs him in and describes that he is "finishing dialysis (home hemodialysis), rapid heart rate, feeling of fist in throat and constant burping." (that is exactly what she wrote down). two nurses are behind the window, one seems concerned and the other says, "well we will get to you we can". in a not so nice tone. there was about 3 other people waiting to be seen in the waiting room, 3 in peds waiting. and nobody was in the back being seen by triage. he waited for 15 minutes before being seen. I am still a student, and have not had experience in triage, but wouldn't they be a bit more urgent and concerned with him? again, i know it all depends on whatever else they have, but their attitude just really kind of sucked. (well the one nurse). anyhoo, turns out he was in afib. his HR was all over the place but seemed to be fond of the high 170s.

my father is the said patient.

[Esme12, ASN, BSN, RN]

That sounds reasonable Stargazer.

OK. I have thought about this, so let me see if I can make better sense. :)

The triage criteria, it seems to me, is often used as a hard and fast rule, when it needn't be. For example, if you are getting slammed, and there is a lot of high volume, higher acuity, that's fine.

But I am wondering why there is often a hard and fast rule to use of the 1-5 scale, when, one can use their thinking skills as well and assess the nature of what is going on w/ an individual as well as globally in the ED?

Please, I am not trying to rock the boat of the ED world. And to tell you the truth, from what I have seen, there can be a VAST difference between EDs and how they generally roll.

All I am saying is, if there isn't that top heavy part, with high acuities, what is wrong with doing what ViceRN recommended?

"Sep 23 by VICEDRN Should have added that we do ekgs on all dialysis patients and I would have sent him to charge nurse when he resulted with a new onset afib with a rate that high. He wouldn't have waited after EKG." Yes, that's what I am talking about.

I am NOT applying this to ALL nurses or ALL EDs, so please don't misunderstand me; but it seems that there have been a good number of times where I have seen needless waiting for urgent and potentially problematic cases, when there shouldn't be. I mean if a triage nurse uses her/his clinical judgment on an individual patient, what is wrong with that?

And yes, ESME, in ICU crises hits, you have many times when you do focused assessments; b/c you are assessing the patients, ideally, very frequently--after the overall assessment. Yes, it often rolls very differently there, for reasons I discussed a while back. But sure, you can be slammed and get say three seriously critically and one coding, and you are like roller skating with these kids through the bay or bays--or at least you wish you had roller skates on.

So yes, there are frequent focused assessments as well there. Some of the kids are so sick, and there can be so much going on where you don't have time to re-do a full assessment. So while you are constantly monitoring and assessing them in some way or another, you have to move to focused assessments. There are plenty of times in a busy critical care unit where you won't get merely two patients. I have had many times with 3 criticals, one of them actively coding, one teetering on the precipice of coding, one relatively stable, but busy with diagnostics--which you must keep up with, and then another admission. This is babies and kids in a serious CICU. So, at some point, focused assessments are used throughout after the initials.

Anyway, thanks for an interesting and lively discussion. I hope no one has any negative feelings. It's good to get all perspectives, and I think those who work in it all the time have insight, but that doesn't mean others cannot. Again, I have seen other nurses use their critical thinking and judgment to move patients along, and then it seems like some others just follow a rigid system, even if it's not necessary at that particular moment. Yes. I get you assign them, but if things aren't so bad, as can be the case, and someone has the potential for problems, like this fellow, couldn't you discuss with charge nurse and try to move the patient along?

OK, that's basically all I am saying on this; but I AM definitely interested in EVERYONE's input.

Thanks again. :)

In 34 years have worked ICU, CCU, CVICU, PICU, TRU (trauma recovery unit), CTPACU amongst my time as a ED nurse and a trauma flight nurse/critical care transport. My focused assessment of 3 critical ICU patient or on the rare occasion 2 critical fresh hearts is vastly different to my triage priorities in an ED with multiple traumas and again vastly different at a mass causality scene/accident.

So, I have a unique perspective from both sides of the discussion. Both areas have their own unique requirements and both areas have their good and bad practitioners. I have always required the staff that work with me have the same high standards for patient care or they can find another department/manager to work.

