2 hour reassessments in Triage

Specialties Emergency

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We have just started having a nurse be the Reassessment Nurse assigned in Triage. We do use a 5 tiered system. But I was wondering if other ER's are doing the same. Are you reassessing the 4 & 5's every 2 hours or are you using a different time criteria for the old "non urgents"?

Input would be valuable as I sense that a lot of staff are very disgruntled and any suggestions would be great as to how other departments are handling this. I totally understand that 2' and 3's should be reassessed q 2 hours but sprained ankles or finger pain for 6 month is hard to justify!

Plus we do have permission to give narcotics in triage under our standing orders (orally only) and so there fore after 20 - 30 minutes of administrating these , we also have to reassess.( which is of course good practice but so time consuming now)

I believe that this is fixing the wrong problem.The processes in the main hospital , lab turn around,s RN 's speed of working etc are the bigger issue .By fixing these things there should hopefully not be patients waiting for 2 hours!

Thoughts and suggestions please!

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Specializes in ER/EHR Trainer.

It's very scary to be out front during the busy times in the ER...as people come up to the 2 hour point I reassess all patients in the waiting room. In the event someone is in acute pain, appears to have a change in condition, or I don't like the way they look-I will reassess and document. I also ask patients to advise me if they have a negative change in condition.

Of course, you always have someone who states they are dying...it's the ones who don't say anything that are usually the sickest! No one likes people suffering....I just believe in doublechecking everything!

CYA and advocate!

Maisy

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Specializes in ER.

First of all if you are truly using a level 5 ESI system narcotics should not be given in triage if someone is having that much pain that bumps them to a five, and having been burned by narcotics per protocol in the past, patients leaving ER I no longer use the pain protocol, and you are responsible for that patient for 12 hours after their depature since they did not sign an informed consent about how the narcotic would affect them. Secondly most of your higher level od care systems are going or have gone to 2 hour reassesments, yes very time consuming but you know people enacting these protocols and policies are not the one using them.

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Thanks for the input. Our 5 tiered system in CA must be the other way than in PA. A 1 is a CPR, a 5 is a prescription refill, so I think you mean that giving a narc bumps them to a 1? Possible a 2 or 3 for us though as no airway compromised, breathing still has a pulse, etc. etc.yadda, yadda.

Our doctors and Risk management have signed off on our narcotic administration but I agree people do walk after sometimes after administration and we do everything we can to control the amount of meds we are giving out in triage.For our FF we have care plans and some of the patients are in a contract with us so they can only receive certain medications and they actually say when they come to triage " I am a care plan patient" so we can resource what they can get for pain once they see the doctor. However, it is nice when you have someone with a clinical fracture and in pain to offer something while they wait for an x-ray and wait then to see a doctor.

The other thing I would like to talk about is physician triage.One of my previous hospitals during 10am - 0200am did MD triage and then we could give everything we wanted in the waiting room and monitor patients with float nurses. Took total liability away from nurses( although our standing orders cover us as they have been through multiple policy, Risk committees to be approved). I am trying to bring that up where I work to see if we can implement it and trial it.

Again I still believe that ER's are overfilled due to poor processes in the hospital in getting patient's discharged,housekeeping to turn around room cleaning, lab turnaround,rides home, doctors to come and discharge the patients in a timely manner etc.etc.the ER always gets blamed for everything but it is a global health care issue.We all need to work together to fix this generic problem that is in all ER's across the U.S.. The 2 hour reassessment could be awash if the hospital flow was better.Bring on the active committees to resolve these issues as a health care system!

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Specializes in emergency nursing-ENPC, CATN, CEN.

we do reassessments including vitals hourly. we do a q 15 min across the room check. we utilize triage lpns to assist with the recheck and reports to the rn if the rn is busy, or the rn does it herself. we also are instituting a 2nd rn to be the reassessment/ second triage nurse to speed things up through the initial phase of triage

we use the 5 tier system- 1 equating to the code situation, 5 being the most minor (tetorifice booster)

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We already have 2 triage nurses, a diagnostic nurse that starts labs , does EKG's and now we are using a reassessment nurse! Just a busy ER, you know how that can be! All those nurses and no computer terminals to use!Thanks for the input!

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Specializes in ER/Trauma.

Wow... We also use the 5 level ESI... But we're lucky if the waiting room patients are reassessed in 12-24 hours...

