Just a question to understand the ER better - page 6

by sheilahdee

10,026 Views | 71 Comments

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... Read More


  1. 1
    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.
    samadams8 likes this.
  2. 1
    OP....I am so glad your Dad is feeling better. Triage nurses are NOT supposed to show panic or extreme concern (unless tha patient is coding and to call for help) Their job is to remain objective and professional......even when being screamed at....to remain in absolute control of any situation. That triage nurse was rude.......if she were a staff member in my department she would have some explaining to do about her attitude....but her triage and the 15 min wait is within all guidelines of safety and standard of care. Her attitude however...should never be the standard.

    Would you have felt differently if she stated...I'll be with you directly we have xyz pending and it will take us 15 min...you will be monitored by me closely and we will get you a bed ASAP....your heat rate is elevated but your B/P is xzy. We will get this ASAP.

    I see both sides. I have worked/managed/directed Emergency Departments. Here I personally feel the triage nurse needs an attitude adjustment. The first encounter with the patient sets the tone of the entire visit Patients need to be greeted with kindness and courtesy......no matter what. I have always told the staff that the sign of a great triage nurse is to convince the parents of a toddler that their babies first chin laceration is NO an need for a trauma alert and the chin laceration is a survivable injury....... WITHOUT ENRAGING THE PARENTS.......is the triage nurse of the year.

    Every year at our Christmas party we had a tongue in cheek triage nurse of the year.......the one with the least complaints wins.

    What/how/when a patient is triaged depends on the facility and what is going on at any given time. I have worked facilities that a multiple gunshot wound doesn't automatically a trauma alert and if the have an 02 Sat and a heart rate less that 150.....they waited. I have worked facilities that would call a trauma alert just because gunshots were heard....nearby. It all a matter of perspective. The perspective of the staff....not the patient or family....but again the goal is not be diversive and rude and it appears that his nurse was .....and that set the tone, not only of that patient visit but this entire thread.

    I have also worked/managed/directed ICU's and see the point of an ICU nurse. These two specialties are polar opposites in the care of the patients and priority. A ED nurses idea of "Head to Toe" assessment is seeing that they are not missing any limbs and nothing is turning blue. An ICU nurses idea of head to toe is palpating every pule and hearing every click and his of muffled heart tones. An ED nurse idea of heart tones is are the there or not. An ICU nurse know exactly where every IV is and what is infusing where an ED nurse just makes sure they are compatible and not infusing on the floor after being pulled out but x-ray, lad, or CT. It the nature of the individual areas.

    I think a patient with an extensive dialysis history, ambulatory to the ED with a heart rate of 150 need to go back ASAP but is by NO means emergent....which in the ED is reserved for active resuscitation. If this patient with a heart rate of 150 with that full feeling in their throat that is not diaphoretic AND hypotensive....can wait and 15 min is well within an acceptable amount of time to register/triage and prepare a room.

    ED triage nurses are trained to be the very unpopular traffic cops and should be the nurses with extensive training in Emergency medicine so they are qualified to make these borderline decisions. The AHRQ.....Agency for Healthcare Research and Quality......... and The Joint Commission......recommends a 5 tier triage system that is utilized by most facilities these days as they relate to more reimbursement. That clearly breaks down the triage mentality/procedure.

    Overview of the Emergency Severity Index


    With all this being said....... This thread has been extensively edited. We can agree to disagree without becoming rude and diversive. We are professional after all. If "we" can't respectfully disagree the thread will be closed and points assigned.
    canoehead likes this.
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    Esme, I hope you will read this in the spirit it is intended, which is not to be confrontational, but just to express a difference in perception. In your second paragraph you said " Would you have felt differently if she stated . . . " I'll be with you directly, we have xyz pending and it will take us 15 min . . . you will be monitored by me closely and we will get you a bed ASAP . . . your heart rate is elevated but your blood pressure is xyz. We will get this ASAP." The difficulty I have with this is that reading the OP I don't feel that the situation was primarily a failure of communication on the part of the nurses and/or a misunderstanding on the OP's part. The OP did not say that he/she observed vital signs being taken by the nurses or anyone else during the patient's inititial presentation to the ER or during the 15 minutes that elapsed before the patient was seen, and reading the OP's post I did not infer anything the OP did not state. The OP did not say that the nurse palpated a pulse or listened to the patient's apical pulse during the patient's initial presentation to the ER or during the 15 minutes prior to the patient being seen, and I did not assume these things were done at that time as the OP did not state they were.

