OPINION PLEASE-er triage situation-overwhelmed!

  1. :angryfire My newER director has recently told us that we are triaging "wrong". As an example, she said that a patient recently signed in as "vaginal bleeding". The pt. waited in the waiting room for 1/2 hour, then left to go to another hospital and miscarried in the parking lot. Her point was, the triage nurse should;ve gone out to the waiting room and asked the pt if she was pregnant. So What? I should have been more assertive, but now I question was the pregnancy viable? Were there 10 people to triage before her? Were we on diversion? Were we holding multiple admits? were there 4 ""chest pain" patients in their 60's and 70's before her? Where was I supposed to put THEM? Was the charge nurse available to help triage? If we were absolutely full to the brim, what was the triage nurse supposed to do? AARRGH. waiting times where I am are 8-10 hours. sometimes even 10-18 hours at county hospital.. If we are full to the brim, what are we supposed to do? I must've blanked out at this discussion, although I was "greatly irritated" (read: really pissed off_) I, for some reason, couldn/t defend us at the time. the more I think about it, the more it irritates me. Any suggestions? Any good replies? I was not the nurse in question. I was in triage last night, and was ordering labs/xrays whatever I could to help speed up things. I do my job and I do it well, but sometimes we are just overwhelmed and we have absolutely no power over the situation. I don't need my "boss" to tell me how to triage. Let's see how SHE does!:angryfire
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  2. 44 Comments

  3. by   canoehead
    If she wasn't orthostatic I would have had her wait too, with instructions to let me know if the bleeding got heavier, or if she started to feel sicker.
  4. by   Noryn
    When I did triage, if they had vaginal bleeding I always asked if they were pregnant. To me that seems like one of the biggest factors to the equation of triage classification along with symptoms. Also I tried to get an amount such as how many pads are you filling up each hour.

    My personal opinion is that the patient should have been asked that in triage. It also depends on how far along they are--some women (especially heavier or first time mothers) can hide pregnancies really well. In early pregnancy though the issue can be raised as to what can be done? Even though you never tell the grieving parents this, a lot of early miscarriages is natures way of terminating an unhealthy pregnancy.

    I think your strongest defense is the patients you had in the ER that day. Noone should have to wait as long as they do but with limited resources (nurses) it is inevitable. Worst comes first--the second worst may be a heart attack, flu, or vaginal bleeding but nurses are humans--we dont have 10 arms, 2 brains, etc. These situations are the primary reason for the nurse shortage.

    Ultimately I think there are 2 issues here. One was the patient triaged correctly as far as guidelines at your hospital and labeled urgent,emergent, etc. The second issue was the bed issue in the ER. Nurses cant magically make beds. If you are on diversion at times you are already stretched beyond your means. Even if the patient was labeled correctly how do you free up a nurse with a critical patient or a bed that doesnt exist? The triage nurse also has a responsibility of seeing the other patients. If you take her away from her responsibilities then you may very well have someone drop dead in the waiting room.
  5. by   ToryAdore
    And if you DID ask if she were pregnant, would the ER Director expect you to have put the (example) 4 chest pain pts. in their 60's or 70's aside...? Of course not. It seems that the Director has 20/20 hindsight. Second-guessing staff is just flat out wrong. It may seem cold but I'd rather see a miscarriage than lose a pt. to an MI. To a lesser degree, if she wasn't visably pregnant but knew she was, wouldn't you expect her to say something like umm..."I'm pregnant and bleeding and worried that I might lose my baby"? Or even if she didn't know, "I've been sexually active and haven't had a period in two months"..? Don't beat yourself up until they install crystal balls to triage pts. and you were at fault because you didn't have yours turned on.
  6. by   sjt9721
    Quote from Noryn
    When I did triage, if they had vaginal bleeding I always asked if they were pregnant. To me that seems like one of the biggest factors to the equation of triage classification along with symptoms. Also I tried to get an amount such as how many pads are you filling up each hour.

    My personal opinion is that the patient should have been asked that in triage. It also depends on how far along they are--some women (especially heavier or first time mothers) can hide pregnancies really well. In early pregnancy though the issue can be raised as to what can be done? Even though you never tell the grieving parents this, a lot of early miscarriages is natures way of terminating an unhealthy pregnancy.

    I'm not sure if the nurse had a chance to ask those questions. When I read the original post, I got the impression that the patient had only signed in and was waiting to be triaged. Maybe the OP could clarify the timeline of events?
  7. by   traumaRUs
    It's always easy to say in hindsight what we would do. One of our questions we always ask women is last menstrual period. However, our policy is to ask how many pads you have used in the last hour. It doesn't automatically get you to the treatment room, but we would have offered a cart and done a hemocue at that point and perhaps orthostatics if indicated. At our triage area, we start IV's, draw labs, order xrays, EKG's and all of this is done at triage. We have the space issue though like everyone.
  8. by   RN-oneday
    I am not a nurse, so I cannot respond to your situation. I do know the triage nurse or nurses can get overwhelmed with all of the patients. But I can say from a patients point of view. When I was pregnant 9 years ago, I started bleeding pretty badly. I went to the ER. I did not have a doctor at the time because I had just found out I was pregnant. At the hospital I went to, you have to sign in with the triage nurse. I explained the situation to her, that I was about 6 weeks pregnant and I was bleeding pretty badly. She told me to sit down and they would call me back. Well I sat there and the financial people called me within 5 minutes. I was not brought back for triage, I did not go in to be seen by anyone for three hours. When I finally went back, a lot of the rooms were empty. They had a bunch of police officers that were doing some kind of event, and they got overheated. So everyone had to wait in the waiting room until they were done treating them. I could not leave to go to another hospital because there was not another one close by. I was lucky and did not miscarry, even though the doctor said I did and wanted to be ready for a DNC.