I think it really depends on how busy the hospital ER is... Because for my hospital, it is IMPOSSIBLE to reassess every patient in the waiting room every two hours, even at 0300... We usually have two RNs triaging and one triage charge RN... The triage charge RN is responsible for looking at everyone already waiting, doing visual assessments, monitoring chief complaints and lining up those who need to be triaged next for the two triage RNs... If we're lucky, we will have three triage RNs, but that's rare... We usually TRIAGE anywhere from 150-250 patients a day only in TRIAGE but we see approx 300 pts a day... I also think they should be reassessed more frequently when they're sitting in the waiting room for a minimum 12 hour wait on average, however it's just not possible at my hospital unfortunately....... There are other people looking at triage assessments in the back, though... We have two sides of the ER: a medicine side for the CVA, MI, chest pain, CHF, dialysis, etc patients, AND a trauma/surgery side for the MVCs, MCCs, abd pain, abscesses, etc... Each side has a charge RN... So there are usually two triage RNs and three charge RNs and one other RN (the position is hard to explain) that monitors the waiting room chief complaints...

But to the ESI acuity level and reassessments: At my facility, there IS NOT a set requirement of reassessments based on acuity, such as 4s/5s need q2hr reassessments... We leave 3s/4s/5s in the waiting room... But if/when we finish triaging all of the patients, we immediately start on reassessments... :nurse:

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Specializes in ER/EHR Trainer.

You have all of that personnel and you don't reassess? That's hard to believe!

Too many bad things can happen if patients are not reassessed! We see as many patients as you, and I will stop triaging new patients for 10-15 minutes and re eval in spurts-charting at least one line. Especially pain, cp, abd pain, weakness or anyone I think looks like crap!

My license is too important to lose over this. I also make note if the charge rn is advised, or physician that a patient appears sick to me(very bad) and they do nothing. I am out front to perform a service....my sixth sense has repeatedly worked for non stemi MI, ruptured appendixes, ruptured cysts and bleeds....if I get the feeling-they are watched like a hawk. Our lazy charge nurses don't like it...too bad. I've been right so many times, no one says anything anymore-a stretcher is placed right in front of them! Safety #1!

Maisy

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Specializes in Emergency & Trauma/Adult ICU.

If you have the staffing to provide an "extra" nurse to do the reassessments ... count your blessings.

We reassess using the same criteria used for patients who are actually back in a treatment room -- an ESI Level 3 needs to have VS at least every 2 hours. An ESI Level 4/5 needs to have VS at least every 4 hours.

It can be truly scary to be the triage RN when you're reassessing a patient or 2 who don't look so good compared to an hour ago ... and there are still a dozen or more "unknowns" who you haven't even triaged the first time yet.

I know there are waiting room narcotic protocols out there, but those frankly make me very uncomfortable ... especially, as has been pointed out, during the busiest times it would mean that I could be giving narcotics to someone who won't even get in to registration to sign their consent for treatment for another 30 minutes.

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Specializes in ER/EHR Trainer.
If you have the staffing to provide an "extra" nurse to do the reassessments ... count your blessings.

We reassess using the same criteria used for patients who are actually back in a treatment room -- an ESI Level 3 needs to have VS at least every 2 hours. An ESI Level 4/5 needs to have VS at least every 4 hours.

It can be truly scary to be the triage RN when you're reassessing a patient or 2 who don't look so good compared to an hour ago ... and there are still a dozen or more "unknowns" who you haven't even triaged the first time yet.

I know there are waiting room narcotic protocols out there, but those frankly make me very uncomfortable ... especially, as has been pointed out, during the busiest times it would mean that I could be giving narcotics to someone who won't even get in to registration to sign their consent for treatment for another 30 minutes.

I agree with you wholeheartedly! We don't do narcs in triage, too much liability! In your scenario, the person that looks like crap would be reassessed. You already have that person on your radar, and are liable. I'd rather reassess for 5 minutes and know nothing has changed, or have to make the call insisting they come in somewhere!

JMO

Maisy

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Specializes in ER/Trauma.

We don't leave certain people in the waiting room... We have triage protocols that require people to automatically be walked back to the ER based on their complaints.. We would never leave a chest painer out in the waiting room cause any one of them would be a true NSTEMI/STEMI, therefore there's no reason to reassess them.. They aren't in the waiting room anymore... Dialysis patients are directly walked back cause they can crump at any time... Certain abd pains don't stay in the waiting room... We don't leave just anyone in the waiting room that's why they can stand to not be reassesed every 12-24 hrs...

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Specializes in ER/EHR Trainer.

How many beds do you have that you can walk these people back? We have 55, plus our fast track area. This does not include hallway assignments. We don't always have space due to holds. We also don't send our patient upstairs to unsafe staffing ratios. Some hospitals do this to keep the ER clear. Or, are the majority of patients BS problems intermixed with emergency? I am just curious, always looking for better ways to move people along.

We are also doing ATP-standing orders in triage to move things along. Abdominal pain gets cbc, cmp, amylase, lipase and ua. Cp gets cbc, cmp, trop. flank pain urine dip. Pretty standard to get people moving along. This way labs are already working, and it doesn't make a difference if they are in the waiting room or in a hallway assignment. We are also sending patients who are coughing with temp to chest xray to start PRO just in case-right from the waiting room. True of dopplers for dvt too!

Maisy

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