    In your seventh paragraph you stated . . . "If this patient with a heart rate of 150 and that full feeling in their throat that is not diaphoretic and hypotensive . . . can wait and 15 min is well within an acceptable amount of time to register/triage and prepare a room." My concern here is that the OP did not state that the patient was assessed and found not to be diaphoretic and hypotensive at the time they presented for care or during the 15 minutes they waited. The OP did not state that any hands on assessment took place during this time. So to my mind, reading just what is stated in the OP, we don't know how well the patient was tolerating their rapid heart rate from the time they presented until they were seen.
  4. 3
    Susie2310,

    Once the patient has been determined to be an ESI Level 2 acuity (which he would be, as a person with ESRD on hemodialysis experiencing a rapid heart rate), no further "hands on" assessment by the triage nurse is needed. The priority is to get the patient back to the treatment area. Further assessment is done at the bedside.

    Once a high risk situation has been identified, you do not need vital signs nor any further assessment to confirm it. You call the charge nurse and tell them you have a "2" that needs to come back.

    Getting the person into the treatment area is the priority concern for the triage nurse. All further assessment is done there.

    You may disagree with it, but that's how it works.
    Last edit by ~*Stargazer*~ on Sep 24, '12 : Reason: clarification
    canoehead, psu_213, and hiddencatRN like this.
  5. 1
    Quote from ~*Stargazer*~
    Susie2310,

    Once the patient has been determined to be an ESI Level 2 acuity (which he would be, as a person with ESRD on hemodialysis experiencing a rapid heart rate), no further "hands on" assessment by the triage nurse is needed. The priority is to get the patient back to the treatment area. Further assessment is done at the bedside.

    Once a high risk situation has been identified, you do not need vital signs nor any further assessment to confirm it. You call the charge nurse and tell them you have a "2" that needs to come back.

    Getting the person into the treatment area is the priority concern for the triage nurse. All further assessment is done there.

    You may disagree with it, but that's how it works.
    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.
    Last edit by samadams8 on Sep 24, '12
    Susie2310 likes this.
  6. 3
    Quote from samadams8
    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?
    Every ED must have a triage system. The ESI system is but one. If that is the system that is used by your facility, then that is the system you must follow. Regardless of which system your facility uses, every patient must be assigned an acuity. That is the essential function of triage.

    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.
    There is nothing wrong with getting an EKG in triage. It happens all the time. In some cases, however, the EKG tech may not be immediately available, and it is safer patient care to get the patient into the treatment area than to wait on the EKG tech. Then, the EKG happens after the patient has been roomed.

    If things are really backed up, blood can be drawn and x-rays ordered while patients are still waiting in the lobby. That way, at least the workup has been started, and by the time they are roomed, it will decrease their LOS in the treatment area, in theory.

    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?
    The triage process IS a process of clinical judgment. This is why ENA recommendations are that a nurse should have at least six months' experience working in the ED, and have taken and passed a triage course, prior to being placed in the position of triage. Personally, I don't think that goes far enough, but it is realistic considering the low staffing levels and high staff turnover of many an ED.

    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?
    That is exactly what you would do, as has been stated repeatedly by several ED nurses in this thread. I'm not sure why you would think that nobody has thought of that, when it has been stated again and again.

    But, if there is no place to move the patient along to, he must wait. Beds don't just appear out of thin air. Someone has to leave; be discharged, be transported to the floor, or die, for a bed to open up. If there is a bottleneck in the ED due to too many people coming and not enough people leaving, then you have overcrowding. It is a national problem that has resulted in countless delays in treatment at best, and deaths in the lobby at worst.

    Every ED nurse on this forum is completely aware of this problem.

