ED triage woes - advice appreciated!

[kmoonshine, RN]

please offer your suggestions on how i should deal with some issues that are really getting under my skin. i need to get some of these thoughts off my chest and even though i love my hubby dearly, he doesn't truly understand the frustrations i am having right now at work (i'm convinced that only fellow nurses truly would understand where i'm coming from).

ok, here i go.

i work in a 32-bed ed that's divided into 3 areas: there's the main ed arena, a second ed arena (open from 11am-11pm), and a fast-track area (open 3pm-11pm). the main ed arena sees everything and is designed to handle it all. the second ed arena is meant to care for triage level 3-5 and is staffed by 2 nurses, 1 tech, and 2 pa's/np's (there's a total of 8 rooms, plus 3 police hold rooms). fast-track is self-explanatory.

i've been staffing mainly in the second ed arena lately. there is a higher nurse-to-pt ratio compared to the main ed arena, but the acuity is supposed to be lower (so i guess it should cancel each other out). lately, triage has been really screwing things up and i've been getting really really sick patients (not to mention inaccurate report from triage). i can handle sick patients; but, not when i have 6 other patients and they are all mis-triaged and in need of immediate medical care.

for example:

1. triage gives me a 39 yo pt with c/o "multiple complaints". urine sent at triage; i ask "were their vs ok?", and their reply is "yeah" (this is the extent of triage's report to me). i grab the chart and go into the room - i see that the pt is tachy at triage (128) and had been in the waiting room for over 2.5 hrs; they were initially assigned as a triage level 2, but this is crossed out and instead "3" is written. pt reports some nausea, abd. pain; tells me she is insulin-dependent and has not been taking her insulin at home, nor has she been checking her blood glucose. states she is really thirsty and has been urinating a lot. the pt had not been revitaled since initially presenting to the ed; i get vitals, and she is still tachy, bp wnl; no one checked her blood sugar at triage! triage did write down "iddm" under her medical history, so why was someone that was tachy with poorly controlled diabetes allowed to sit in triage for over 2.5 hrs while no one grabbed a blood sugar on them?!? i grabbed a quick accucheck and the monitor read "critical high". anyone wanna guess the diagnosis? drumroll please.....the pt was in dka. so, they get the full workup complete with an insulin drip (i'm not sure which unit this pt ended up being admitted to).

2. triage brings back a 10 month old child, c/o fever (104.3 pr at triage). i ask "was tylenol given per protocol?"; the answer was "no". triage states that the pt saw their regular doc and had a negative chest xray, states the pts vitals are wnl; i ask "has the child been vomiting or had diarrhea?"; triage states "no". i go in the room, and the kid looks toxic - hr 210, rr 66, wheezing, lethargic, pulse ox 93% on room air, no urine output, crying without tears, rash across entire torso...w-t-f?!? the child is inconsolable and is barely fighting me (usually cranky kids will get increasingly upset as i assess them, but this kid just gave some pathetic grunt-cries which was not normal); mom looks very worried. needless to say, i call the charge nurse and i tell her that i need a main pediatric room for this pt (its our pediatric code room with appropriate pediatric equipment), and i take the kid over to the main ed arena. within one hour of transfering the pt to a new room, i had overheard something about the pt needing a non-rebreather mask - the kid was definately admitted. wanna guess what the triage nurse gave for the pts acuity level? how about a 4... (and this was a slow day; no one else at triage, many rooms open in the main ed arena). toxic appearing, high fever, dry mucus membranes, tachycardia, tachypneic; plus, their age would make them "high-risk" - arent they automatically an esi 2?!?

3. i get a phone call from triage - they have a patient with a "possible inguinal hernia" and there wasn't any available rooms in the main ed arena; so they want to know if they can bring this patient back to me in the second ed arena. i grumble "fine". i am reassured by triage that "we're downgrading him from a level acuity 2 to a level acuity 3 so we can bring him back to you." the pt finally comes back to me. i look at the chart - they are hypertensive (200/120), c/o sudden onset abd. pain pta; the pt was 81 years old and had been in the waiting room for 3 hours!!!! no one has revitaled the pt since they initially presented to the ed; no one initiated protocols (cbc, cmp, ekg, troponin, ckmb, lipase, ua...). can we say r/o aaa? hello!?!? as i put in an iv and draw labs, the pt states "my pain is actually gone now." stat ct shows a incarcerated bowel. the pt is admitted and was scheduled for surgery. due to the pts age, shouldn't they be considered to be a high-risk population? coupled with high bp and "excruciating" pain - aren't they automatically an esi 2 and should be seen asap? the pt really looked uncomfortable and was so nice about everything - he didn't complain at all, which is why taking care of the sick elderly can be so difficult (they can be crashing and won't bother you at all; meanwhile, the 22 yo next door is abusing the call light because "my toe has been hurting for months now and i need pain medicine right away!!").

