Dealing with triage

XmasShopperRN, ASN, RN · Jan 13, 2013

I've worked with some triage nurses who are as tough as nails; no matter what someone or even a group of people says to them, it just rolls right off of their backs. Easier said than done I know. You can't please everyone all of the time. There's always going to be someone who, whether out of a sense of entitlement or just feeling really crummy, will believe they are the sickest of the sick and deserve to be seen now. But you're the one in control. You're the one with RN after your name. Remain confident in your clinical judgement, and keep reassessing per protocol. For those who refuse to follow the rules, firmly set limits. Where I worked, a cop was always present less than 10 feet from triage, and had no issue with intervening and even tossing unruly people out on the street if need be. There was actually an instance when the cop had to taze an out of control person in triage!

XmasShopperRN, ASN, RN · Jan 13, 2013

Also, I'm not sure about how your ER works, but utilizing any protocols that your ER has in place prior to patients being seen may help alleviate some patient frustration. For example, whatever the cc is, perhaps you can initiate tests in triage that you anticipate would be ordered eventually (xrays, line and labs, urine hcg, etc). Patients appreciate when they don't feel like they're being put on the back burner.

TeresaEDRN06 · Jan 13, 2013

I simply say that I am trained to know who is sicker- that's my job. That's it. I don't get into a big discussion because of what was stated above- the more you try to rationalize, the more people will argue.

Teresa

Esme12, ASN, BSN, RN · Jan 13, 2013

My last triage shift two babies with colds came in, stable vitals, low grade fevers. Both to the waiting room, and one was a 3, one was a four triage level. Obviously the three went in first, but the four was fussy and crying in the waiting room, resulting in more snot, and general misery. Dad came to triage angry that the less sick baby got to go in first, and I told him the sickest are seen first. He felt his child was obviously sicker, and got some support from the waiting room crowd.
His child was more vocal, and better hydrated, and not as sick per triage rules. The other baby had an RSV and intubation history, but I can't tell them that because it's confidential. But the entire waiting room turned hostile that night, because it was obvious to them who was sicker. No matter what I said or how, in their eyes I was wrong, and could potentially be called rude. I offered all the nursing interventions I could, like juice, or diapers, but they wanted to see the DOCTOR, not me.
Some variation of this happens every night. Twice I've had patients pee in the triage chair and all over the floor, and say they couldn't possibly go to the waiting room, triaged a 4 before they peed. There are lots of tricks to get ahead of the line, and it gets wearisome.
Vomiting is another one, a retching patient looks pitiful and usually goes back, but they've jumped several hours of waiting. A young woman was over served the night before and came into the ER with the dry heaves with her Mom. Mom didn't know why she was vomiting. Pt wasn't orthostatic, and she was clear about the cause, so I made her a 4. My life would have been much easier if I'd brought her right back, because with the chest pains and an MVA she was lying on the ER chairs for 4 hours, and had stopped retching, but looked darn pathetic. A volunteer firefighter, unrelated to the patient, helpfully told me how sick she was, and that she needed to see a doc. (Thanks a lot.)
So who else has this problem, and how do you avoid the triage nurse hatred syndrome? I've tried bringing out unused gerichairs to the waiting room, but I have to police that, so it has drawbacks. Also, next time people come in they ask for a recliner that may not be available, or they may not even be the sick one in the group. (roll eyes)
Anyone have ideas?

Depending on your facility....there may be some things you can do to placate people........but for the most part it's not possible that is why we always called it the penalty box. You are the evil witch of the west. Grab a broom and wear it with pride. Some days there is just nothing you can do to make it right.

I will tell you that even after working a rough inner city the most threatened I ever was by a commercial airline pilot who felt that his child's (documented 99.9) rectal temp after immunizations wasn't care for emergently enough, grabbed and cornered me in triage threatening he was going to show me what urgent was if his child wasn't seen.....and to think he sits behind the controls of an airplane loaded with people. (he went to jail by the way)

((HUGS)) just some days it stinks. I explain that the reasons behind why one person is seen versus another is very scientific and that all the staff are educated and experienced in this.....and that I cannot discuss the reason nor the other patients case and that is a breech of confidentiality and HIPAA....that they will be seen a soon as we can......then go tell the charge nurse and the sup that they are being a pain and is stirring up the natives. When I would be in charge sometime I would move these people even to a wheel chair in the hall just to stop them for firing up the Waiting room and causing a riot....a crowd control issue.

