To al ER nurses - Triage?Register Today!
- by CEN35 Jun 29, '00
OK to all the nurses out there that work in ED's.
In our ED we have been seeing approximately 35,000-38,000 patients a year. Recently in the Cleveland area, two hospital systems have been trying to take over the market (IMO). Anyhow, with the increased ED volume d/t other recent hospital closings, longer lifespan, more patients in nursing homes etc, our census has skyrocketed, and we have seen many more patients than anticipated. One of the things I am currently trying to do, is come up with some new ideas on how to appropriately triage the large numbers of patients that come through the ED,
more efficiently. So let me ask you a few questions about your ED's current triage methods, and your thoughts on them?
1) How does your ED triage it's patients?
2) Do you think your system works well? or not? If so why does it work or not work well?
3) If you were to restructure your current triage system, how would you do it? Staffing
4) Any suggestions on what thoughts might make a triage system better?
Currently, we have one triage nurse in our system. This person is overwhelmed with way too many responsibilities. Triage itself, and communicating between family members, and updating them on their loved ones condition, checking the locked refridgerator for drug specimens, etc. Clearly too much for one person to handle on some of our busier days.
A) Using two nurses in triage, to assess get vs, and catagorize the patients as they come into the ed. Something along these lines?
B) How to arrange it to be more expedient, and see patients soon as they come through the door, not 5 to 20 minutes later, or longer.
C) In what particular way to use these two nurses?
****Note: For all those out there that are unaware of this fact: It is a violation of COBRA rules, to have the patient register, provide any demographic info, or insurance or payment, without being assessed by a health care worker first.
Thanks for any input provided, Rick RN CEN
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- Jul 5, '00 by CEN35NO comments by anyone?
- Jul 7, '00 by CEN35Any input here at all?
- Jul 15, '00 by JOANNE YASTIKHELLO RICK - I AM AN ER NURSE FROM THE DETROIT AREA AND SAW YOUR POSTING. I, TOO, HAVE POSTED A FEW ITEMS W/ NO RESPONSE - FRUSTRATING! WE SEEM TO BE IN THE SAME SITUATION. WE HAD A HOSPITAL APPROX 3 MILES AWAY CLOSE, AND THE 40,000+ PTS/YEAR THEY SAW NEEDED TO GO SOMEWHERE. ALTHOUGH, IT SEEMS WE ARE ALWAYS LOOKING FOR WAYS TO IMPROVE TRIAGE.
WE CURRENTLY ALSO HAVE ONE TRIAGE NURSE AND IT IS NOT UNCOMMON FOR THAT NURSE TO BE 20 DOWN, DOING THE BEST THEY CAN, TAKING THE CARDIACS, RESP DIFFICULTIES, ETC AS THEY COME IN. OF COURSE, AS YOU WELL KNOW, THIS CAUSES GREAT DISCORD IN THE WAITING AREA FROM THOSE WHO "SIGNED IN FIRST". FOR A WHILE, WE TRIED PLACING A CLINICAL TECH (NURSING ASST) IN TRIAGE DAILY W/ THE RN ON THE AFTERNOON SHIFT. THE TECH WOULD DO VS, BGM'S, DRESS WOUNDS, ETC WHILE THE NURSE WAS INTERVIEWING THE PATIENT. THE CT WOULD ALSO TAKE THE PATIENT BACK TO THE TREATMENT AREA IF THE PATIENT NEEDED TO COME IN RIGHT AWAY. THE CT WOULD ALSO REVIEW THE SIGN IN LIST OF COMPLAINTS AND LET THE NURSE KNOW WHAT WAS IN THE WR. THIS PROCESS ONLY LASTED ABOUT A MONTH DUE TO NOT ENOUGH STAFF. WE ALSO HAVE A PATIENT GREETER DURING THE PEAK VOLUME TIMES FOR US - 2P-2A. THE GREETER DIRECTS PEOPLE WHEN THEY ARRIVE AS TO WHERE TO SIGN IN, WHERE TO WAIT, AND ACTS AS A LIASON BETWEEN THE PATIENTS IN THE TREATMENT AREA AND THE VISITORS IN THE WR SO THE NURSE DOES NOT HAVE TO STOP TRIAGING TO INQUIRE. OCCASIONALLY, THEY DO END UP CHECKING OR LEAVING TO PULL A PT OUT OF A CAR, BUT THAT IS THE EXCEPTION. THEY ALSO DO NOT HAVE THE ADDED RESPONSIBILITES AS YOU MENTIONED WHERE YOU ARE AT. WE HAVE RECENTLY REVISED OUR TRIAGE FORM SO THAT MOST ITEMS ARE CHECK OFF RATHER THAN TAKING THE TIME TO NARRATE. WE ALSO HAVE A CORE GOUP OF NURSES WHO PREFER TRIAGE AND ARE ADEPT AND EXPEDIENT. WE ALSO ONLY DO WALK IN'S FROM THE TRIAGE AREA OR THOSE EMS PTS WHO HAVE JUST RECEIVED A RIDE AND WHO CAN SIT IN A W/C AND WAIT THEIR TURN. THE EMS PTS ARE ASSIGNED TO A TEAM ON ARRIVAL AND ARE TRIAGED BY THE NURSE ON THAT TEAM OR CHARGE NURSE IF THEY ARE FREE.
TRIAGE ALSO USES A "DOT" SYSTEM TO CONVEY PRIOITY TO REGISTRATION AND THE CHARGE NURSE. RED DOTS COME BACK IMMEDIATELY (CP, OD'S, SUICIDALS) YELLOW CAN WAIT UP TO 1 HR (ABD PAIN, SOME ASTHMA'S) GREEN COULD SIT IN THE WR TIL NEXT TUESDAY AND PROBABLY SHOULD HAVE STAYED HOME AND BLUE IS OUR URGENT CARE (WHICH ALSO SEES GREENS FROM 1PM - 11PM) OU REGISTRATION WILL REGISTER A RED DOT FIRST EVEN IF THERE ARE 3-4 YELLOW AND GREEN WAITING.
