OPINION PLEASE-er triage situation-overwhelmed!

[Uptoherern]

:angryfire My newER director has recently told us that we are triaging "wrong". As an example, she said that a patient recently signed in as "lady partsl bleeding". The pt. waited in the waiting room for 1/2 hour, then left to go to another hospital and miscarried in the parking lot. Her point was, the triage nurse should;ve gone out to the waiting room and asked the pt if she was pregnant. So What? I should have been more assertive, but now I question was the pregnancy viable? Were there 10 people to triage before her? Were we on diversion? Were we holding multiple admits? were there 4 ""chest pain" patients in their 60's and 70's before her? Where was I supposed to put THEM? Was the charge nurse available to help triage? If we were absolutely full to the brim, what was the triage nurse supposed to do? AARRGH. waiting times where I am are 8-10 hours. sometimes even 10-18 hours at county hospital.. If we are full to the brim, what are we supposed to do? I must've blanked out at this discussion, although I was "greatly irritated" (read: really pissed off_) I, for some reason, couldn/t defend us at the time. the more I think about it, the more it irritates me. Any suggestions? Any good replies? I was not the nurse in question. I was in triage last night, and was ordering labs/xrays whatever I could to help speed up things. I do my job and I do it well, but sometimes we are just overwhelmed and we have absolutely no power over the situation. I don't need my "boss" to tell me how to triage. Let's see how SHE does!:angryfire

[Noryn]

I worked the ER for a few years and near the end I was ready to quit, take a minimum wage job and go back to college. It is bad--when you have management that doesnt understand or doesnt support you it is unbearable.

I would show the ER manager the recent report that Emergency Care in the US is getting failing grades. You can only do what you can do. If you have someone short of breath or having chest pain I dont see how you can put someone with lady partsl bleeding ahead of them unless they are bleeding out.

I misunderstood your original question. I thought she meant the nurse was not asking the correct questions during triage.

My only advice to you is to quit the job if you are that unhappy. Again the ER is really really bad. It would be hard enough if it was only being used for emergencies but with everything it is just crazy.

You can try to talk with the nurse manager or management but most arent going to listen to you. There are so many factors to the equation. Even if you had more nurses, you would need more beds then you would need more doctors. It is a no win situation. I wish I could be more positive but you sound as if you know what you are doing and you know what the problem is. I have a feeling you are venting here because the nurse manager wont listen to reason--imagine that :angryfire

[CrunchRN, ADN, RN]

Ya gotta love it when management holds you to this high standard, but will not give you the staffing required to meet it. My heart goes out to you.

[ernurse23]

My thoughts exactly. Every pregnant vag bleed is a miscarriage/possible miscarriage and if they dont need a d&c that night, they go home. We never fix vag bleeding and save the fetus.

[Uptoherern, RN]

ah well, vent over....gotta go to work!

Actually, I am supposed to work 9-9 today, but am on call making something like $2 per hour. Then, when they need me, (and they WILL need me..it is Monday!) they will pay me time and a half. I usually make more money when I am on call, than I would have if I just went in when I was supposed to in the first place. Oh, but I forgot! Our HOURS look better to management! OK! Makes sense to me now!!

[10MG-IV]

And if you DID ask if she were pregnant, would the ER Director expect you to have put the (example) 4 chest pain pts. in their 60's or 70's aside...? Of course not. It seems that the Director has 20/20 hindsight. Second-guessing staff is just flat out wrong. It may seem cold but I'd rather see a miscarriage than lose a pt. to an MI. To a lesser degree, if she wasn't visably pregnant but knew she was, wouldn't you expect her to say something like umm..."I'm pregnant and bleeding and worried that I might lose my baby"? Or even if she didn't know, "I've been sexually active and haven't had a period in two months"..? Don't beat yourself up until they install crystal balls to triage pts. and you were at fault because you didn't have yours turned on.

That is why it is called TRIAGE, although the whole system needs an overhaul IMHO. Don't beat your self up. We need you to work Thursday.

[TraumaNurseRN]

It had nothing to do with the safety of others. They had some kind of competition going on and they got overheated because they were not used to the Florida sun. The person in charge of the ER chose to treat the police officers first and then the rest of us. We were not told anything. When I asked if they knew if they had an idea when I was going back, they said they did not have any open rooms. The only way I found out was because the tech that took me for the sonogram said they had been busy with the police officers. The nurse confirmed the information, when I mentioned it.