4. elderly lady with a cast on her left arm - broke her wrist new years eve. this is the full report from triage: increased left hand pain, decreased cap refill, and swelling with redness. guess the triage level - how about a 4! i go to see the pt; decresed cap refill distal to the cast; digits taut, shiny, reddened/purple in color, and hot. pt reports paresthesias in the left hand. i come to find out the pt has a history of left breast mastectomy. i guess the cast "fell off" on wednesday and was replaced by ortho on friday. shouldn't someone with compromised peripheral circulation be given a higher esi level than a 4? isn't compartment syndrome considered to be limb-threatening? this situation just irked me because if you can't triage this, then why are you out at triage at all?! scary...

5. middle-aged lady with sudden onset abd. pain last night. pt is diaphoretic, short of breath, and tachycardic; she can barely get into the bed. has a history of small bowel obstruction, ovarian torsion, hypothyroidism, iddm, chf, asthma, pe, pad, htn, kidney failure (not on dialysis yet but dang close), appy, chole, hysto, strangulated hernia, morbid obesity, and so on. my report from triage was "abd. pain". ck was 588, trop was "gray zone", wbc of 20, potassium of 2.7, ckmb of 9.7, bnp

i understand that triage gets busy. i've done triage myself and i must say that triage in this hospital is much easier compared to other places i've been at (lower patient volume, not having to pull people out of cars, rarely are there more than 4 people waiting to be triaged at any given moment; in contrast, i'm used to being 10 pts deep at triage at other facilities). triage is a big responsibility, and leaving some of these pts waiting is negligent! someone is going to get killed should this behavior continue. when you triage someone, cut through the bs, get the data you need (blood sugar if necessary, since it will influence whether someone can wait, or whether someone needs to go back to a room now), and send them to a room right away if they cannot wait. imho, hyperglycemia, febrile, tachy, and severe pain cannot wait unless you can explain to me why they are able to wait (ie 45 yo c/o severe toe pain for 3 weeks, ambulating and eating chips at triage, no obvious distress, no beds available; or, 25 yo c/o nausea without vomiting, fever of 101.1, tachy at 104 but bp wnl - tylenol given per protocol, pt instructed to notify staff if change in condition while in waiting room, no beds available).

the second ed arena is meant to function for stable pts who can be cared for efficiently then discharged. for example, 22 yo c/o nausea/vomiting (a few episodes), normal vs; so i'll put in an iv, draw cbc/cmp, get a ua and check for preg, give iv fluids, perhaps give some zofran and pain meds...maybe the pt will have a bedside us or go for ct with contrast. we get them feeling better, rule out any immediate problems, and either admit for observation or discharge home with meds. this type of pt is fine to wait in their room for a bit should i be tied up with another pt. the situation is different if it is an 88 yo c/o nausea/vomiting, tachycardic and hypotensive, extensive medical history including dm, esrd, chf, mi, bypass, small bowel obstruction, and is acutely confused with low pulse ox. can i handle this pt? heck yeah. can i handle this pt with a high pt load, along with not having the necessary equipment to treat this pt since they are in a lower-acuity ed arena? no.

i am getting very nervous working in the second ed arena as the above situations are just a few examples of what has happened to me over the past 3 days. i've been weary of increasing my pt load for fear that there is "more to the story" and i'll end up with a critical pt and no resources. or worse yet, i walk into a room after the pt has been waiting 20 minutes, and i find them circling the drain. its one thing for triage to say "there are no main ed beds and this pt needs to be seen now; they need an iv i'll have a tech start that; i ordered an ekg and some preliminary labs, and i got a urine sample; i'm concerned about this pt so let me know if you have any other questions." its another thing to say "here's another pt, here for abd. pain - they're fine."

i feel like i can do my job much better if i have the whole story. i feel like there are some things that triage overlooks (both accidently and intentionally). i know you only have a few minutes with a pt; but if i can look at a chart and say "great, i bet this pt is in dka; why don't we have a blood sugar from triage?", then there's something else going on. i am a very thorough person and i don't know if i'm just being nit-picky, or if my response to this situation is justifiable. because quite honestly, in the end i feel like i'm not doing enough despite running my butt all day. i keep thinking "these people should be in and out; and since i'm backed up we now have a full waiting room but i can't take on more pts because i have one pt that is going to icu, another who i haven't seen yet, a pt who has a small bowel obstruction, a pt complaining of suicidal ideation, and a med clearance in the police room who is combative." i look at the tracking board and see "esi 4, 3, 4, 5, 3" and think "esi 1, 2, 3, 2, 3".

