How does your ER handle level 3 ESI pts?

Guest219794 · Aug 4, 2019

Not sure what the question is. ESI 3s are seen, orders written and carried out.

Could you clarify? Are you looking for specifics for the admit process?

CTFD_RN, BSN · Aug 5, 2019

I am asking what process you use to get these type of pts seen and dispo’ed. Our current process leaves them in the lobby for a long time and/or they take up rooms for longer than our goal time.

Jasel, BSN, RN · Aug 5, 2019

The ER I'm currently contracted with assigns 4 - 6 patients. 2 being hallway patients. I've heard when extremely busy you can have 7 or 8 but apparently that's very rare. Also before bringing the patient to a bed the techs are starting IVs, ordering, and sending labs before they get to my bed. Patients who are completely worked up, dispoed, waiting to go to the floor, etoh, waiting for discharge papers, etc can be moved to the hallway to make room for new patients. Rinse and repeat.

I also find another problem is it takes too long to transport patients to the floor. Doesn't seem to matter if it's only techs, if there's transport available, or a combination. That seriously slows things down.

Could also be a staffing issue. Maybe not enough providers?

amyjm333, RN · Aug 5, 2019

Our ESI 3s generally get labs (according to complaint), rad studies (again, according to complaint), a bag of fluids and appropriate meds to control symptoms. Once tests are resulted we either dc them w/ referral to specialist, or work on admitting them.

I can’t say I feel they clog up the department, as many end up having legitimate complaints confirmed by labs and/or X-RAY/CT. I feel that the level 4&5s are the ones that should visit one of the local urgent care clinics, and could use a bit of drain-o. ???

JKL33 · Aug 7, 2019

On 8/5/2019 at 6:51 AM, CTFD_RN said:
they take up rooms for longer than our goal time.

I guess you need to clarify whether there are backlogs that standout or if this is more a matter that the nature of 3s is inherently hard on throughput. But, if there are backlogs, where are they? Radiology? Simple lab results? Waiting for them to urinate for a UA sample? Requiring a bunch of extra information documentation that is not pertinent to the visit? Waiting for nurse to be available to discharge? Messing around with "my pain is still a 10/10"? Ordering a bunch of inappropriate IV meds to begin with? Over-treating of chronic/mostly-unchanged conditions? Unnecessary testing (or testing protocols) being ordered? 3s don't, as a rule, require a bag of fluids and IV meds just because someone can't presently determine their dispo.

Some of them are likely being over- or under-triaged to begin with. Evaluate that.

Can you explain how your V and H system is helping? (Not saying it isn't). How does it work. Give an example of each type of patient (I suspect this might elucidate something...that's why I'm asking).

Prolonged admit decision-to-admission time? (Major time hog in the past)

Inpatient processes that are not operating efficiently?

Staffing?

3s take more resources, otherwise they would be 4s/5s. The main ED-related way 3s take up unnecessary time (in my observations) is related to indiscriminate ordering (with or without the use of protocols), delays in the imaging process and the resuting of tests, and just overall unnecessary ordering or piecemeal ordering and the lack of staffing it takes to quickly perform the orders on all of these people. At some point those wringing their hands about throughput have to pony up the necessary resources to get what they want.

CTFD_RN, BSN · Aug 11, 2019

On 8/7/2019 at 8:46 AM, JKL33 said:
indiscriminate ordering (with or without the use of protocols), [...]unnecessary ordering or piecemeal ordering and the lack of staffing it takes to quickly perform the orders on all of these people.

This is what I am talking about. We have some providers that order a head CT, IV fluids and IV meds (migraine cocktail) for every HA pt. Management seems to think it is a nursing problem when it is more complex than that. They keep trying different "systems" in order to speed up the process with no real results. Their current 'solution' is to have a zone for these pts whereas the pt is pulled to a room, triaged (if needed, we also triage up front), provider sees, orders in, orders and meds carried out and then pt back to lobby to await results. It sounds do-able but it is often not the case. Pts are coming back 3, 4, 5+ at a time and we (providers and nursing) can't keep up the flow. Or they are more complex than their CC made it seem. Or not appropriate to send back to lobby ect ect. Next thing you know we have 1/2 the zone filled/clogged. It just feels like an assembly line. Do other places do it this way too?

CTFD_RN, BSN · Aug 11, 2019

On 8/7/2019 at 8:46 AM, JKL33 said:
Can you explain how your V and H system is helping? (Not saying it isn't). How does it work. Give an example of each type of patient (I suspect this might elucidate something...that's why I'm asking).

An example of a 3V would be flu like symptoms, NV, pelvic pain, UTI symptoms in a generally healthy adult ect. A 3H would be ABD pain, generalized weakness in elderly without CP, cellulitis with failed outpatient treatment ect. Stuff that would generally require/receive an admission for further testing or monitoring.

JKL33 · Aug 26, 2019

On 8/11/2019 at 10:54 AM, CTFD_RN said:
This is what I am talking about. We have some providers that order a head CT, IV fluids and IV meds (migraine cocktail) for every HA pt. Management seems to think it is a nursing problem when it is more complex than that. They keep trying different "systems" in order to speed up the process with no real results.

That is unfortunate; no real helpful advice. It's going to be difficult to significantly improve anything without addressing the indiscriminate ordering.

On 8/11/2019 at 11:01 AM, CTFD_RN said:
An example of a 3V would be flu like symptoms, NV, pelvic pain, UTI symptoms in a generally healthy adult ect. A 3H would be ABD pain, generalized weakness in elderly without CP, cellulitis with failed outpatient treatment ect. Stuff that would generally require/receive an admission for further testing or monitoring.

Sounds pretty good although there is almost certainly some mis-triaging going on (mostly because that can happen anywhere especially when people learn over time to do things like assign an ESI based solely on something like a particular provider's known prescribing patterns, or when people are placed in triage with inadequate training, etc., etc.). Basic UTI sx in a healthy adult could be a classic example. That's a 4; they need one resource (lab). Generalized weakness in elderly can become a 2 fairly easily. I'm not trying to nitpick, just saying it can't hurt to review this. ?

Good luck, hopefully something will give...