OUR SYSTEM WORKS FOR THE MOST PART, ALTHOUGH WE DO HAVE OUR DAYS OF GETTING BACKLOGGED. WHEN WE DO HAVE THE STAFF(RARELY) TO SEND A SECOND NURSE TO HELP CATCH UP, WE ARE FACED WITH A SPATIAL PROBLEM AND CONFIDENTIALITY ISSUES ARISE.
WELL, I HOPE THIS HELPS. IF YOU HAVE ANY OTHER QUESTIONS OR WANT TO SEE A COPY OF OUR TRIAGE SHEET, I'D BE HAPPY TO SEND IT TO YOU. MY HOME E-MAIL IS SINKERS16D@AOL.COM. GOOD LUCK!
P.S. JUST AN FYI - ONE OF OUR ER NURSE'S HUSBANDS WORKS AT ANOTHER LOCAL ER AND THEY ARE TRYING TO IMPLEMENT A "30 MINUTES OR IT'S FREE" FROM THE TIME THE PT HITS THE DOOR, GETS TRIAGED, REGISTERED, AND PLACED IN A ROOM. IF THIS DOES NOT HAPPEN WITHIN 30 MINUTES, THE PATIENT DOES NOT GET BILLED/HAVE TO PAY FOR THE VISIT. THE STAFF IS IN AN UPROAR!
- Jul 16, '00 by traumaRUsWhew, sounds like my ER here in IL. Our triage system/problems are same. The hospital across the street is also implementing a 30 min to see the doc or your visit is free scenario. Our ED sees 70k/year and is level I trauma center while the one across the street is level II and sees 40k/year. And yes, everyone in this area is also in an uproar. Good luck
- Jul 21, '00 by KSEFLINKOur ER sees ~50k per year. We use RN's and techs in our ER. We have a triage system in place whereby the patient checks into the triage area first (except ambulance patients go straight into the back). A triage nurse and tech work in tandem and then decide who gets priority. We have a "rapidcare" area open in the late afternoon to early AM. We send patients with less acute illnesses, and injuries into a separate area where the wait is less and the main area of the ER can service the acutes more efficiently. The triage "office" is right inside the ER door, so the patients hit this area first. It has worked well for a number of years. The ER is now doing admission right at the "stretcherside" so the wait-time is decreased and we can get patients in and out quickly. The ER also has a medical side and a trauma side so equipment is readily available and duplication is not neccessary. Hope this helps. E-mail me and I can put you in touch with our managers in ER. Good Luck
- Jul 21, '00 by PPLOh great! Who's gonna take the flak when you can't possibly get 'em in by thirty minutes, 'cause you're already so short staffed, and so the hospital loses money by not collecting for the visit? Let's guess who...the nurses??? I feel for you guys and gals. I feel for all of us! Hey, maybe your hospital can really save money if they'd hire one of the greeters from Wal*Mart! They can even use their shopping cart to collect all the bodies that waited too long for treatment, 'cause you're too short staffed to get to 'em. I applaud you! I applaud us all. We're approaching a meltdown!!!
- Jul 25, '00 by mystt53Originally posted by CEN35:
NO comments by anyone?
- Jul 28, '00 by Jo_deye_yuhI work in a physician owned/run clinic with Family Practice drs, Urology, ENTs, Neuro, Internal Medicine, OB/GYN, Surgery, Orthopaedic and Sports Med practices. We have one (1) Triage Nurse for the entire facility. I am the Ortho/Surg nurse and at one time in addition to being the Ortho Nurse, I was the Triage, and Urology Nurse. We recently hired a nurse to specifically do Triage. The sheer volume of calls and walk-ins is staggering and impossible.
*The current process is...the receptionists take a brief (sometime illegible) message, call for the chart, then the chart with message is placed in a wall mounted chart rack made to hold one chart...usually 5 charts are crammed in it, with 5-8 stacked on the floor below it. Then the Triage Nurse, keeping a frugal eye on the "box" comes by to retrieve the stack and begin the process of deciding who to call first to see what exactly they need or the problem is. After making a few calls, she is paged to another department to take a B/P on a walk-in, or give an allergy shot or B-12 inj, or hunt for med samples for a patient. All the while the "box" is filling with more messages, people she called ealier but did not answer are calling back after recieving her message...etc etc. Then she stacks the reviewed charts into piles of urgency. Then has to go to the dr of that particular pt to ask course of tx. But at that time the dr is in a room seeing his scheduled pts. So she stands waiting for the chance to pounce the minute the door knob twists. Then at the end of the brutal day...after walk-in head lacs, spotting OB's, sick babies, and running errands for all the other nurses...she then starts to delve into the mountain of charts of pts req med refills. Finally, document everything she did for each pt.
The one thing we have established that facilitates a bit of expedience is, obtaining standing orders from most of the drs. This allows her to just flip through the dr list and see his req and if labs and visits are up to date can call in the refill without having to wait for him to verbally Okay. All in all our clinic Triage is horrid.
I have read the above posts and though mostly directed at hospitals, I can draw some valuable tools for the trade. I would welcome any and all additional input toward Triage. Ideas that promote timely response, appropriate, streamlined questions to ask the pt calling, and ideas for forms/systems that allow for pt satisfaction and adequate information for tx.
[This message has been edited by Jo_deye_yuh (edited July 28, 2000).]