    Edited to add: In fact, I think we've beaten this dead horse beyond recognition.
    Last edit by ~*Stargazer*~ on Sep 24, '12
    canoehead, psu_213, and hiddencatRN like this.
  7. 1
    Quote from ~*Stargazer*~
    Every ED must have a triage system. The ESI system is but one. If that is the system that is used by your facility, then that is the system you must follow. Regardless of which system your facility uses, every patient must be assigned an acuity. That is the essential function of triage..
    Yes, assign away. It doesn't change the fact that many times, at least in a number of suburban EDs, I have witnessed patients getting a delay in treatment needlessly. I won't argue that further, and I appreciate the time you took to respond.

    I sense a terseness in your response, but I acknowledge I could be reading into that. This is tough to tell at times online. If so, you needn't be; and and there is no need for being defensive.

    If you and your ED facility are doing the absolute best that you all can, and you honestly know this to be consistently true, you needn't feel offended at all. I say, "Great job at doing your best to work in a tough area!"


    OTOH, we have to be honest and face the reality that there are indeed times that people take liberties with the assignment system. I have witnessed it in several ED's, and if you have been around, I will bet the farm that you have too. So, if my loved one was symptomatic and as tachy as this particular man was, you can hate me ALL you want; but I am gonna stress the need for the him to be seen. The exception would be if there were major traumas going on, or the like. I'm a reasonable person; but I have witness needless delays, and it's unfair and just plain wrong to hide behind a system--systems are guidelines, not rules etched in stone; thus a person's judgment must move beyond that.

    Now what you are talking about nationally in terms of EDs is truly a huge problem, and really it's a whole other issue for another thread.



    Quote from ~*Stargazer*~
    There is nothing wrong with getting an EKG in triage. It happens all the time. In some cases, however, the EKG tech may not be immediately available, and it is safer patient care to get the patient into the treatment area than to wait on the EKG tech. Then, the EKG happens after the patient has been roomed.

    If things are really backed up, blood can be drawn and x-rays ordered while patients are still waiting in the lobby. That way, at least the workup has been started, and by the time they are roomed, it will decrease their LOS in the treatment area, in theory..
    It's great if someone has the care or presence of mind to think, "Hey this man's HR is significantly high. Let me assess this further or get an EKG. But here's the thing, and this is the heart of what I am talking about. Once a person does this, however, then he or she is obligated to follow-through with more immediacy with what is assessed. So, why bother? Why not hug tight on to the ole "Well we use this system. So, eh, let him sit down." When people do that they are taking a risk and justifying a temporay turf or blow off. And I have witnessed it, again, in several ED's, more than a few times.



    Quote from ~*Stargazer*~
    The triage process IS a process of clinical judgment. This is why ENA recommendations are that a nurse should have at least six months' experience working in the ED, and have taken and passed a triage course, prior to being placed in the position of triage. Personally, I don't think that goes far enough, but it is realistic considering the low staffing levels and high staff turnover of many an ED..
    This is neither here nor there in terms of what I am talking about. People have also said repeatedly that there is a lot of subjectivity to the process. Just mentioning that that is so tells me that these processes are dubious, relative, and people have to exercise the best clinical practice judgment beyond the simplified triage guidelines--except when they really can't, b/c, say literally there are more acuities that anyone can handle in the ED. There are, again, plenty of times when that is NOT the case.


    Quote from ~*Stargazer*~
    That is exactly what you would do, as has been stated repeatedly by several ED nurses in this thread. I'm not sure why you would think that nobody has thought of that, when it has been stated again and again.
    What's with the tone, which isn't necessary?

    It isn't that no one has not thought of it. It is that there are times when it can and should be done, and people don't do it. We've all seen it. I don't give a crap if you've seen 200 people on your shift. Yes, it will definitely fry the hell out of you; but each person, pain in the arse or not, is a human being. For just about every one of these human beings are other human beings that care about them. No one should be blown off b/c someone can claim hold to a guideline system.

    Again, if you and yours are doing your utmost, you can go to bed with a clear conscience. But there are PLENTY of times stuff gets needlessly blown off or delayed, especially in some of these goofy butt suburban ED's I have seen.

