How many triage nurses does your clinic have?

[elprup, BSN, RN]

I am working as a New RN in Triage and on the floor, at a rural clinic. We currently have 2 Doctors and 3 NP's. Usually we have 2 providers on any given day (except Monday which is one of the busiest days of the week - go figure). And each provider usually has their own MA/LVN to assist them. There are usually about 4 people in the front office. Then there are the other medical records/admin/billing/HR (about 15 people).

Then there is Triage which is always one person, fielding all the calls passed to them from front office, all refills/pre authorizations, doctors notes, checking up on patients, triaging pts that come into clinic for help, answering everybody and anybodies questions, and a million other things I am learning every day. We have over 2100 patients on file and are usually scheduled all day every 15 min except for lunch. And we are not on Electronic Medical Record Yet, so everything is done with charts. Oh, and there are "no set protocols" for Triage. We write everything into a blank spiral bound notebook, and of course document into the charts. I pray everyday that I make it through. And the person above me is not a nurse, so I always have to go to the MD (who usually have no clue how my stuff is supposed to work/paperwork/etc).

I was just curious if this is standard? One triage nurse? I am not sure if I can do this most days, although I really do like the job and the people I work with. There is one other "triage nurse" who is an LVN.

Curious, Elprup

[LaughingRN]

At my practice, we only have one RN working triage on any given day. A handful of RN's trained in triage rotate on a weekly basis. (i don't work triage though)

Our practice consists of 7 doctors and 32 RNs. Yep...32 RNs

Very atypical from what I am hearing, but the "Main" doc believes in this philosophy :)

[mappers]

We have 1-2 nurses working Triage any given day. We prefer two. We have 11 MDs and 1 NP (who is on materninty leave right now.) We are an oncology practice with outpatient chemo. We probably employ 18 or so RNs, most of us work in the treatment area. A few rotate through Triage regularly. We have two RNs that work in CT, one who works with the MDs and the rest of us do treatments, injections and Triage.

We do have electronic records and we don't do PAs. The nurse who works with the MDs does the chemo PAs and other office people do the other ones.

[LuxCalidaNP]

we have a rotating schedule of telephone triage for a 56 exam room clinic...1 nurse on every shift. and I'm the ONLY spanish RN for the whole clinic. frick

[elprup, BSN, RN]

Thanks for your replies! Ok, one more question...

I am worried because our clinic does not have any written procedures for triage. One day I am told to do this, the other I am told to do that. I did some research and triage especially should have protocols because of the litigation factors. Do I have a valid reason to be worried before I open my big mouth (as a new employee and new grad? Thanks

[kcmylorn]

I'm an old RN who just started working primary care/clinic in the past 5 months. We have 13 providers- a mix of NP's, PA's and MD's. We have Family practice, Women's Health and Peds. We have 5 RN's- 1 RN/ 2 providers, except Peds which has 1 RN/3 Pediatricians and Women's Health has 1 LPN /2 providers in addition to 3 tech's for each Nurse/provider team. All 5 of us RN's do triage. LPN's and tech's are not allowed by state law to do triage. Only an RN can triage patient's. I think this is for all 50 states but check the Ambulatory Care speciality website(AAACN). Yes, we have protocals- our 2 references for protocals are Woodke and Barton Schmidt. (A good general over view resource book is the Ambulatory Care Core Curriculum Textbook) When we do symptom based telephone consultation(encounters) we have to site the protocal in our documentation- esp. in Peds.( this is what covers your butt) We have all computer documentation- the format: we call a "t-con". Our call line directs calls to the appropriate RN and is based on who the patient is assigned to as their PCP. Each nurse provider team has approx. 2,500 patients. I would receive the call from the appt line if the patient was assigned to one of my 2 providers, The patient is already in our computer system so I look them up based on the SS# and the DOB, I listen to the pt's c/o, ask history based questions- ie: vomiting. I know to ask the when it began, associated sx, any fever/chills,nausea, diarrhea, pain- pain scale characteristics of the pain- this is where it gets sticky, you real have to listen to what they are NOT telling you because you can't see them- are they anxious or calm, do they really mean abdomen or is it flank, are they drug seeking or hemorrhaging, you just have to go with the flow of the conversation, direct your questions and know the s/s of other posibilities/ conditions, and make a decision from there- either call 911( in which case you can NOT tell them to do, conclude the conversation and hang up the phone. You have to get another staff person to call 911 and stay on the phone until 911 arrives there) Or direct them to the ED, urgent care, make an appt for today or can it wait for a few days or can it be the flu-home remedies. This is where the protocals come in. Those protocals are like the algorithms of the ACLS- If this, do this- this is the CYA of triage)Never are you 'winging it'. I then electronically document the entire patient conversation and the outcome/disposition of the patient.

