Time to Triage

Oct 04, 2009 03:33 PM

by SheaTab

Premium Member

Hi ED nurses!

I am hoping someone might know of some data that states the maximum amount of time a patient should wait to be triaged or at least be assigned an ESI (not fully assessed) by an RN upon initial presentation to the ED.

Has anyone worked in a system where a tech or an LPN sits at the triage desk with a registration personnel? The tech/LPN decides if the person checking in should see the triage nurse immediately or if the patient can wait. The triage nurses see the patient on a first-come/first-serve basis otherwise. In other words, all chest pains (regardless of nature) are seen immediately, where a belly pain may wait for some time. What can obviously happen is that an acute ABD waits WAY too long and a CCC gets immediate help. Subtlties can be missed by less experienced personnel. The patient, if determined not urgent by the tech/LPN, might wait hours to be triaged. Any thoughts? Any clinical practice guidelines that you all are aware of?

Can we discuss how you all have managed triage concerns creatively?

Thanks in advance!

Tabitha

whatdayoftheweekisit · Oct 04, 2009, 07:34 PM

Re: Time to Triage

Tabitha,
I am our designated ER triage educator at my facility. ENA has some specific language about how long a patient should wait - you can check their website for times for your state. ESI (emergency severity index) and ENA both state that the type of triage you describe is not best practice...first come first serve is dangerous. My facility is a large-volume ED that supports a nurse and tech at triage 24/7 and sometimes 2 RNs and a tech...just depends. If you don't have a lot of volume, you should look at a nurse being available to triage patients within minutes of arrival.

*SheaTab* · Oct 04, 2009, 07:42 PM

Re: Time to Triage

I checked out ENA and wasn't able to find anything. Any hints?

Nurses do work in triage, just not at the front desk in the case I speak of. It isn't preferable, that's for sure. I'm trying to find evidence and see what the rest of America is doing. Can you explain specifically what you mean? Do you mean that an RN looks at a patient the second they walk in the door? Does she/he also ask the patient questions, assign ESI? The patient then waits to be fully assessed (Vitals, etc.) if not in immediate danger?

I really appreciate your help!

Tabitha

*mwboswell* · Oct 04, 2009, 11:35 PM

Re: Time to Triage

Hi Tabitha,
I'd be happy to share with you what one of our local hospitals does.
They are a Level I trauma/university teaching facility
90+ ER beds
250+ pt's per day volume

We have a two tiered triage.
Step 1: A RN at the greeter desk does a "rapid assessment" (ABCD's) as the pt signs in and that RN notes the initial finidings. If Emergent/critical they go straight back, if not, they go to the lobby

Step 2: The "triage" RN pulls pt's based on the "Greet RN's" primary survey and completes a streamlined process. If beds are open in the back, the upfront RN does a partial triage, then the pt gets the comprehensive triage in the treatment room.

If beds are full, the "Triage" RN does more of the comprehensive triage up front.

It's workign pretty well so far.

Hope this helps!

whatdayoftheweekisit · Oct 05, 2009, 06:04 AM

Re: Time to Triage

Hey Tabitha,
Boswell described a great two-tiered system. This is an ideal way for triage to work but if you have only one nurse then the primary assessment or rapid triage has to be performed by the RN on all patients. The RN should be able to see the front door with patients coming in...good communication with the treatment area is key as far as knowing what beds are open. Anyone requiring immediate bedding go back immediately. The triage RN must, however, document how the patient arrived/appeared...the treatment nurse does the comprehensive triage though. A lot of our comprehensive (non-sensitive) triage questions are asked at our front desk where the nurse is still able to see the door...after a brief history is obtained, the patient has VS taken by a tech in our triage area - nurse documents triage plus ESI level and tech may document VS.

LilgirlRN · Oct 06, 2009, 11:32 PM

Re: Time to Triage

I'm the designated triage nurse at our facility. The idiots upstairs decided that our security officers should sit at the front desk where pt's sign in (they're lower paid that registration). Ughhh.

We use Cerner-Millenium's First Net to track our patients, great program! As the patients are registered I can see what the chief complaint is. Of course chest pain is priority. We have a designated STEMI nurse that takes patients to a room if they're older than 25 with chest pain. Otherwise, if we are busy and the patient is young, we'll do an EKG in triage, have the doc take a look at it. If' it's OK, they can wait to be triaged, if not they'll go straight back.

We have 30 beds, we hAve 6 trauma rooms, 17 regular rooms and 7 fast track beds. We see about 220 per 24 hour period although it's been much higher than that since the media decided to make people believe that swine flu will kill them in about 20 seconds.

MikeyBSN · Oct 07, 2009, 01:04 AM

Re: Time to Triage

This is a huge, huge, issue for me in the ED. I have been pushing for more of an RN presence in the triage area and, in four years, I have not seen it. Although it has gotten a little better, I still think our triage system stinks. We have a "greeter" who might, from time to time, tell me if a patient is having "chest pain." It doesn't matter if the person is 15 or 50. Sometimes they tell me there is an "asthma" waiting to come in. It is better than nothing, but still not very good. Sometimes patients wait far too long to be triaged, and the triage nurse literally cannot physically get to the patient in a fair amount of time.

The person at the desk might alert me about the 21 year old who has "chest pain" because he was lifting boxes all day and now his chest hurts when he moves his arm around. Yet the 50 year old diabetic patient with nausea, vomiting, arm tingling and dizziness has been out there for 30 minutes now but doesn't have "chest pain" because her pain receptors are shot due to neuropathy. In my opinion, RN's need to be the ones who rapidly triage these patients. Anything less is a dangerous game.

*SheaTab* · Oct 12, 2009, 08:36 AM

Re: Time to Triage

Thank you all so much for your replies. This information has been very useful.

Tabitha

LLLLiiiFFEsaveer · Oct 13, 2009, 09:56 AM

Re: Time to Triage

Originally Posted by SheaTab

Hi ED nurses!

I am hoping someone might know of some data that states the maximum amount of time a patient should wait to be triaged or at least be assigned an ESI (not fully assessed) by an RN upon initial presentation to the ED.

Has anyone worked in a system where a tech or an LPN sits at the triage desk with a registration personnel? The tech/LPN decides if the person checking in should see the triage nurse immediately or if the patient can wait. The triage nurses see the patient on a first-come/first-serve basis otherwise. In other words, all chest pains (regardless of nature) are seen immediately, where a belly pain may wait for some time. What can obviously happen is that an acute ABD waits WAY too long and a CCC gets immediate help. Subtlties can be missed by less experienced personnel. The patient, if determined not urgent by the tech/LPN, might wait hours to be triaged. Any thoughts? Any clinical practice guidelines that you all are aware of?

Can we discuss how you all have managed triage concerns creatively?

Thanks in advance!

Tabitha

I have not read any of this thread yet, but can tell you that every ED should probably have a point triage RN + a comprehensive (Or Two) triage RN's. I am at a facility that has tried out both ways, using even the facilitator's when I first started, as the first to see the pt coming through the front doors - vs - A Point RN seeing them first, as they walk up to the front desk with their complaints.

One way is significantly better than the other!

LilgirlRN · Oct 14, 2009, 03:47 PM

Re: Time to Triage

Really weird... I came to work today only to be told that the triage nurse will now triage all patients at the bedside. That is until we are full and then I will triage in the triage office. There will be a tech at registration to alert me to any true emergencies. However the tech that is doing this today expresses his concerns, what if he misses something? Can the patient then sue him? All questions that I don't have the answer to.

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Time to Triage

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