Published
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.
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.
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.
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.
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 :)
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 :-)
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.
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 :-)
Esme12, ASN, BSN, RN
20,908 Posts
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.