how does your er triage?

[Uptoherern]

If anyone has seen a thread re: this, please let me know. I did a search, but couldn't find anything.

My question is......how does your er triage? Our goes like this......

(I'm talking about walk=in patients in the lobby only) The first thing a patient sees are the registration clerks. The patient is told to fill out a form (name, dr name, bday, reason for visit, etc) then gives it back to the clerk. The clerk then puts the pt. in the computer where we can see name, age, reason for visit, and how long they;ve been in the computer. The clerks will tell us if someone seems esp. ill (bleeding all over, laying on the floor, gasping for breath...) whatever. We then have an area that we call patients over to and triage them there. If someone IS really ill, we take them straight back (hopefully we have an open bed), and triage them back there. If we are able, we triage in order of arrival (with the exception of the ill people), then take immediatley to a room or return to waiting room to await open bed.

ok.

We are being told that we are the only ER that does triage this way. (Mgr). We are being told that our triage system will change. Which is ok with me if it works....... We are told that in most ER's, the first person a patient has contact with is not a registration clerk, but an RN.

Please.........tell me how your triage works. If our triage nurse is going to be a meeter and greater, how is she going to be able to triage? We are told that we need to keep an eye on the waiting room door and watch what walks in. If I am triaging, I am watching the pt. I am triaging, not the door! I am also not sitting there the entire time, as I am constantly going to the back and to fast track to take pts to their rooms. I don't see how I can watch the door, if I am not there.

please let me know what you guys do for triage. The only solution I see is to have 2 triage nurses.

We see approx. +/- 100 patients per day.

thanks

[HAPPYNPROUD]

in our er, the first person a pt sees is what we call nurse 1 who is sitting at the desk when they walk in the door--that person asks for demo info, chief complaint and how transported to er and acuity is assigned---then they move into a triage room (we have 2) and the triage is completed by nurse 2 (sometimes we have 2 nurse 2 people, not often)----then that person completes triage, while a tech takes vitals, by asking more detailed questions about presenting problem, hx, meds, etc---the acuity can be changed by this person and if nurse 2 finds it necessary to get a room right away, the charge nurse is called and we transport the pt to a room--a 4th year resident is also available if needed for leveling---now we also have some ems arrivals that are taken directly to a room whether it be trauma or emergent care situations and the pts are triaged in the treatment room---our system works well, i think, but our ed is so busy, the wait is sometimes excessive for the d acuity pts with the cold symptoms x 1 week who are afebrile, but we do have protocols that we use in triage to get the pt's started like tylenol, ibuprofen, chest x rays, etc

[Jabramac]

About three years ago we changed our triage system. The way it used to work: a pt would arrive and first see registration. Registration rung a bell into the back area and an RN wuld come out to ask the pt what the chief complaint was and then decide if pt could continue to register, or if needed to come back immediatly. If they could register they would, and then be triaged in a small room in the lobby. If they needed to come back right away they would be brought back and traiged in the room.

We did extensive studying of other local hospitals and found that we were one of only two in the area that performed that way. We also found that our registration staff was very uncomfortable with being the first person pts see.

So, we changed and now the triage nurse stays in the traige room in the lobby all the time (except nights, when we revert back to the old way). The triage nurse should greet all pts as they walk in, but our set up allows for the nurse to see the lobby from the triage room and eye ball pts as they walk in, and we are able to usually hear the chief complaint when the pt tells registration. In this way we still are aware of what is going on, but do not have to interact with every person that presents to registration. However, our department discussed that it is very important for the triage nurse to know what is going on in the lobby, it is the triage nurses license on the line if something happenes in the lobby. We also found it very helpful for family/visitors and issues that present in the lobby. Registration staff are not medical, and usually have no idea what is happening to pts in the back.

Yes, it can be frustrating when we are busy to have to stop everything you are doing and get up and go check with new arrivals. However, my opinion is that if you eyeball a pt you can usually tell if they can wait a minute or two for me to finish triage, or if I need to check on them now.

As far as HIPPA is concerned it can be a problem. We have a window and a door that can be closed, aso that helps. Our management tells us that it is accetable to get two peices of information from a pt in the lobby even in front of others, that can be two of 1)first name 2)last name or 3)complaint. Of course we want to know the complaint.

I much prefer to staying in the triage room and the lobby then to helping in back and doing triage. I feel like I am in control of what is going on, and that I canfocus even more on just triaging. It sounds like our triage is similar to yours in the questions we ask, but we do no paper work, and all our notes are on the computer. When we get busy my goal for triaging a pt is 3-5 minutes, depending on the complaint.

[LuvDaTrauma, BSN, RN]

Isnt against medicare policy or Cobra or something to ask for insurance information before being triaged? We cant ask for that information until after because we dont have the right to refuse patients and we see everyone no matter if they have insurance or not. Am I way off base here?

[confused101]

We strictly follow the guidelines given to us by Good Housekeeping

That just made my day. I read that post last night!

[KristyEDrn]

Yes, it is a violation to be registered prior to being seen by a nurse. I believe it is EMTALA, not COBRA. COBRA is the anti dumping one. : )

[KristyEDrn]

Last year we saw 116,000. This is our busiest time of year, so right now 300-400/day; less in the summer.

HOLY COW! That is amazing. I worked at a hosp. that saw 80-90,000 and it was very stressful...of course, we were short staffed so that makes a HUGE difference. I think any ED can handle that amount (with the right equip., etc) if they have enough staff to support it.