We also have what is called"nurse run walk in clinics" for UTI, URI, sore throat, Depo injections and B-12 injections. We have facility protocals for these also. The pt's have to meet certain criteria. If they don't they have to make an appt. The check-in clerks call the appropriate nurse, I would get the pt form the waiting room; bring them back to the exam room, get their vital signs, ask the history questions related to URI or sore throat. I do a focused assessment- listen to the lungs, look in ears, up noses and in throats. I run my assessment by the provider. They tell me what to order( give me verbal orders), I take the verbal order, enter it into the computer and go back to the patient- and do all the teaching. I then document my assessment findings in the SO section(subjective/objective) in the computer, if labs need ordering example: a throat c/s and rapid strep, I go ahead and collect them during my assessment and enter them into the system( or the lab won't do them) all the teaching and interventions get documented in the EMR note section. To me, it's like an APN without prescriptive priviledges. The patient doesn't even see the provider- only the nurse. The provider during all this is continuing with his every 15 min regular schedule office visits with the tech to assist him/her unless they want meds given then the RN's have to give the meds.( example: a pt comes in for a check up with a BP 210/110, provider wants catapres given, the RN has to give it. or someone is dehydrated from vomiting all night- the RN has to start the IVF or a IM of toradol for pain) Our EMR program has templates for the nurse walk in clinic. It's a point and click program. If a URI or UTI, I would chose the template for URI or UTI or depo injection or b-12 injection and fill in the VS, assessment, intervention (med given w/dose).

Clinic and clinic triage does have it's legal implications and yes there is supposed to be "written" protocals. For me- I love it, It bets the hospital any day. After 30 yrs I hope to NEVER go back. I have died and gone to nurse heaven. After 30 years, I finally get a lunch and a pee break.

[kcmylorn]

As an FYI- if this health care reform goes through, which iI hope it does, Money is going to be invested in expanding health clinics(I believe) especially in rural America. Ambulatory care has virtually no state health dept. regs. at this point in time. Try an get those protocals in place before the gavel comes down. Ask the office manager to invest in a copy(s) of Woodke protocals, the Barton Schmidt protocals and a copy of that Ambulatory Care Core curriculium texbook.

[Jeniffer34]

Instead of the protocol books, which are bulky and not really easy to remember. I always felt I am forgetting something that may be important for doc. I have searched on google for clinical software, found some mobile apps and computer software. One that is promising and stands out is Clinical GPS by Medgle. I am amazed by the product!! No-Guess work!! precisely tells you what to ask, what is relevant question and what is not? dont need to remember any protocols, ITS SIMPLE... also it documents and tells me the ESI and symptom relief advice I can offer etc...

[elprup, BSN, RN]

Thank you all. I am actually writing out a letter to the director as I write this because things have gotten so bad. I will either make the higher ups very angry (which seems to be norm in medicine and I will be out of a job) or it will help to make changes. None the less, I cannot just sit and perpetuate the problem.

[NurseGizmo]

We have Five stand alone clinics,which run 80 providers in just the clinics, all primary care and specialties. We have two Clinical Resource nurses each in the two largest sites, One in our call center and then we have two smaller sites that have RN supervisors who do their own Triage/advice calls. The five clinical resource nurses do infusions, change port dressings etc for the major areas, however they do not do clinical time with the physcians. The LVN/MA team does all of the auths, give medications etc. We have about a

65,000 patient base. We also use the Briggs Nurse telephone advice protocols, Barton schmitt telephone advice, and we have an OB/ GYN that I can not think of the name right now. I am one in the smaller site, and I have peds and primary care. I also work on the floor with the clinicans and most of the time I have an LVN/MA team so I do all of my own diabetes teaching, anticoagulaiton monitoring etc. Working with patients we only have about 8 RN's. A few management RN's but they don't do patient care at all.