i feel that it is critical to have an experienced nurse triaging (someone who knows what they are doing, mind you). using esi gives us objective data that can be used to advocate for resources (staffing, equipment, etc). it is useless to down-triage someone to make it appear "ok" to take them to a room that is not adequate to handle the pts condition. incorrect esi assignment makes it appear as if a nurse has a manageable pt load ("hey, she only has a level 4 and 5 - one pt needs 1 resource, another needs 0 resources; give her another pt").

fyi: 4 out of 5 of the above pt scenario examples had been triaged by one specific nurse. this very nurse put a 60 yo alcoholic in fast track, c/o head lac after falling and hitting head; pt smelled like a beer barrel. can we say esi 2 - ct head, labs, etoh=high risk, suture repair, and so on? well, this pt had a subarachnoid bleed - totally not appropriate for fast track. med refills, simple toothache, sprained ankle = fast track. what was triage thinking?!

all of this is way beyond your simple "surprise" pt (you know, the pt that looks great, requesting to go home, vague symptoms; and wham, labs come back and something is way off; a one-in-a-million situation that no one saw coming). if i can look at a chart and see "it" coming, then its not a "surprise" pt. i don't know it all, but i do know that spending an extra 30 seconds to triage someone appropriately can make a difference!

thanks for reading this whole long post, and thanks for your time. i want to see the positive in my coworkers and get all these negative frustrations behind me.

[Kingbandit]

#1 Your institution should invest in computer charting of some sort where you (staff RN) can see what is out in triage in real time.

#2 You need to go to administration with documentation of specific events. When this happened in my institution administration forced the particular offender to take a remedial assessment class and pass a proficency test before she was allowed back into triage.

Patient safety is the number one goal and inappropriate triage puts patients at risk. I worked hard to get my license and I can't say "well she didn't triage right." I am ultimately responsible for my patient that is assigned to me. If you do not agree with their triage call the charge or go over her head but do not risk the patients life because "you don't want to get anyone in trouble."

[Altra, BSN, RN]

#1 Your institution should invest in computer charting of some sort where you (staff RN) can see what is out in triage in real time.

#2 You need to go to administration with documentation of specific events. When this happened in my institution administration forced the particular offender to take a remedial assessment class and pass a proficency test before she was allowed back into triage.

Patient safety is the number one goal and inappropriate triage puts patients at risk. I worked hard to get my license and I can't say "well she didn't triage right." I am ultimately responsible for my patient that is assigned to me. If you do not agree with their triage call the charge or go over her head but do not risk the patients life because "you don't want to get anyone in trouble."

I can't emphasize enough how much I agree with Kingbandit's post above.

Who is changing the assigned acuity of patients and why?? Is it one or more charge RNs who misunderstand the purpose of assigning acuity? Or is it one or more triage RNs who are thinking they are accomplishing something by emptying the waiting room?

Triage is NOT simply someone who smiles prettily enough to placate the waiting room of angry people and puts some data into each box on a piece of paper. I've had the misfortune to work with a manager who believes this to be the case -- I feel your pain.

[Vito Andolini]

Your triage nurses are screwing up badly. Please go to the Manager, supervisor, Chief doc, somebody in authority and see to it that this stops. All the cases you describe sound like terrible nursing judgment and care, life- and limb-threatening. How is the child with the resp rate of 66 and p > 200????

[rn-n- 2005]

I agree with all the above posters. We have a Dr who has stated on more than one occasion that triage is "one of the most important jobs in the ER." The triage nurse must have good sound nursing judgement and lots of experience. We have 2 people at triage from 11 am -11pm. That seems to help, also. New grads should not be out there.

All of your scenarios, I totally agreed with you ; kids are so scary because they crash so quickly and the elderly man with the sudden onset of belly pain, hypertensive, AAA is what you r/o first!!!!

Management needs to be aware in writing because this is a terrible accident waiting to happen.

[mcvaragon]

I would suggest the following:

1. If you have shared governance, suggest they do an ESI Audit Tool. If you don't, bring it up to leadership.

2. I would ask that your leadership approach flow differently as unfortunately, many nurses choose answer "C" or ESI level 3. There are some hospitals that perform the flow a little differently: The 1's and 2's go straight back to main, the 4's and 5's go to the urgent care/ Fast Track. The 3's get protocols, some point of care testing, get re-evaluated and sent with the 1 & 2's or back with the 4's and 5's.

3. I would also remind your charge RN that just because a patient came in as a level 2 doesn't mean they remain there.... you could have turned around a CHF'er and now there a 3. Also, the little old lady who came in as a 3 for the perpetual "altered mental status" is now in the late stage of sepsis from her UTI so of course she has altered mental status and now she has no "pressure".