[Rio, ASN, RN]

walk-ins report to the triage RN. the triage RN dose an initial brief assessment and does a pre-reg., no insurance info is required. the pt is then brought up onto the board with room number, name, cc, assigned nurse and acuity. the pt is then placed in the room (if one is available) and report is given to either the charge nurse or zone nurse (sometimes the 'zoned' nurse). The full reg is then done at the bedside by a reg. clerk.

[Rio, ASN, RN]

Isnt against medicare policy or Cobra or something to ask for insurance information before being triaged? We cant ask for that information until after because we dont have the right to refuse patients and we see everyone no matter if they have insurance or not. Am I way off base here?

It is an EMTALA violation to inquire as to the patients ability to pay prior to a Medical Screening Exam. The MSE only must satisfy: does an emergency condition exist. If yes, then treat/stabilize/transfer... whatever is required irregardless of ability to pay. If no, then patient may be treated or referred to primary care or whatever your policy guides. Every institution should have a policy in place to address the MSE. ie: WHO does the MSE ? When is the MSE done ? etc... It is law, es la ley, that it shall be posted in every ED (USA) the right to a MSE.

[Uptoherern, RN]

OK...............found out in a meeting today what the plan is. We have been doing the 5 level triage system (trying, I should say). When the patients present in the waiting room, the triage nurse is to go to the front desk and find out the complaint. If they are obviously ill , a level 1,2,3, then they go straight back to a room and get triaged in the room (like we do with ambo pts. and I might add, usually did anyway, if the pt looked like they needed a rm. asap) The change is that we are to call the charge rn and tell them that we have a pt. needing a bed, and the charge rn is to faciliatate getting the bed. The nurse assigned to that room then does the actual "triage" (the triage rn may get an initial set of vitals, the assigned nurse would do the entire actual triage process). If a pt. presents with a level 4 or 5 complaint, we will tell them to go ahead and sign in, and will be with them as soon as we can. Once they are registered, we are to call the fast track LPN and tell them "I have 3 (or whatever) patients here for you to come get" . The fast track LPN is then expected to come get the patients and complete the triage for these people. She wants at least 50% of all patients to be triaged at bedside, wants level 3 patients to be in a bed within 15 minutes of arrival to ER, and wants level 2 patients to be in a bed within 10 minutes. Supposedly level 1 patients only come by ambo.

This sounds a little complicated to me. First of all, the fast track nurse is an LPN. I thought they weren't supposed to do triage. Secondly, the fast track lpn has no tech. They have 5 beds by themselves with a PA or NP. MGmt says that if we have eyeballed the patient with the broken toe, then our assessment is done. ??? I also don't get how the nurses in the back are going to be able to stop whatever it is they are doing, in order to get in to see this new pt. right away and do the triage. Nurses in regular ER have been having 4 pts., + possibly a hall assignment. I also don't know what is going to happen when there is NO BED AVAILABLE. we are told that we can have the dr. come out to triage to assess the pt there (we have curtain and small, old cot). The doc can order whatever labs/xray he wants and then put pt back out into waiting room to await open bed.

the 10 and 15 minute to-the-bed times seem unrealistic to me. actually, the whole thing is confusing to me. I can see how the triage nurse would be doing more assessing and labeling into level 1,2,3,4,5. But it also puts more burden on the nurses in the back to triage more.

comments? haven't started this yet. I see a WHOLE lotta things that will need to get ironed out..................

[Anna57]

In our ER it depends on the time of day as to who they see first. During the daytime, volunteers sit at a greeter desk and direct people where to go. During the night, the triage nurse sees EVERYONE (visitors, lost people, homeless, patients, etc...) The way it works with us is that the PATIENTS fill out a form with name, time of arrival, date of birth and chief complaint. It is a carbon copy. I get one copy, the second copy goes in a box (upside down inside the window) for registration. If we are slow(not very often) I usually triage the patient then send them to a room. We have 2 registration attendants, one out in the lobby and one back in the er (for people taken directly back, ambulances, etc.) If they are sent straight back from triage, then registration comes to their room and gets their information, if they are going to have to sit to wait on an available bed, registration calls them to the desk in the waiting room to register them.

If a patient is critical or having chest pain and looks like a MI, we take them straight back without triage and the nurse triages as she is getting them hooked up and assessing them herself.

Another thing that we do that I really like is we have 3 ED techs on duty. 2 of them split the board (doing EKG's, Urine's, Vitals, Making beds, etc...) for 1/2 of the patients. The third tech works in Triage helping take vitals and actually taking the patients to their room and place their name on the board. Our hospital policy is that the triage nurse is to be at the desk at all times. We have Nextel phones that we can contact the charge nurse, techs, registration, and fast track if we need something or need to inform registration that there is a new patient in a specific room (those that we took straight back or that went back before they were registered). Also, the Fast Track Nurse comes over and calls back her own patients after I have triaged them and decided they qualify for FT.

Sorry so long, but this system really works well.

[Uptoherern, RN]

jeez, we have one tech, usually 6p to 6a. one triage rn. I figured out I saw and traiged 60 patients on my 9a-9p shift a few days ago. of course, not all evenly spaced out!

I think our mgr got the 10-15 minute wait thing from a hospital on the east coast that advertised 15 minutes to see the dr., or the visit was free.

you want it your way?....................