how far do u go in triage ?

Nurses General Nursing

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So, we are evidently starting the new standard of practice in ER's. We will now have a physician in triage to divert those pt's who are not true ER pt's before they get to main side. But, they also say we will be giving antiemetics, drawing blood work, starting IV"S and giving fluids in triage area while people wait. I'm sure it won't be long until we give narcs out there, because we have the all mighty, Pres Ganey's , strive for 5 ! :bowingpur You know that formula 3mg dilaudid = 5 on pres ganey. We, on average have 50 people waiting, 4 RN's . One at the desk, two triaging and one protocol. Now supposing we are actually staffed like we should be, we will need to assess pre and post med, what if we get critical labs back and the pt is sick of waiting and have left. What if they leave with their IV in. The list of questions go on and on. Is any one else doing this in their ER. The staffing as we should be is the major key to me. You know how it goes, " Sorry , we don't have 4 RN's tonight, you'll have to do it with 3". Then , suddenly it becomes OK to do it with 3 all of the time. You know the srory. It ain't pretty. :chair: I'm all for change, but, this seems risky to me. If people have to wait because they are a triage level of 5 then so be it. Means they don't need to be there any way, If they need lab work and fluids they should be in the back, not in a chair in triage area. What cha' think ?:twocents:

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Specializes in Cardiac, ER.

We don't have a doc at triage but we do have a pretreatment area. We have protocols that allow us to order labs, EKG, et Xray. If someone needs fluids or antiemetics we grab a doc real quick and might get an order for a fluid bolus or Zofran,..no narcs. If someone leaves with their IV we call local law enforcement and report it,.they are supposed to make physical contact with the pt and either verify the IV has been removed or instruct the pt to return to the ER.

I have mixed feelings about this,..IF we are staffed well,...it does speed the process if the labs, strep screen and CXR are complete when the pt gets back to see the doc. It also puts the triage nurse in a position of actually caring for pts while also trying to triage everyone that walks in the door. With all the guidelines about door to drug time, door to CT time,.door to EKG time etc,..in theory this is supposed to help,....but if I get overwhelmed at triage and I don't get that CXR result of LLL pneumonia for two hours,..now it's documented that the pts CXR was read pneumonia at 1950,.but no antibiotics were hung until 2200,...who's fault is that? If I give 4 of Zofran without results I'm not able to move on to a different med at pretreatment. I'm also not allowed to give pain meds which really makes many people very upset. I like the idea of having complete diagnostics ready for the doc,..not sure triage is really the place to do it,....hire more staff,.open up a few more roooms and move more people through!

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Specializes in ER/PDN.

We have recently (last July) started a program similar to this called Physician Expediting. I am the main nurse that does it and what we do is pull the patient back if there is a wait, Get a basic history and chief complaint, start IV's, draw blood, get urine, get ultrasounds, Start that patient drinking for CT or order a CT if needed, order vascular dopplers and in some cases, clear a patient to go to the Acute Care Center (urgent care) or even in a rare case, discharge them. We also may do an EKG if it a Young Chest pain and we send them for plain x-rays as well.

Here is what we DO NOT DO: Give IV/IM meds, give IV fluids. We have no way of monitoring these people (yet) because we send them back to the waiting room. We do give PO Zofran ODT if warranted, narcotic PO meds,-basically anything PO we give.

About your concern about IV's Walking out-I have had a few IV's walk out but most people do let us know if they want to leave. I also use my judgement as far as putting an IV in someone that looks like they will walk out or are a shooter.

I am the dedicated nurse that does this. Triage has 2-3 other nurses that actually triage and I help whenever I am not busy. I also float to ACC and to the main ER if needed.

I hope this helps and Feel free to PM me for any other questions.

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Specializes in Emergency & Trauma/Adult ICU.

I think this is not the appropriate use of MDs in triage ... the purpose should be to do the MSE and weed out the the triage level 4 & 5 patients. IMO, the waiting room is not the place for people with saline locks who can easily decide to leave. It's easy to make the case for giving antiemetics ... until you consider that if you're going to provide that symptom relief, why SHOULDN'T you also provide pain relief. And that is a slippery slope that I don't think anyone wants to start sliding down.

This has financial implications for the hospital as well ... can the hospital bill for the treatment of those folks who decide to leave after they've stopped vomiting ... when the patients can legitimately state that they were never in a treatment room?

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Specializes in ER/PDN.
I think this is not the appropriate use of MDs in triage ... the purpose should be to do the MSE and weed out the the triage level 4 & 5 patients. IMO, the waiting room is not the place for people with saline locks who can easily decide to leave. It's easy to make the case for giving antiemetics ... until you consider that if you're going to provide that symptom relief, why SHOULDN'T you also provide pain relief. And that is a slippery slope that I don't think anyone wants to start sliding down.

