Flow of your Triage/MSE area

West_Coast_Ken, BSN, RN · Nov 5, 2006

Hi Tara,

I just read an interesting article from the AP newswire today titled "Hospitals, MDs Addressing Long Wait Time" that addresses long wait times in the ER. (And like nurses aren't envolved in the issue, too...) :angryfire

I know this won't answer your question now but I found the ideas fascinating. Like everything it will take money, time and committment to address long wait times at the ER.

Regards,

Ken

TaraER-RN · Nov 5, 2006

Thanks Ken...I read that article too...its actually based around what happened to that one patient in a waiting room in Illinois who came in for CP and waited to long in the waiting room and ended up having a cardiac arrest....one of the reasons that we are going to ESI so that the CP patients aren't out there waiting. Is there anybody that can tell me how their flow is in triage from the time the patient enters? I need ideas to give to my manager that will be more effecient. Thanks!

Altra, BSN, RN · Nov 6, 2006

Hello....I am looking for ideas from people who work in busy ER's (greater than 130 coming in daily) on how you manage your triage flow. We just started using ESI (emergency severity index) and its important to us to have a nurse be one of the first points of contact to make sure the patient is safe to take a seat, "ok to wait", for their medical screening exam and not a priority 1 or 2 that needs to be taken immediately back. We are an HMO that uses name and medical record numbers to put people into our computer to track everything including the initial triage and MSE. But I am finding our flow just doesn't seem to be working, especially when it is busy. We have only 1 triage nurse and 1 MSE nurse, so its getting pretty backed up and people are waiting longer to get their MSE (and the patients and us are not use to the longer waits---so we are having a lot of complaints!) also with our flow we have a lot of bouncing around, and the patients getting up/down a lot to see the triage nurse, then to see the MSE nurse and then to see the receptionist and then again to go to the back. SO I thought I would like to see if anyone out there uses a computer system like this and is using ESI and how you guys manage the busy patient flow....thanks in advance!

I'd like to help but I don't quite understand how your flow is working now or was working before. What is the function of your MSE nurse? (not familiar w/that term) Why is the utilization of the ESI making for longer waits?

Our flow goes something like this: pt. presents to waiting room, gives name, DOB & chief complaint to registration clerk. We have one triage nurse. Depending on pt.'s complaint, they might continue with the registration clerk & give demographic & insurance data, or the triage nurse might call them in immediately (if it's a perfect world and there aren't 10 other people to be triaged, lol ...). Pt. is triaged & assigned an ESI number. It's the responsibility of the triage nurse to continuously "eyeball" each new pt., even if their chief complaint listed is something minor, and assess whether to stop everything & get that person back immediately if it's warranted.

ESI "4"s and "5"s get directed to the urgent care side of the ER, as well as "3"s that won't require cardiac monitoring.

Our volume is such that ESI "3"s do frequently have to wait during the busier times of the day/night.

Hope this helps?

spiritdancer · Nov 6, 2006

We are a similar size ER. We started using ESI this past spring.

The way our flow works is that patients present their name and cheif complaint to registration clerks/greeters. That information is entered into our computerized tracking board. We use two triage nurses from 9am until 11pm. Patients with chest pain and other more serious complaints are triaged before less serious complaints. We practice comprehensive triage, including institution of standing orders. If a bed is not immediately available for a patient triaged ESI 2, we initiate EKG, labs, heparin lock, ASA, etc. in the adjoining sub-acute area until a monitor bed is available.

Medical screening exams are done by physicians and mid-levels when patients are "seen." That is our main problem now, because during high volume times, patients triaged ESI 2 can wait 4 hours to be seen. We simply need more physicians and mid-levels to see patients and get them dispositioned.

tweety55 · Nov 6, 2006

We see 100-110 pts per day in our 25 bed ED. We started using ESI about one year ago. It has helped with more accurate triage, but that is about all. Two years ago, we had one triage nurse with a triage room right in the admission/registration area. The triage nurse would triage each pt, then assign rooms. When we were busy, the triage nurse could initiate protocols, get labs and we also have a 4 bed holding area that we could use for those that had to wait, but needed a bed. Now, our triage nurses are to go to registration immediatly, bring the pt straight back, assign an ESI level, turn the pt over to the primary nurse. The emphasis is on filling the beds and having no one in the waiting room. If there are pts in the waiting room, our director will come out and find out why. We closed our Fast Track and now use that FNP and nurse in the ED.

The expectation is that our triage nurse has to eyeball the pt in less than 10 minutes.

If she is in the middle of doing another triage or assisting in a trauma, or with a cp that she just brought straight back, she is expected to drop everything and get that pt triaged. I have come on shift to find a frequent flyer migraine in one of our major trauma rooms because we have to fill the rooms! This goes back to pt satisfaction and also the the beloved Press Gainey"s

RunnerRN, BSN, RN · Nov 6, 2006

Here is how our Level 1 works....

Front desk in WR/triage w 1 experienced RN and registration. Pt presents w cc, RN 1 "eyeballs" pt and decides whether to take pt directly to room, if pt can go to WR, or if pt needs to be triaged quickly. If a Lvl 3 or 4 (or stable 2), registration will continue doing what they do, and the patient will be asked to have a seat. RN 1 assigns a temp ESI acuity. Triage RNs assess pts in order of ESI and arrival, then sends pt back to WR. RN 1 assigns rooms and an RN or tech takes the pt back.

EMS patients come in the back hallway and let a triage RN know they are there. If it is a critical, there will be a RN or tech waiting to take them to a room. Our ED was built so EMS pts do not need to be sent right back to a room, but so they can be triaged like everyone else and given an acuity. (Doesn't always happen like that, but supposedly should) Also, our triage rooms all have monitors, gasses, etc so we can board pts in there in case of MCI or high volume.

Hope this helps!