UK_RN_AJ · Jan 13, 2013

My last triage shift two babies with colds came in, stable vitals, low grade fevers. Both to the waiting room, and one was a 3, one was a four triage level. Obviously the three went in first, but the four was fussy and crying in the waiting room, resulting in more snot, and general misery. Dad came to triage angry that the less sick baby got to go in first, and I told him the sickest are seen first. He felt his child was obviously sicker, and got some support from the waiting room crowd.
His child was more vocal, and better hydrated, and not as sick per triage rules. The other baby had an RSV and intubation history, but I can't tell them that because it's confidential. But the entire waiting room turned hostile that night, because it was obvious to them who was sicker. No matter what I said or how, in their eyes I was wrong, and could potentially be called rude. I offered all the nursing interventions I could, like juice, or diapers, but they wanted to see the DOCTOR, not me.
Some variation of this happens every night. Twice I've had patients pee in the triage chair and all over the floor, and say they couldn't possibly go to the waiting room, triaged a 4 before they peed. There are lots of tricks to get ahead of the line, and it gets wearisome.
Vomiting is another one, a retching patient looks pitiful and usually goes back, but they've jumped several hours of waiting. A young woman was overserved the night before and came into the ER with the dry heaves with her Mom. Mom didn't know why she was vomiting. Pt wasn't orthostatic, and she was clear about the cause, so I made her a 4. My life would have been much easier if I'd brought her right back, because with the chest pains and an MVA she was lying on the ER chairs for 4 hours, and had stopped retching, but looked darn pathetic. A volunteer firefighter, unrelated to the patient, helpfully told me how sick she was, and that she needed to see a doc. (Thanks a lot.)
So who else has this problem, and how do you avoid the triage nurse hatred syndrome? I've tried bringing out unused gerichairs to the waiting room, but I have to police that, so it has drawbacks. Also, next time people come in they ask for a recliner that may not be available, or they may not even be the sick one in the group. (roll eyes)
Anyone have ideas?

As harsh as it sounds, there is no hard and fast way of keeping everyone happy. Your the nurse and at the end of the day, the one whose decisions will save someones life and its not up to the patients to decide who goes first as it will be you who will lose your registration not them, if something goes wrong.

Some of the things I do is to keep the patient and family as up to date as they can be. Explain things to them as you do it, explain there signs and symptoms , and why your doing a blood pressure, keep you tone light and friendly and smile back. Answer any questions they have as honestly as you can, be in control.

if you get a spare minute (on the extremely rare occasion) redo there blood pressure get them a glass of water if allowed. If someone is stirring up trouble in the main waiting room as esme12 says try and move them away from the others, it doesn't mean they will get seen any sooner but they will be one less ingredient to disaster.

BrnEyedGirl, BSN, MSN, RN, APRN · Jan 13, 2013

I've been known to say things like,...."Obviously I'm not allowed to share a patients personal health information with others in the waiting room, but we have had a couple of babies in tonight who had open heart surgery a week ago, and as you can imagine that adds to the urgency",....sometimes it works, sometimes people just don't care.

hiddencatRN, BSN, RN · Jan 13, 2013

"A loud baby is a reassuring baby. If your child was quiet and limp we'd be worried, but your child is producing tears, and has plenty of fight in her."

Rhi007 · Jan 14, 2013

Just out of curiosity was the person who brought the 2 kids in the parent? If they were why can you not tell them about the history of a child re: RSV and Intubation?

I think you need to be thick skinned to do triage....I did my 4th shift in triage and I had a bikie gang come in demanding to see a member, bikies scare the crap out of me but I got backup with security and senior RN....

**canoehead, BSN, RN** · Jan 14, 2013

Thanks, I'm in triage tonight and just had a 20yo faint twice without a change in vital signs or pallor. I get that people don't feel like walking 10 feet to triage, but that mean they CAN'T. CAN'T involves a change in vital signs.

While I'm at it, "I can't breathe," in the ER means sats less than 95%, otherwise it's just hard to breathe.

Perhaps I'll give an impromptu inservice.

**canoehead, BSN, RN** · Jan 14, 2013

Rhi007,

Two different sets of parents, each with their own child. so I can't discuss one child with the other child's parents.

hiddencatRN, BSN, RN · Jan 14, 2013

And if it was one family, that would be a twofer and they go to the same room together at places I work. AND if it was the same family, it'd be really weird for one parent not to know about their other child's intubation and higher risk status and to be freaking out that their other child is getting treatment.