Triage guidelines are not inclusive of the standard orders that accompany a certain presentation and diagnosis...that ventures into standards of practice and standing orders for treatment of the varied presentations and diagnoses....not apart of the conversation here. Triage is the decision making tree that gives guidelines for time to room/MD priority only. A standard to keep every one on the same page.

There is a ton of information and communication that occurs behind the scenes in a well run ED and the appearance that nothing is going on is a ED that is run well. Triage "guideline" are just that....guidelines that have been tried and true....especially the ESI which is accepted and standard of care by evidenced practice researched by the AHRQ Agency for Healthcare Research and Quality (AHRQ) Home The Agency for Healthcare Research and Quality who is the lead Federal agency charged with improving the quality, safety, efficiency, and effectiveness of standards of care and practices.

I hope this discussion has given an inside perspective.

[Guest343211]

In 34 years have worked ICU, CCU, CVICU, PICU, TRU (trauma recovery unit), CTPACU amongst my time as a ED nurse and a trauma flight nurse/critical care transport. My focused assessment of 3 critical ICU patient or on the rare occasion 2 critical fresh hearts is vastly different to my triage priorities in an ED with multiple traumas and again vastly different at a mass causality scene/accident.

So, I have a unique perspective from both sides of the discussion. Both areas have their own unique requirements and both areas have their good and bad practitioners. I have always required the staff that work with me have the same high standards for patient care or they can find another department/manager to work.

Triage guidelines are not inclusive of the standard orders that accompany a certain presentation and diagnosis...that ventures into standards of practice and standing orders for treatment of the varied presentations and diagnoses....not apart of the conversation here. Triage is the decision making tree that gives guidelines for time to room/MD priority only. A standard to keep every one on the same page.

There is a ton of information and communication that occurs behind the scenes in a well run ED and the appearance that nothing is going on is a ED that is run well. Triage "guideline" are just that....guidelines that have been tried and true....especially the ESI which is accepted and standard of care by evidenced practice researched by the AHRQ Agency for Healthcare Research and Quality (AHRQ) Home The Agency for Healthcare Research and Quality who is the lead Federal agency charged with improving the quality, safety, efficiency, and effectiveness of standards of care and practices.

I hope this discussion has given an inside perspective.

I think it does. Thank you for sharing your perspective. I have learned from it, and I find it helpful in understanding the situation.

I do think a big part of it is in how the ED runs. In general, at least in the hospitals that I have worked, not necessarily those I have had transports to, or friends or family in, etc, I find there is, in general, more of a spirit of unity amongst those that work in the ED. Of course this is not always true. When it isn't, it's a huge problem in my mind. ED's really do need to function as a team--and a well-oiled machine. The ones that don't do seem to be much more fragmented, but of course there are usually other issues as well. That would certainly include the bigger problems Stargazer has mentioned.

[hiddencatRN, BSN, RN]

Aside from allowing you to determine who needs a room first and who can wait (and for how long) triage levels are important in data gathering for research and QI.

[JustBeachyNurse, LPN]

I think the original poster has received several responses to her original question, a wide variety of opinions on possible scenarios, and definitely quite a lot of information on the standards of triage used in emergency departments.

[Esme12, ASN, BSN, RN]

I think it does. Thank you for sharing your perspective. I have learned from it, and I find it helpful in understanding the situation.

I do think a big part of it is in how the ED runs. In general, at least in the hospitals that I have worked, not necessarily those I have had transports to, or friends or family in, etc, I find there is, in general, more of a spirit of unity amongst those that work in the ED. Of course this is not always true. When it isn't, it's a huge problem in my mind. ED's really do need to function as a team--and a well-oiled machine. The ones that don't do seem to be much more fragmented, but of course there are usually other issues as well. That would certainly include the bigger problems Stargazer has mentioned.

Absolutely....like any dysfunctional family. One broken link and it all unravels. I agree with Beachy. I think we have discussed this extensively and the OP has her answer.

[ecerrn]

Please also keep in mind, how you respond to a patient with any complaint. Whatever the level, or reason they are there, they don't need to be talked down to, if you've ever had some one speak to you in that dismissive way you'll know how obnoxious it is, and it makes the rest of us look bad. Always be kind and professional. (Studies show you are then less likely to be sued) not you personally, I meant the dismissive one, we can learn what not to do in triage as well.

[DC Collins, ASN]

People with afib have a good chance of having a stroke, among other serious/critical problems. Some folks don't tolerate rapid Afib for very long.

Sorry guys. Unless there were mass casualties going on, I'd get that pt at the least on a monitor ASAP. Call me crazy.

I won't call you crazy, but I will say that there are MANY times in my ED where there just isn't a monitor available. Every room is taken and every hallway bed as well so there is no place to move anyone out of a room. /shrug Still would have had him sit in a w/c near the triage desk.

But the triage nurse with the bad attitude needs to go!

DC :)

[DC Collins, ASN]

Put them in the freaking hall on a monitor near the nurse's station,

DC==If the hall beds are full? Plus where I work there are no monitors in the halls. No room for such things.

or better yet, listen for an apical rhythm and get an EKG.

DC==Okay, still no beds - maybe, *maybe* someone can be moved out of a room to sit in a chair somewhere. That still takes time.

[Triage begins with a general assessment of the patient. The nurse must look at the patient and take note of the patient's condition as he or she approaches the triage desk.

DC==Much deleted for brevity. All true! Now the question still remains, not a single bed available. If a less critical patient is in a room, sure they can be moved out, *if* there is some place to move them. In our ED *every* possible bed is often occupied. But as for triage itself, we are one of the many hospitals that are moving toward immediate bedding (when one is available). No actual triage occurs until the primary nurse gets to the room. Which sometimes takes a while. Do I think this is the safest policy? No. Do I know that with Medicare paying based on pt satisfaction, rooming every pt immediately when a bed is available is the way of the future.

My BP is going up just thinking about it.

I don't deny your points have merit. But the reality is that the ED is 'the best of our resources'. Just knowing someone is having a-fib with rvr doesn't mean there is a resource available the minute the pt hits the door, whether brought in by family to the triage desk or by ambulance.

DC :-)

[Guest343211]

I don't deny your points have merit. But the reality is that the ED is 'the best of our resources'. Just knowing someone is having a-fib with rvr doesn't mean there is a resource available the minute the pt hits the door, whether brought in by family to the triage desk or by ambulance.

DC :-)

First, 99% of what you quoted was from someone else and not me. :)

Second, surely you are correct. My point was that such patients need to be, at the very least, closely observed and not just made to go back to being mixed in with those in the waiting area. And yes there are times when thus and such occur; but there are also plenty of times when the "thus and suches" do not. Be real about the situation at the time. People that should be taken or at least put as close to observation as possible are too often just put right back out in the waiting area--mixed in with the crowd. Certainly exceptional circumstances may be one thing--and in some ED's they can almost become the norm. Nonetheless, brushing aside something that could become a life-threatening problem in a heart beat (no pun intended), well that should not become the routine and standard of practice. Your ED may be excellent and go above and beyond--through all the normal rushes of hell and high water--such that other EDs may not even have a clue about. Yep, I have seen the functional and realistic differences between one kind of ED over another. But I have seen operations of EDs, plenty of times, where more close attention to things was needed--and these EDs tended to be the not so high acuity/volume kind of EDs. So I am also saying, don't let the necessary exceptions, due to uncontrollable circumstances, become the routine or standard of practice. The exceptional situations are what they are for a reason, and they sure as heck should be truly exceptional if such situations caused a bypass a standard of practice, and then, good grief, someone decides filing suit is a good idea b/c something important was blown off or missed. Other than that, why miss the opportunity to help someone as soon as possible, especially if it is a condition as changeable or potentially dangerous as the OP 's situation was with her father?

When you come to play on the field, come to play, and give it all you got, every game. Of course if your clavicle gets broken, you must be wise about the situation. Once it heals, however, go back to really playing. Don't let the exception become the new rule. That's really all I was saying.

[DC Collins, ASN]

When you come to play on the field, come to play, and give it all you got, every game. Of course if your clavicle gets broken, you must be wise about the situation. Once it heals, however, go back to really playing. Don't let the exception become the new rule. That's really all I was saying.

Hear, hear!

DC :-)

[RNFiona]

15 minutes? That's pretty darned good. In some of the crapholes I have worked, you are lucky to see a doctor before Christmas.

[RNFiona]

That being said, I would have seen that particular pt right away.But that's just me.