I understand there are many situations that come before possibly losing a baby, but not being told anything really irritated many of the people including myself. I just think in my situation itwas handled poorly. The triage nurse is the first one in the line of fire, so unfortunately they are the first to be blamed. They can only do so much.

Good luck triage Nurses.

One thing that the sonogram tech (who has no clue what is going on in the ED) may have failed to know and tell you is, many ERs have specific rooms for specific complaints. Such as an ENT room, psych room, and even vag bleed rooms and if they were taken it might not have been feasable to treat you in a regular room. People who don't know how an ER works can second guess the system.

[TraumaNurseRN]

To clarify, again, the patient was never seen. She signed in and then left. I don't know how long she was waiting. We try to have someone do a second triage station, but unfortunately, we are not staffed for this and everyone was swamped. How are you supposed to triage someone within 5 minutes of their arrival to the ER when 15 people show up at the same time? IMHO, the three elderly people with sign in complaints of chest pain probably needed to be seen before the lady partsl bleeding complaint. As for the legal nurse with the triage suggestions, I know HOW to triage, and I know WHAT questions to ask........ That is not the point. We work as fast as we can, but wading thru triage of others with complaints that sound more serious takes a while, and she chose not to wait. She left on her own. My original beef with mgmt was that she thought the trage nurse that night should have gone out to the waiting room and asked her if she was pregnant. What good does that do? IF ALL the rooms are full, and everyone is running full speed, and ambo's are lined up like a choochoo train in the hall.........are we supposed to sit her in a chair at the nurses desk? There is NO ONE available to help her at this moment. We try! WHAT do I do with the information, if I have NO resources...... we are packed full like sardines. This is what irked me. Charge rn is busy, nursing supervisor is busy, this is evening shift........no director, no mgmt around.

Sometimes it seems as if these people are all lemmings, and instead of running as a pack to jump over a cliff, they are all running into the er waiting rooms. aaaaaaaaaaaaaaaaaahhhhhhhhhhhhh!

I agree with you....and as far as the legal nurse, she is mistaken....if a person leaves the ED without being seen, there is no legal misconduct on the hospitals part. The patient left without being seen, their choice.

[TraumaNurseRN]

The fact that you were overwhelmed in Triage and your ED was packed will not hold up in a court. The fact is simply that "you are a professional" and any judge will tell you " you should have known better". This patient in question was lady partslly bleeding. The questions to be asked:

1. pregnancy ? Last menstrual period? Could this have been an ectopic?

2. How much bleeding-How many pads used in how much time?

3.vitals stable?

4.postural vital signs obtained?

5.history.

You state that you were overwhelmed in the ED, then you MUST let your resource know, your manager know and if necessary the CNO know your situation and DOCUMENT, DOCUMENT, DOCUMENT. that is clearly your only defense. If all avenues are covered and documented properly and you did everything in your power to prevent this from occuring, as well as have the patient sign the form for leaving against medical advice, after having discussed it with the MD on duty then, and only then are you "covered". I realize what you are saying about being overwhelmed, but you are a professional, as so indicated by your license and you must act in accordance with the standards set by that license and by your facility. The fact that your facility was overwelmed will not matter in a court of law.

Iam a Legal Nurse Consultant as well as a very seasoned ED nurse and I would be the one to do chart reviews on this case. I know what needs to be in place on the chart before it goes to court.

Nursechick01 RN, BSN, LNC

If the patient left without being seen.......there was no misconduct on the triage nurse's part. As triage nurses you have no control over who walks in...or out of the doors and to suggest that we have a legal obligation to do so is outrageous. And it floors me sometimes with chart reviews....lmao...sitting back in the ivory tower looking at one single chart and not all charts during that period floors me. One time a chart was reviewed and brought back to me for not reassessing pain 30 minutes after a med was given. What they failed to see was the Code I was in on a 9 year old. Should I have left the code to assess pain? (Certainly not!!!!!) You Blue Coats make me shake my head......

[LilgirlRN, ADN, RN]

Get your ER director to buy t-sheets, they prompt you to ask the right questions. However, a place where I used to work, we used t sheets but if I had 5 or more waiting I only had to fill out the 1st half.... the pregnant question is in the last half. So when they got a patient that had been waiting for 2 hours and was 30 weeks pregnant... she just looked fat to me, they were mad at me. I mean come on... if you were 30 weeks pregnant with belly pain wouldn't you tell someone that you're 30 weeks? I know I would!!!