triage

45margie · Oct 17, 2000

I work in a busy Ed where we see 30,000-35,00 patients/year . We currently use a 5 tier triage system, which gives more flexibility , but still a little vague.

Most of our patients ,however are level 4-5 and this is often upgraded based on the wait time or the patient,s condition. This system can also be used with a color coding for each level.

Since this system is relatively new we are still evaluating and devising more guidelines for a better triage of our patients.

How do you evaluate your triage? Do you chart audit, Survey ?

Any feedback appreciated!

CTURNEY · Oct 17, 2000

Originally posted by 45margie:
I work in a busy Ed where we see 30,000-35,00 patients/year . We currently use a 5 tier triage system, which gives more flexibility , but still a little vague.
Most of our patients ,however are level 4-5 and this is often upgraded based on the wait time or the patient,s condition. This system can also be used with a color coding for each level.
Since this system is relatively new we are still evaluating and devising more guidelines for a better triage of our patients.
How do you evaluate your triage? Do you chart audit, Survey ?
Any feedback appreciated!

CTURNEY · Oct 17, 2000

We use chart audit to review. I am interested in your statement about changing the triage category due to wait time. Our policy is to document a recheck on all patients every two hours or sooner if condition warrants it. We only change the triage category if the patient's condition worsens, although sometimes it is tempting to change the category if the person waiting is a "problem". I recently attended a lecture discussing the 5 tier system and upgrading the categories r/t the number of resources a patient would need. for example, labs, x-rays, procedures, medical social work referrals, etc. Our triage nurse is also triaging patients to our Express Care. Does your facility have an urgent care on campus? Does the same triage nurse care for both? thanks for any feedback. cmt

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epsaksces · Sep 6, 2007

use 3-tier now and find that we have a lot of 2 1/2's but that's not a choice so I guess we need more tiers

BrnEyedGirl, BSN, MSN, RN, APRN · Sep 6, 2007

We use the 5t system r/t resources,..average 250 pts a day, we have a fast track (10 beds), ED side (12 beds + 4 hallway beds) and the Trauma side (12 beds + 10 hallway beds)...everyone is triaged by the same staff,.generally 4's & 5's can go to fast track (if it's open). I've never used a different system,..but I've noticed that the acuity level doesn't always coincide with the "acuity" of the pt,.for instance kidney stones are supposed to be considered emergent per ENA,.they are seen quicker than a migraine for instance, but may only utilze 2 resources,.we are now trying to use "severe pain" to bump up the acuity,.which of course is often difficult to assess. I'm told that using this system has increased our billable income,.more money for the ER, equates to more staff, supplies,etc yadda, yadda,...... wasn't in the ER for the "old" way so can't really compare.

MAISY, RN-ER, BSN, RN · Sep 6, 2007

We use 5 tier system, however, you rarely see 4 and 5 used. Even our Fast track gets 3. The reality is that anyone who appears not to need a workup is going to fast track.

Cp, and sob, are the first ones in regardless, the poor renal colics 10/10 and NV seem to languish in wait room. Our triage nurses will triage for all areas, until we have two nurses in Fast track, usually at 11am. Nurses do bedside triage for patients brought in by ambulance who are emergent. Our general triage will also do pediatrics until a third nurse reports to peds ER.

Triage is responsible for ekg of cp, sometimes ordering of xrays for obvious frx if pt going to ft, initial first aid, tylenol or motrin for pain or fever, ice packs, and even initiating cardiac workups. In addition, we too are to reassess after two hours.

New nurses must wait one year before a triage class, then an 8 hour class is held to go over acuity levels and triage procedure.

Our ER is 55+ bed (hallway if we need adds another15-20), we see over 75k patients annually. This past Monday we saw 329 patients in 12 hours-It was nuts!! I think we'll be closer to 100k this year!

Maisy;)

scattycarrot, BSN, RN · Sep 6, 2007

Triage is responsible for ekg of cp, sometimes ordering of xrays for obvious frx if pt going to ft, initial first aid, tylenol or motrin for pain or fever, ice packs, and even initiating cardiac workups. In addition, we too are to reassess after two hours.
Our ER is 55+ bed (hallway if we need adds another15-20), we see over 75k patients annually. This past Monday we saw 329 patients in 12 hours-It was nuts!! I think we'll be closer to 100k this year!
Maisy;)

Ok, whats the secret...how do you manage to reassess every 2 hours and do you really in practice? Where I worked last we were supposed to reassess but with only one triage nurse and a continual flow of patients it was almost impossible. Obviously, we would do our best and reassess those we were worried about but everyone? No way. My worse fear was going out to find a dead patient, which actually happened to a friend of mine. I actually like Triage but if you stop to think about it the reponsibility is awesome.

MAISY, RN-ER, BSN, RN · Sep 6, 2007

We have two triage nurses and a flow coordinator. In the event the waiting room is insane sometimes management will help out. It is hard to keep on top of those 2hour windows. The worst I've seen our wait is 8 hours. I am not sure it is done all the time, I have received patients that were never reassessed after 2 hours. I suppose it depends on the patient, but our most acute never wait anyway. Another thing we have is a cp protocol sheet-if a patient meets 2 of the criteria, they are taken in right away and given an ekg-a doctor then looks at it and decides if the patient is coming in or not. (Over 40, hyperlipidemia, DM, Cardiac Hx, Smoker, Family HX) we also have a stroke sheet, and pro pneumonia.

We actually had someone have the "big one" right at the greeter desk in front of everyone. We have a AED right there, code button too! Unfortunately, he passed-the nurse who was greeter did not do well

with that one and hasn't been the greeter since. I am not sure I'd do it again either!

Triage is a huge responsibility-med reconciliation, accurate description, getting all the details, and really assigning the correct acuity! I am always worried, and am probably more in tune with patient's problems when I sit at that desk. I also use alot of intuition, appearance, and really listen to them

Hope this helped.

Maisy;)

FlyingScot, RN · Sep 7, 2007

I just quit a job in a 47+ hallbeds ER that saw 85K per year. We used the three-tier system which I agree does not paint an accurate picture. We usually had one triage nurse with a tech and a float nurse (but no tech) who stepped in to help when we were getting backed up. The RN would do the triage while the tech got vitals and put them in a room if one was available. Somehow we managed to keep our waits down to about 2 hours, at the most, to at least be triaged with occasional days that were outlyers (40 people triaged waiting for beds and 40 people waiting to be triaged). Our policy was to recheck patients every hour which the tech usually did and believe me if it wasn't done our unit director would be on our butts. We were fully computerized and she'd watch the tracking board which had timers set to turn the lettering red on any patient who waited longer than 20 minutes to be triaged or who didn't get that hourly check. Funny thing is she never checked the patients herself just hunted us down (sorry I'm a little bitter). All CP's got an immediate EKG in triage. If the patient did not have any other symptoms the EKG was taken back to a doc who made the decision if they could wait. If they were symptomatic they went straight back. I don't have to tell you how fast some of our FF figured that one out even going as far as throwing water on themselves to look "diaphoretic". But I digress. Our computer system allowed us to classify them by color( Red-Emergent, Blue-Urgent, Green-Non Urgent) which would show up in the letters of their name and chief complaint. I think triage is such a subjective thing. Some nurses would make everybody blue or red. I wouldn't use red unless they were PNBr's or about to become one. The kidney stones and migraines (real ones) were blues but if they were really miserable I would take them back myself and get the attention of the doc in that zone so they wouldn't have to wait. All the docs were used to the peculiarities of each nurses triage style so they knew if I marked them as emergent they'd better get they're butts in the room pronto but if Fran did they probably had a paper cut. We were looking at the 5 tier system when I left because we all know that there is a category or two below "non-urgent" even if we technically did not have it. Those would be the "let them wait until next week" and the "go home" categories. Plus we had an Urgent Care attached and we really didn't have an appropriate category for those type of patients.

Toquay · Sep 7, 2007

We went from a 3 tier to a 5 tier and I like the 5 tier better. All level 5's are fast track and our ER MD's have guidelines like under age 3 or over age 75 they have to go to main ED unless case reviewed with ER MD and approved for fast track. Assigning level 4 seems to be the kiss of death for wait times since fast track will tend to ignore them if level 5's are present and the main ED tends to pass them up waiting for fast track to see them. We really have to watch the triage times for these people so they don't fall through the cracks.

The hospital I work for has protocol policies for triage... EKG with in 5 minutes for any CP even adolescents and teens (think this can be over the top at times & should be nurse discretion based on other factors, history, cocaine etc), abd pain protocols (upper & lower), head injury, etc etc. The problem lies in that we are very rarely staffed to handle this when we are busy. Oftentimes, we have just one RN to triage and if lucky a tech to get the EKG's and bloodwork, most times we share the tech with fast track. There is no way to get EKG's in 5 minutes when one walks into triage waiting room full (many needing reassessments), 5 waiting to be triaged and more coming through the door with peoploe knowing if they c/o CP they go back faster. I think these policies are more to cover the hospital if something goes bad in the waiting room and of course the nurse will be to blame since they did not follow policy. I do think the protocols are great and help alot with turn around time but I would also like to be staffed to actually keep up with it.

Toq