    But from my point of view, I was scared to death because I could have been losing my baby, and anyone in the position to care did not care. But I was not the only one they did not care about, there were many of us out there. As for me, I WILL NEVER GO BACK TO THAT HOSPITAL. It was not the triage nurses fault, it was the person in charge that told them not to send anyone back.
    Last edit by RN-oneday on Dec 17, '05
  9. by   nialloh
    Quote from RN-oneday
    I am not a nurse, so I cannot respond to your situation. I do know the triage nurse or nurses can get overwhelmed with all of the patients. But I can say from a patients point of view. When I was pregnant 9 years ago, I started bleeding pretty badly. I went to the ER. I did not have a doctor at the time because I had just found out I was pregnant. At the hospital I went to, you have to sign in with the triage nurse. I explained the situation to her, that I was about 6 weeks pregnant and I was bleeding pretty badly. She told me to sit down and they would call me back. Well I sat there and the financial people called me within 5 minutes. I was not brought back for triage, I did not go in to be seen by anyone for three hours. When I finally went back, a lot of the rooms were empty. They had a bunch of police officers that were doing some kind of event, and they got overheated. So everyone had to wait in the waiting room until they were done treating them. I could not leave to go to another hospital because there was not another one close by. I was lucky and did not miscarry, even though the doctor said I did and wanted to be ready for a DNC.

    But from my point of view, I was scared to death because I could have been losing my baby, and anyone in the position to care did not care. But I was not the only one they did not care about, there were many of us out there. As for me, I WILL NEVER GO BACK TO THAT HOSPITAL. It was not the triage nurses fault, it was the person in charge that told them not to send anyone back.
    In fairness to ER nurses, if they had a situation where they had multiple police officers there, they then have to take safety into account. If they took you into the back in the middle of this and you got hurt, that really would have been their fault.
  10. by   Katnip
    It does sound like the patient didn't get triaged for a long time, rather than she was triaged and sent to sit and wait.

    1/2 can be a long time for someone who is bleeding, but you don't know what else was coming in the door and how many triage nurses were available.

    With miscarriages, if a person is having one, the ER isn't going to be able to stop it. All they do is confirm whether there's a viable fetus or not the refer the patient to a gyn. The bigger concern would be an ectopic pregnancy. We almost lost a patient because triage not not think bp of 76/40 needed to go back immediately.
  11. by   Mermaid4
    You can only do so much but if that occurs again as a gyn/ob nurse, I have to say the triage would depend upon the amount of vaginal bleeding and how long it had been going on. A miscarriage can hemorrhage and bleed out quickly, but if there is spotting and no obvious distress, I would have to say the chest pain people and trauma come first. Now that nurse will always ask if a vaginal bleed is pregnant. This is how we learn and this is why triage isn't perfect, because we aren't. More than likely the couple threatened to sue and your director is trying to alleviate the situation by blaming the staff. It is a huge mistake most hospitals make. All you guys can do is move on from here, continue to do your best, and be grateful that you learned something more in the event you are faced with a similar situation...
  12. by   RN-oneday
    It had nothing to do with the safety of others. They had some kind of competition going on and they got overheated because they were not used to the Florida sun. The person in charge of the ER chose to treat the police officers first and then the rest of us. We were not told anything. When I asked if they knew if they had an idea when I was going back, they said they did not have any open rooms. The only way I found out was because the tech that took me for the sonogram said they had been busy with the police officers. The nurse confirmed the information, when I mentioned it.

    I understand there are many situations that come before possibly losing a baby, but not being told anything really irritated many of the people including myself. I just think in my situation itwas handled poorly. The triage nurse is the first one in the line of fire, so unfortunately they are the first to be blamed. They can only do so much.

    Good luck triage Nurses.
  13. by   Kidrn911
    At the two ER I worked at in two different states it was required to ask all femle patients if they are pregnant.

    We all make mistakes, we can live and learned from them. The manager should have been a little more understanding
  14. by   CrazyPremed
    To the OP, I'm not a nurse, but I work as an ED tech in the same area. I actually think that I used to work at the same hospital that you do.

    No matter how good a nurse/tech/doc someone is, working in a bad enough environment can be enough to cause mistakes (not that I'm saying you made a mistake). The hospitals in our area can be crazy, and a 6-8 average wait in one certain hospital is not uncommon. The problem is that - when the $h!t hits the fan, it's the nurse that gets blamed.

    I do feel sorry for the patient - don't get me wrong. Good luck in your situation. If need be, leave that place. PHX has plenty of better hospitals that can not only save your piece of mind, but your licensce as well.

    CrazyPremed

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