We need to use our assessment skills and more importantly our "reassessment" skills. Always ask for help, even if it is just for 10 minutes to get you out of the woods. I know nurses hate to ask for fear of the 'dramatic eye roll and the deep sigh' or worse yet "I've got nobody to send you".

but always ASK!

[cookienay]

Completely agree with above poster. What many nurses do not realize is the triage nurse has one main duty. That is to KNOW "sick" or "not sick". Lethargic child with HR >200 and RR 66 is sick. If a child is that ill you can take one look at them and know that. And we all know kids compensate for a long time, but when they stop... watch out.

I don't know what your culture is at your facility, but here is how I would handle it. First go to charge nurse and have them address the inappropriate assessments. As a charge nurse, I have pulled nurses out of triage before. Not a popular thing to do, but necessary. If it continues, approach the manager with specifics. Hopefully, your management team is as effective as ours and will address it.

Also, keep in mind triage is a tough place to be. It is a hard job to be the gatekeeper to hell.

best of luck to you.

[Dragonnurse1, ASN, RN]

Well Kmoonshine, :banghead:you certainly are at the mercy of a very incompetent triage nurse. A pediatric patient with resp of 66 should not have stayed in triage at all once the nurse counted those resp.:doh: That patient should have come in by ambulance, bypassed triage, do not pass go and no $200, and should have been in the "main ED" (around here that would be the trauma beds)

As the others have posted you need to give your charge nurse a "write-up" on all the incidents you mentioned. We have a form that we used for "unexpected outcomes" and we placed these kinds of bad assessment and level assignment on those forms. Keep a copy for you and if nothing is done contact your shift supervisor, here once the shift supervisor (on nights anyway) got the report he/she made sure the complaints are forwarded to the correct administrative department for follow-up.

There is always one nurse that truly does not belong in triage, doesn't like triage and would do just about anything to get out of the assignment. The bum-fuzzing of this level can land everyone on your shift in hot water.:smackingf

Here a level assignment cannot be changed :angryfire unless the patient has been re-evaluated and the charge nurse approves the change but so many of the scenarios really required the patient be treated as a 1 or 2 and these patients are not triage patients - they should be walked back and placed in a bed and give the charge nurse a quick report on the patient:redlight:

No one is a perfect triage nurse but using common sense makes things better -I would rather take a borderline patient to the back and find out that the patient was not as critical as I felt. Two of my favorites were a "broken member" and a very sweet lol with resp difficulty. Everyone on the fast track burst out laughing about the "broken member" until I told them that 1: yes it can break and 2: it is very serious and the patient could not wait (he was a 3). Patient went to surgery within 20 minutes. And the little old lady she walked in, she answered all of the triage nurses questions, was directed to wait in the waiting room. I walked out of the ER to get a drink from the coke machine and noticed her using pursed lip breathing, her very barrel chest and got the triage nurses o2 spot checker - 43 O2 sat on room air. I tried again, 43 no way, guess what - way. We took her back and her ABG's were 32:smackingf. Lasix, bumex, demadex then levophed:eek: Leave them dead levophed - the lol was able to walk out when she was discharged.

Hang in there and write up the problems, I know this sounds like the proverbial beating a dead horse but you must - it is your licence and we all promised to "First do no harm".

In the words of our most beloved ER MD - Koko

[llltapp]

kmoonshine,

I feel your pain. We have been 20-30 deep in triage for the last few weeks... but we have had two triage nurses and a PM revitalizing. It can really rock your world when the triage nurse is clueless. Make no mistake.... it IS the most important job in the place. I used to do full time triage during busy season and most of the time you can paint a bullseye on your back because nobody is happy all the time lol. But in your case, you need to document your concerns with this nurse, keep it on file........ and to be honest with you, if they let her work triage after that without significant education and remediation.... I'd quit in a minute! Wish you well

[busymother24]

I am a triage nurse and I think I do an excellent job, but from all the points that you listed, I think the triage nurses at the facility you work at should take more time out and pay attention to what they are doing. As triage nurses, specially new ones, some tend to think their job is not important but we are getting the vitals, finding out what's going on with the patient and getting them ready to be seen. One triage nurse, who is no longer with us at our clinic, might I add, had an EMT license and didnt even know how to take a BP. He was sending back "stroke" level BP's, not to mention, not alerting the M.D or P.A on duty but just highlighting them and so when it got back to us in the treatment area, we recheck it and it's twenty times lower than what was initially recorded. I think supervisors should be alerted and something done about matters like this, because these are real people you are dealing with and once they get to your facility, their life is in your hands. We need to all work together to see that everyone does their part so that patient needs are met. Great Blog and so true. I hope everything gets better where you're at, for the patients' sake.:up: