Paramedic triage

Triage is what paramedics do every day. I'd be comfortable with planting them in triage anytime.

Being both a paramedic and a RN I have mixed feelings about the triage position. Back in the day the two most experienced people in the ER were the charge nurse and triage nurse (often with a minimum of 10 years or more time on the job). Those two people together determined what kind of day the ER was going to have. The question/comparison is moot when RNs with 1 to 2 years of experience are placed in triage. When the amount of experience of the provider (RN, paramedic or otherwise) is that low then there will be problems. Patients will be either under or over triaged. I know under triage is worse, but man, I can't stand it when I get a triage nurse thats sends everyone back marked "red".

Now correct me if I am wrong, but I thought it was a JCAHO requirement to have an RN in triage. I have seen this "gotten around" by having EMTs or paramedics "collect data" and the RN signs off. So if I am right about JCAHO, and paramedics are by themselves in triage then something is wrong in terms of compliance. Not saying the patients are not being triaged properly. Again, that depends on the experience of the provider and (this is important) how much of that experience has been working in a hospital environment. Which leads me to my next point.

I have seen several people make comments that paramedics triage all day long. That is just not true. If anything, a paramedic is more likely to be working in a "reverse" triage situation: two EMTs/medics to 1 patient. Even when there is an MCI the parameters are different. Try black tagging someone in the waiting room and see what happens. Pre-hospital triage and waiting room triage are two different beasts. In the field as paramedics we are allowed certain, umm, allowances because our resources are limited. We don't have almost instant access to x-ray, CT, labs, physicians, surgeons, various medications/procedures. In the hospital the availability/proximity of those items are closer. This changes the rule of triage. In the field unless the circumstances are extreme we are not with our patients for a very long time. Also in general, during an MCI, we get a batch of patients with similar complaints (fire, smoke, exposure, trauma) and that is it (not including your various MCI triggered heart attacks, asthma attacks, and baby deliveries). Contrast that with the waiting room. We might have a patient for 6-12 hours or more. Add to that we are constantly getting new patients with various complaints. So our triage "pool" is always changing. Is there crossover in this skill subset? Yes. And paramedics can do well in hospital triage. I have worked triage in the ER as a paramedic (with my charge as my RN "backup"). I learned how to do it (I think I did well), but it was not the same as field triage.

Ivan

i concur. i think some states have laws that say assessment must be initially triaged by an RN, if its not a full JCAHO policy. I know at my level 1 ER we do not put medics in to triage pts.

i believe that medics do have the possibility to be able to triage; however, their assessment class/skills are a different set than an RN's.

Basically, I think that if a Medic has enough training to scrape your butt off the asphalt and keep you alive on the way to the hospital then they can triage anything that walks through or is dumped at the ER door. I also agree somewhat with the post that said an EMT-B would be like having a CNA triaging. Yes, some basics are really good and know their stuff, same goes for some CNAs with ER experience. But come crunch time I'd rather have someone with more training on my team. Granted maybe there should be a short course the Medics should take to learn the ropes for triage in the hospital setting, but other than that I would be fine with it.

From ivanh3's post I see where some pitfalls would come in.

Having people wait 3-4 hours does throw a wrench in the works, and reassessing, and basic hospital politics. I still think any advanced EMT could do a great job, given some time and training.

I know medics who would be brilliant at ED triage, and others who wouldn't. In-hospital is definitely not like being "on the street" -- as both an ED RN and a paramedic, I can say that with certainty. Two different worlds -- yes, with some overlap, but I wouldn't expect a paramedic to be able to step into ED triage and function flawlessly in the RN's usual role any more than I'd expect an ED RN to step out onto the streets and function flawlessly in the paramedic's usual role. Both would require time and training, and I'm sure those places using medics for in-hospital triage require some training/orientation to that role, and/or, as Ivan had, an "RN backup."

I am a paramedic and I also work primarily in triage at a level II facility that sees about 200 patients per day.

In our triage, the EMT or paramedic completes the triage process (hx, vitals, c/c, etc.), initiate any immediate treatments based on written protocol (such as an ECG for chest pain), and will make a rough determination on the patient's severity and priority. Also, when things get hectic, the EMT or paramedic will also go ahead and obtain blood draws, medicate, temporary-splint, or whatever else can reasonably be done in the triage area (we have 5 treatment rooms available). However, in all circumstances, the RN must review the chart and sign to comply with set rules. Depending on who the EMT or paramedic may be and their proven experience in triage, they could either be trusted in their assessment and the chart signed with minimal questioning, or the nurse has the right (which is respected by the EMTs and paramedics) to start the 20-question process. We all get along great with a one or two person exception --- usually, those folks don't remain for long anyway. We all need each other, and that's well understood in times of overcrowding.

Taking a fresh-from-the-field medic into triage does require some additional education, as one poster said it right, we are not all that familiar with the details on some of the interventions and disease/condition states that would affect what actions are taken in the ED. I learned A LOT from working in the ED, and use it nearly daily when I am out in the field (seeing my partner's eyes glaze when I discussed a lot of the conditions of our patient with Tetralogy of Fallot was priceless the other day). But, paramedics (in our area in particular) may have significant experience or training in areas, such as 12-lead ECGs, that help some of the nurses that have a weakness in that area. For example, if we misinterpret an ECG in the field, our butts get reamed by the doc or in our case review, so we always have a painful incentive to keep our proficiency up, lol!

Just some thoughts from both sides of the game. The best thing for your ED is to have written protocols for both the RNs and medics to adhere to. That prevents 90% of any problems in triage, in my experience.

Hi there,

I work at a level 1 trauma center, average census >300/day and frequently work triage which is staffed with a minimum of 3 RNs, sometimes 5 depending on the census.

I'm shocked at the responses of nurses who agree with EMT-Ps working at triage. In my state (CA), RNs must perform the initial assessment whether the patient is received by ambulance or walk-in.

Aside from that, I appreciate how medics work and function in the field but there exist fundamental differences between the professions. Medics are taught to follow and function according to protocols. Nurses are able to think outside the protocol. Yes, some experienced medics are more knowledgeable in emergency care than some nurses and medics perform assessments under very difficult circumstances. However, nursing is able to address a wider spectrum of patient care than medics. Even the educational requirements of the professions differs and nurses are exposed to so much more.

Assigning a triage number based on ESI is more complicated than following the algorithm. From my experience and education as an ER nursing educator, it makes me nervous to even consider a paramedic working the triage zone. Considering the liability alone, I firmly believe that paramedics can assist in the emergency department however, assessments and triage should remain solely a nursing function.

No. Nurses also follow protocols/rules/policies. You say tomato, I say tomato. Yes, nurses can address a wider spectrum of care, but in triage, deciding if the patient is going to die now, later or eventually due to anything but the chief complaint is something both can do.

I beg to differ. Triage is simply more than deciding if someone is dying or not; it's not that cut and dry.

We can argue the issue until the cows come home but ultimately, I'm glad that my state affirms what I strongly believe.