This has financial implications for the hospital as well ... can the hospital bill for the treatment of those folks who decide to leave after they've stopped vomiting ... when the patients can legitimately state that they were never in a treatment room?

In our ER, the triage level 4-5's go to ACC. Triage nurses are responsible for this. We do, however, see the patients that are borderline ACC criteria. they "vomited one time" or "coughed to make them vomit". We have cleared those to go back to ACC. This helps because they don't have to wait 4 hours for something that is trivial and can be turned over faster.

We have not had the problem with those that have stopped vomiting or are relieved of pain. We found that people are happier and tend to be more patient in the waiting room and are more likely to stay when they are seen by the doctors. We also have discharged those that have stopped vomiting and are feeling better.

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The 20-bed ER in which I work piloted a Physican in Triage (PIT) program. "The PIT", as we all fondly called it, started in November 2007 and ended in February of 2008. Medication administration did not go any further than tylenol, motrin and maybe some steroid and antibiotic shots prior to d/c of the patient. It also allowed several of our physicians to "cherry-pick" their cases.

The PIT had positive and negative points - as does everything. To me one of the biggest draw backs was patients expected to be in and out of the ER even faster - like at the McDonald's drive through. The system perpetrated the instant satisfaction many have come to expect in modern America. I can't tell you how many times we heard "I am tellin' all my friends you is fast doctors here." All the nurses wanted to reply, "Please don't." :no:

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We once tried a system many liked but administration didn't. We hired a nurse practitioner and provided him/her with a small staff. Once they checked into the ER it was decided if they needed "quick care" or not. Quick care was for the colds, flu, infection, and other relatively minor stuff that most people would normally go to their GP or a clinic. It did result in lower wait time in the ER but it was wages being paid for staff that wasn't needed for several hours a day so they got rid of it and the ER wait is back up again. Sometimes that's the fault of the patients.

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Specializes in Cardiac, ER.

"this has financial implications for the hospital as well ... can the hospital bill for the treatment of those folks who decide to leave after they've stopped vomiting ... when the patients can legitimately state that they were never in a treatment room? "

our er has a charge just for triage,..if you have seen the nurse, are triaged, placed in the waiting room then aren't there when your name is called to go back to see the doc you are charged for triage.

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Specializes in ER, ICU, Infusion, peds, informatics.

the hospital where i used to work triage did not use an md or midlevel in triage,but it had "triage protocols" that enabled us to do quite a bit.

in general, we drew blood, asked for urine, started ivs, did ekgs, ordered cxrs for pneumonia, ran cardiac tests (trop, bnp), and gave abx (po for pneumonia only), asa, tylenol and motrin.

except for the pneumonia/chest pain protocols, they were all optional. so, if we were backed up, we didn't waste triage time drawing blood, etc. often, though, once caught up, we could go back through the waiting room and draw blood/recheck vs on those that were still waiting.

the iv starts were mostly to save the patient from getting a second stick once in a room. if i was afraid that the patient would elope with iv in place, i would forgo the iv and just do a vp for bloodwork. if i misjudged, and they left with the iv in anyway, we would call the police to escort them back to the hospital for removal. (and i always warned patients of this when i put an iv in and sent them back to the waiting room. i always explained to them that the iv was to their benefit, that it would save them a stick later, and that by drawing the blood in triage, i was expediting the process. if they fussed at all, i wouldn't do it. tracking them down with the police really was a pita. usually, though, they were good about going to the window and letting us know they were leaving so they could have their iv removed first).

all alert labs on wr patients got called to the triage nurse, so we were able to address it. this was actually one of the main benefits to the system, since it would get them re-prioritized over another patient. if the patient had left, we would attempt to locate them and ask them to come back. (the put down their phone number when checking in (and they were surprisingly accurate, so we were usually able to locate them).

while we rarely ordered any radiology study (beyond the cxr for pneumonia) from triage, when they were walked back to the room, the nurse would then usually order any appropriate xrays (at least plane films) so the film would be ready when the doctor got the chart.

this way, when the doc went in to see the patient for the first time, the basic labs were usually already resulted and on the chart. sometimes the patients were ready for an rx and discharge; sometimes, additional tests were ordered.

in general, this system worked out really well. it does have its problems, but did wonders for expediting er flow while helping to pinpoint some of the sicker patients in the wr via abnormal labs.

and, assuming we had accurate billing info, the patient/insurance would get billed for any testing done via triage.

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Supervision keeps trying to re-invent the wheel. If it works o.k. today, they'll do their best to screw it up for tomorrow. Yes, patients have left our ER with heplocks. Yes, they've left after Xrays. Yes, they've left after their children got meds for fever. Instead of getting enough nurses to watch all these patients, they want to jump start the treatment and hope the patient hangs around long enough to see the doc...

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