    Personally, I wish every person that was too burned out or just didn't care enough, or was too selective with whomever is in need of care of treatment, would just leave nursing and medicine. God knows, there are tons of other nurses that do give a crap and can empathize. They understand that this person could be their loved one--and I know nurses in ED that still have that sensitivity. Good for them I say.

    I have had plenty of docs and medical students ask me about slow or fat butt (their words) ED nurses that seem to spend more time at the desk or chatting with others than actually addressing, prioritizing, or caring for patients.

    ONCE more, so no one misses this. If it is NOT you, don't worry about it. It doesn't apply to you. But there are plenty for whom it does apply. And you know it.

    Quote from ~*Stargazer*~
    But, if there is no place to move the patient along to, he must wait. Beds don't just appear out of thin air. Someone has to leave; be discharged, be transported to the floor, or die, for a bed to open up. If there is a bottleneck in the ED due to too many people coming and not enough people leaving, then you have overcrowding. It is a national problem that has resulted in countless delays in treatment at best, and deaths in the lobby at worst..
    Again, a different issue for a different thread.



    Quote from ~*Stargazer*~
    Edited to add: In fact, I think we've beaten this dead horse beyond recognition.
    No doubt.
    Last edit by samadams8 on Sep 24, '12
    Susie2310 likes this.
  8. 0
    Quote from samadams8
    Yes, assign away. It doesn't change the fact that many times, at least in a number of suburban EDs, I have witnessed patients getting a delay in treatment needlessly. I won't argue that further, and I appreciate the time you took to respond.

    I sense a terseness in your response, but I acknowledge I could be reading into that. This is tough to tell at times online. If so, you needn't be; and and there is no need for being defensive.

    If you and your ED facility are doing the absolute best that you all can, and you honestly know this to be consistently true, you needn't feel offended at all. I say, "Great job at doing your best to work in a tough area!"


    OTOH, we have to be honest and face the reality that there are indeed times that people take liberties with the assignment system. I have witnessed it in several ED's, and if you have been around, I will bet the farm that you have too. So, if my loved one was symptomatic and as tachy as this particular man was, you can hate me ALL you want; but I am gonna stress the need for the him to be seen. The exception would be if there were major traumas going on, or the like. I'm a reasonable person; but I have witness needless delays, and it's unfair and just plain wrong to hide behind a system--systems are guidelines, not rules etched in stone; thus a person's judgment must move beyond that.

    Now what you are talking about nationally in terms of EDs is truly a huge problem, and really it's a whole other issue for another thread.

    It's great if someone has the care or presence of mind to think, "Hey this man's HR is significantly high. Let me assess this further or get an EKG. But here's the thing, and this is the heart of what I am talking about. Once a person does this, however, then he or she is obligated to follow-through with more immediacy with what is assessed. So, why bother? Why not hug tight on to the ole "Well we use this system. So, eh, let him sit down." When people do that they are taking a risk and justifying a temporay turf or blow off. And I have witnessed it, again, in several ED's, more than a few times.





    This is neither here nor there in terms of what I am talking about. People have also said repeatedly that there is a lot of subjectivity to the process. Just mentioning that that is so tells me that these processes are dubious, relative, and people have to exercise the best clinical practice judgment beyond the simplified triage guidelines--except when they really can't, b/c, say literally there are more acuities that anyone can handle in the ED. There are, again, plenty of times when that is NOT the case.




    What's with the tone, which isn't necessary?

    It isn't that no one has not thought of it. It is that there are times when it can and should be done, and people don't do it. We've all seen it. I don't give a crap if you've seen 200 people on your shift. Yes, it will definitely fry the hell out of you; but each person, pain in the arse or not, is a human being. For just about every one of these human beings are other human beings that care about them. No one should be blown off b/c someone can claim hold to a guideline system.

    Again, if you and yours are doing your utmost, you can go to bed with a clear conscience. But there are PLENTY of times stuff gets needlessly blown off or delayed, especially in some of these goofy butt suburban ED's I have seen.

    Personally, I wish every person that was too burned out or just didn't care enough, or was too selective with whomever is in need of care of treatment, would just leave nursing and medicine. God knows, there are tons of other nurses that do give a crap and can empathize. They understand that this person could be their loved one--and I know nurses in ED that still have that sensitivity. Good for them I say.

