Efficient triage system????

Crocuta, RN · Jul 22, 2009

Our system consists of four "bays": a sign-in booth, two triage bays, and a registration bay.

During peak times, flow goes like this:

Patient presents to the sign-in booth which is manned by a member of the registration department. They sign in on a form which gathers the basics - name, DOB, C/C. Reg clerk assembles a chart and places it in a basket. Pt then waits to be called (goal 20 minutes or less.)

Pt is called to one of two triage bays by an ED tech who gathers vitals, allergies, meds, bands the patient, and field dresses anything dripping blood.

Nurse takes over Patient #1 while ED Tech gets next patient into the other bay. Nurse completes triage and returns the patient to the waiting room. Chart goes in a needs to be registered box. If registration gets to them, they'll call the patient to the registration bay and complete insurance, L&I paperwork, etc. Sometimes I'll have registration just come over to my triage bay and do registration if in my estimation it would be a burden to keep moving the patient around. When reg is done, they put the chart in a "fully registered" basket. We do not hold in the waiting room for registration, though. We have bedside registration folks, and if there are rooms, we just bypass the front reg people.

With the right ED tech and the right patients (i.e. none who try to tell their whole life story in triage) I can see one patient every five minutes during peak times by the tech and myself alternating back and forth between the two triage bays and directing them to return to the waiting room. If rooms are available, we can triage and room a patient every 7-10 minutes. If the tech is just starting with the next patient, I'll take the patient I just finished with back to the room myself. If it sounds like the tech is nearly complete, I'll go jump on the next patient while the tech rooms the previous one.

We also do quick triage during periods where patients are coming in faster than I can see them. Sometimes we do it ourselves, but often we can get another nurse or the charge to grab the entire stack of waiting to be triaged charts out to the waiting room and we see everyone for 30-60 seconds right where they're at. We just find out why they are there and do a quick eyeball assessment. That time gets noted on the chart along with the c/c and major symptoms. We're able to keep our time to RN under 20 minutes this way.

That's how we do it. As I said, and you know, it all depends on the staff assigned to triage. Triage has one point: to decide who needs to be seen and who can wait. That can be done in less than five minutes for most patients. It's not about full assessments. Prolonged triages in my experience usually come from nurses who have anxiety about missing something and sending a critical patient back to the waiting room.

Now where it really gets rough is when our waits start hitting 2-3 hours, then I add in a whole component of blood draws, EKG's, radiology studies and preemptive lab work. Those are the times I'd love to have a second tech and another curtained bay available. Then I could really process some patients.

Hope this helps - good luck!

gentle_ben_RN, ASN · Jul 23, 2009

My hospital started using what we call a "pivot" nurse and it has been very successful. An RN is stationed in the lobby along with a tech and a greeter. The reasoning is that the RN is the first person to lay eyes on every patient that comes through the door. That way, depending on the criteria they meet, we can direct them straight to fast-track (stitches, wound recheckes, toothaches) or to regular triage, or we take them straight back if they are really sick (possible MI, CVA ect.). Also, the pivot RN takes all patients who are C/O chest pain directly to an EKG room where we do and EKG in less than 10 mins of arrival. That way if the patient is having an acute MI or STEMI, we can score a really fast door to balloon time for the cath lab. We've been doing it since february and it has really made a big difference.

cookienay · Jul 23, 2009

All of our nurses sign in with an RN upon entering the dept. Depending on c/c, gross assessment, and protocols the patient then goes to one of three places: directly to a bed, triage room for completion of triage, or lobby. Obviously, patients go to bed if one available. Otherwise they are triaged according to severity. If we get several patients backed up and have beds open, they go to bed and triage gets completed back there. THis works most of the time and we have 2 triage bays open for peak times. We also see over 200 pts a day most days. Must have for the triage nurse- GREAT assessment skills, customer service skills, thick skin, and not easily swayed by histrionics. Have fun.

Rickbos · Jul 23, 2009

At my hospital we use a 5 level triage system and try to limit the intake to 3-5 minutes maximum for each patient. I designed a patient executed triage sheet that the patient completes prior to being triaged. It has their name, DOB, PCP, reason for visit, allergies, and medications. The med list is verified by the triage nurse and the sheet becomes part of the record. The med list completely complies with the Joint Commissions NPSG #8 for medication reconciliation. We find that this triage sheet shortens the triage intake dramatically. Time can be dedicated to the patient's past medical history and the reason for their ER visit instead of sitting there watching them fumble through their purse/wallet looking for their med list or telling you their doctor knows what meds they're on. We don't have electronic charting but use a Nursing T-Sheet system that focuses your triage to the specific patient complaint.

Crocuta, RN · Jul 23, 2009

We find that this triage sheet shortens the triage intake dramatically. Time can be dedicated to the patient's past medical history and the reason for their ER visit instead of sitting there watching them fumble through their purse/wallet looking for their med list or telling you their doctor knows what meds they're on. We don't have electronic charting but use a Nursing T-Sheet system that focuses your triage to the specific patient complaint.

I've been trying to get traction for a patient completed med rec for a while. How long have you been doing this, and how did you make the transition? How do you deal with crummy writing?

We also use the T-system. Do you just fill out the left hand side of the front (Triage section) or do you also do the Initial Assessment section?

Rickbos · Jul 23, 2009

About a year ago, in an attempt to comply with NPSG #8, our hospital wanted full med recon sheets filled out on every ER patient, including dose, route, frequency,and last dose, despite the fact that TJC allows a modified 3-tier med recon approach for ER patients. In the majority of cases it requires a less stringent med documentation unless the reason for their ER visit dictates a more focused review of specific medication dosages etc. As you know that full list completion can be very time consuming and can bog down the triage process.

My research and communication with TJC produced info that said a photocopy of a pt med list, or a patient generated med form would be in full compliance with the standard as long as the triage nurse documents verification of said list and it is made part of the record. There was resistance from my management who found it easier for them to track to have their form used everywhere, despite the time it took for us in the clinical setting. We are unionized and represented by the Massachusetts Nurses Association so our ER staff first signed a petition to institute the patient executed form. When this was denied I filed a grievance involving a change in working conditions. As the date for arbitration closed in management agreed to trial the form for a month and review it. I withdrew the grievance, the review was favorable, and we have been using them for about 4 months now. It really has streamlined the triage process. We correct spelling if needed on the medication area or re-write the list if there is bad handwriting, but that is still far less time consuming than doing the whole thing from scratch. We also have the patient sign the form so they are taking responsibility for their own safety while in the hospital setting. This is encouraged in NPSG #13.

In regards to your T-Sheet question, in triage we only complete the left side/triage portion of the T-Sheet and if we give any anti-pyretics or other triage allowed medication, we chart that in the medication section. Hope this helps.....

Rickbos · Jul 23, 2009

Crocuta

I don't know how to get you a copy of the Triage Form you requested via private message. I cannot reply to you for some reason in that area......