trouble triaging

  1. Hello, I am a new grad of april of 06, started working directly in the ED dept post graduation in a small hospital. I have recently moved to a larger hospital with a lot more serious cases. It is the Cardiac/neuro centre of the province. Since I have not had any experience triaging, working in the different pods (acute, chairs, and less ugent sections) when an ambulance comes directly in we are required to do the triaging and take report from ems. I am having a hard time determining level of acuity for the patients. for instance a CHF'er came in, visual wheazing like nothing ive ever heard, edema to legs bilaterally but was sating well. I did all her vitals, bp was about 170/90 but she stated to me " i don't feel sob at all". I triaged her as a Urgent instead of emergent.. Another nurse who is more experienced grabed the doc right away which signifies an emergent/resuss. Am I way off on this? any help would be appricated
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  2. 10 Comments

  3. by   chartlooe
    Regarding the specific case...maybey she was thinking she is or could flash pulmonary edema? Those lungs can fill up fast. Cardiac backup? If the pt doesn't say they feel SOB and you see obvious damage, they're probably chronic cardio, holding co2, acidotic, and could get funky cardiac. Lungs dry or wet? Who knows where that train might crash. That doesn't sound like someone you want sitting in obs or waiting for hours to see a doc.

    But hey, you know your stuff and I wasn't there, and it depends on the hospital. What did the medics think? That's pretty important, since who does more triage than field medics? They can usually sniff out fake drama from real drama.

    It's that irritating gradient of pt who's sick enough to be in real trouble but isn't there quite yet...do you shuffle the line to get them in, or save a bed for someone else who might not be as acute, or could be fast track, or or or? That's the kind of pt that might get you growled at by a doc either way - because the weren't quite dead and you bothered the doc, or because they almost are and you waited too long.
  4. by   bill4745
    When in doubt, triage up, not down. Better to have an annoyed doc than a dead pt.
  5. by   nursebrandie28
    I was a new grad in the emergency department and speaking from experience, triaging is the most difficult thing to do. I always triage worse than they are because I mis triaged a women having a severe MI. And in those really tricky situations, always ask. And, if you did triage this pt wrong, she still receive medical treatment, learn from mistakes and try more next time. Triaging is just so difficult because it is all GRAY
    . Anyway, keep up the good nursing.......
  6. by   Radnurse54
    First of all I have to say that I am very surprised that new graduates are doing triage. It is been my experience as an ER nurse for 28 years, that only the most experienced nurses should do triage.
    Here is another question, does your department not have a traige system in place? Do you get training and testing with that system to make sure that you understand how it is used and the resources such as your charge nurse?
    The problem with always triaging up, is that your coworkers will stop trusting your judgment kind of like the little boy who cries wolf. Dont misunderstand I think it is important to do what is in the best interest of the patient but everyone cant be emergent.
  7. by   nursemoons14
    exactly well thast the thing right... you have to be in emerg for 2 years before you can triage at the entrance, but if an ambulance comes in directly to the rooms im in charge of, I am expected to triage? figure that out ahah
  8. by   NYCRN16
    [QUOTE=Radnurse54;2024347]First of all I have to say that I am very surprised that new graduates are doing triage. It is been my experience as an ER nurse for 28 years, that only the most experienced nurses should do triage. QUOTE]

    I agree with this. I started in ER as a new grad, I am still here 3 1/2 years later and I was not trained to triage any patients until I was there at least 1 year. A new grad does NOT have the foresight to be able to see the entire picture and develop nursing judgement without experience, no matter how well you did in school, or the fact that you were a CNA or whatever before. I am not saying this to bash new nurses because I too was a new nurse in ER, there is nothing wrong with being new, you just have to learn whatever you can and use that knowledge to advance your practice. I also believe that the ENA recommends 1 year of experience at least before you triage. Another point is, the triage nurse holds a lot of liability if a patient is mistriaged and suffers harm from it. A previous poster who said that she mistriaged a patient who had a massive MI is lucky that the patient survived and that she did not lose her license for it. Of course something like this could happen to anyone, but I feel comfortable saying that a more experienced nurse would probably have picked up on something that wasnt right with this patient because we have seen it many times before. New grads should not put themselves in a position to get burned, and unfortunatly the hospitals sometimes dont care as a new grad is still a warm body with a license.
  9. by   Aliakey
    Quote from nursemoons14
    exactly well thast the thing right... you have to be in emerg for 2 years before you can triage at the entrance, but if an ambulance comes in directly to the rooms im in charge of, I am expected to triage? figure that out ahah
    I've been on both sides of the fence... maybe I can explain why our ED policies are similiar (general entrance triage nurses must be experienced, while new ones can accept report from EMS).

    As an EMT, we are educated and drilled on patient assessment 'til we drop. It's one of the most important skills we have, as we are basically "triaging" our patient at his home, or worse, upside-down in a dark, midnight wreck. Stabilizing the patient is our next priority; physically and medically. Hopefully, the patient we bring to the ER is in better condition than we found him. If that's not the case, the Charge Nurse will already know about it via radio report, and in this area, it is only the Charge Nurse that accepts critical patients from EMS. For our less critical patients, we give verbal and written report to the accpecting RN or MD that is understood medically, and treatments were rendered per a standing protocol that is well-accepted by the area hospitals. (I'm just referring to my rural area, not including some large cities like Houston where things are kinda whacked, lol!).

    I now see the other side of the fence, working in a large ED and spending a lot of time in triage as well. People who walk into the ED require a different method of assessment at times; it's almost like you have to dig and dig to get the info you need. Your patients tend to be more "medical", not trauma. It really helped me having the EMS background and the patient assessment skills under my belt, but I still have different things to learn in triage and am still learning.

    For example, I triaged a one-year old girl who's young mother kept complaining that the medicine she gave for the kiddo's fever wasn't working. The child's fever was 103 and she could barely stay awake {gulp}. In someone's home, I can ask the mother to show me the medicine and that's taken care of pretty quickly. In the ED, she didn't bring it with her and couldn't remember the name. A few questions asked while basically triaging/walking both to their room (sleepy fevery quiet kids = not good), I found out she gave Benedryl, not Tylenol.

    {slam head on computer to continue}

    Sorry for the long reply. Hope it helps explain some of the unusual policies that you may be facing.
  10. by   Altra
    Quote from nursemoons14
    Hello, I am a new grad of april of 06, started working directly in the ED dept post graduation in a small hospital. I have recently moved to a larger hospital with a lot more serious cases. It is the Cardiac/neuro centre of the province. Since I have not had any experience triaging, working in the different pods (acute, chairs, and less ugent sections) when an ambulance comes directly in we are required to do the triaging and take report from ems. I am having a hard time determining level of acuity for the patients. for instance a CHF'er came in, visual wheazing like nothing ive ever heard, edema to legs bilaterally but was sating well. I did all her vitals, bp was about 170/90 but she stated to me " i don't feel sob at all". I triaged her as a Urgent instead of emergent.. Another nurse who is more experienced grabed the doc right away which signifies an emergent/resuss. Am I way off on this? any help would be appricated
    This does get easier with additional experience.

    Since there are two simultaneous "incoming" paths to the ER (arriving in the waiting room/triage and arriving via EMS) it's impractical to expect the triage nurse to leave the triage area to come back to get report from EMS on those patients arriving by ambulance.

    In your example, "wheezing like nothing I've ever heard" ... using your assessment skills and knowledge of patho ... do you think that she's going to continue to maintain good O2 sats for very long, or do you think the situation has the potential to quickly go downhill? Does a SpO2 that is currently within normal limits tell the whole picture of respiratory function? Remember, treat the patient, not the monitor.
  11. by   Comanche_1
    Waw, what an interesting post. I'm in the process of applying for nursing this fall but for the last few years I have worked EMS. Triaging is what we do over and over and over again, all the time thats what we do.

    I don't know that I can actually give you some hints or help because I am discovering the nursing end and how things work and unfold in nursing, having said that thank you for posting this topic.

    Sorry I couldnt be of any help.
  12. by   NicoleRN07
    When I started working the ER, I was a nurse with 5 years experience under my belt, and I was not allowed to triage patients because I was new to the ER, but, new grads with less than 2 months experience were already doing triage. I could not and still do not understand the concept of new grads triaging patients, but they are allowed to triage at our facility. We do have a specific triaging system, but that doesn't always clue you in to the patients "true condition". Sometimes it's hard for an experienced nurse to pick up on certain things, much less a new grad who may not have cared for a person having an AMI who seems perfectly fine other than she "just don't feel right".

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