    I have had plenty of docs and medical students ask me about slow or fat butt (their words) ED nurses that seem to spend more time at the desk or chatting with others than actually addressing, prioritizing, or caring for patients.

    ONCE more, so no one misses this. If it is NOT you, don't worry about it. It doesn't apply to you. But there are plenty for whom it does apply. And you know it.



    Again, a different issue for a different thread.





    No doubt.
    samadams8, thank you for an excellent, thoughtful response, and for being such a strong patient (and family member) advocate and conscientious nurse.
    Last edit by Susie2310 on Sep 24, '12
  9. 0
    Quote from Susie2310
    samadams8, thank you for an excellent, thoughtful response, and for being such a strong patient (and family member) advocate and conscientious nurse.
    Thank you for that.
  10. 0
    Quote from Susie2310
    Esme, I hope you will read this in the spirit it is intended, which is not to be confrontational, but just to express a difference in perception. In your second paragraph you said " Would you have felt differently if she stated . . . " I'll be with you directly, we have xyz pending and it will take us 15 min . . . you will be monitored by me closely and we will get you a bed ASAP . . . your heart rate is elevated but your blood pressure is xyz. We will get this ASAP." The difficulty I have with this is that reading the OP I don't feel that the situation was primarily a failure of communication on the part of the nurses and/or a misunderstanding on the OP's part. The OP did not say that he/she observed vital signs being taken by the nurses or anyone else during the patient's inititial presentation to the ER or during the 15 minutes that elapsed before the patient was seen, and reading the OP's post I did not infer anything the OP did not state. The OP did not say that the nurse palpated a pulse or listened to the patient's apical pulse during the patient's initial presentation to the ER or during the 15 minutes prior to the patient being seen, and I did not assume these things were done at that time as the OP did not state they were.

    In your seventh paragraph you stated . . . "If this patient with a heart rate of 150 and that full feeling in their throat that is not diaphoretic and hypotensive . . . can wait and 15 min is well within an acceptable amount of time to register/triage and prepare a room." My concern here is that the OP did not state that the patient was assessed and found not to be diaphoretic and hypotensive at the time they presented for care or during the 15 minutes they waited. The OP did not state that any hands on assessment took place during this time. So to my mind, reading just what is stated in the OP, we don't know how well the patient was tolerating their rapid heart rate from the time they presented until they were seen.
    Absolutely.....and I hear what you are saying. I agree that the triage nurse by the OP's account, didn't communicate well...the rest of my psot was explaining how it could have been handled differently. You are correct we don't know how well the patient was or was not handling the RHR so the entire discussion/thread is a actually moot point.

    My comments were a version of how a triage nurse can impact the patient and families interpretation and experience in the ED...not that they were actual facts of the OP's post or the reality of the actual situation. We have only one side reported....the families. The ED is a very difficult place to work. You see people at their most frightened and vulnerable and their family is always the only family that is present and ill. It is the nature of the beast. The ED is unique into itself and it takes a certain kind of nurse to do it well.

    I know she didn't say these things I am merely giving a different point of view to the scenario. It is impossible to know how to respond and truly not know the entire sequence of events. I have the faith that most of us nurses have the patients best interest at heart. I feel if the first contact with he triage nurse wasn't a triage nurse with a bad attitude....this OP might not feel slighted. Her first contact with this ED was with a nurse that didn't portray concern. Thereby causing the family undue concern. Everything could have done to perfection after that point and the OP and her family would never feel safe and cared for appropriately for the rest of the ED visit.

    My paragraph was a scenario of how the visit could have been better handled without having all the necessary information. The triage nurse may have been way off base....but she could have been completely appropriate....we will never know. The ensuing debate has been about triage time and triage nurses judgements which are difficult to understand is you have not been appropriately trained at triage. The system isn't perfect but no system truly is.......but a patient with a rapid heart rate that is not syncopal and is ambulatory with a 15 min lag time is appropriate from the information given in the original post.

    The good news is the OP's father is doing well!


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