Published Apr 30, 2003
I work in a busy ER in a rural setting (a town of about 30000, with a large rural catchment area) and we have been using a triage system for about a year. We are having difficulties with certain aspects of the new system, and are making some changes. I am interested to hear from other areas what happens to patients from the time they walk in until they leave. Our area is also unique in that there have been no doctors taking new patients for about 6 months, and there is no walk in clinic. The doctors we have often are not able to see their own patients who are ill as they are booking 2 - 4 weeks down the road. So in our emerg we have the critically sick and ill, as well as the sore throats and colds that either don't have a doctor or can't get into their doctor. This makes triage a challenge, because there are many many non-emergent cases who have to wait a long time for care.
In our hosp, when a patient walks through the door (from 9am-9pm, we only have triage 12h) they see the triage nurse, who does an assessment, and then they register with the unit clerk. Their chart is brought to the emerg desk and the nurses on the floor determine whether enough of an assessment was done, do further assessments, and then put the chart in the pile according to triage number (1-5). The assessment done in triage depends on the nurse, and how busy it is. The people who need to be seen immediately are sent in, and the others (some 3s, and most 4s and 5s), wait until they are called to the back. Triage reassessments are supposed to be done according to level (level 4 q1h, level 3 q30min etc.), but they often aren't because the triage nurse is too busy.
If those of you out there who have a different system could just give me a brief run down of what your hosp is like it might give me some good ideas to pass on at work. Some of our problems are d/t the long wait times and large volumes of non-emergent pts, but there has to be some modifications we can make to use our nursing time to its full potential. Since triage was implemented, people who need to be seen quickly are identified by a nurse (before it was a unit clerk), which is an improvement, but many aspects are frustrating.
Thanks, sorry for being long winded - Chaundra
In our facility, which see's about 250 pts per day this is the way that it works. The patient signs in at the front desk giving their name/bd/chief complaint to a greeter who enters it into the computer. The names come up on the triage nurses computer screen with complaint and age. We as the triage nurse call the patients back in order of complaint urgency or time order. We complete our triage sheet with name/bd/complaint/pmh/allergies/daily meds/vital signs/and visual assessment. If it is busy...which it almost always is. We start our lab work, we always do EKG's on our CP/Sob pt's. The patients are then divided up into 2 areas. Fast track - minor injuries etc. or main side. The patients get registered, chart goes to the back and the charge nurses brings the patients back as we have open beds.
Can the RNs order lab work? We can do the EKG on pts without an order but not lab work.
In our ER, the triage nurse is the first person the arriving patient sees. Our triage area is relatiely small and can only accomodate one patient at a time. This means that the t nurse must screen the patients at the window and bring back the one that seems to be the priority. They are then registered and either placed in an exam room, or back to the lobby, depending on census and their triage status. When it's busy, this can be scarey - hoping that you didn't "miss" something. I like the idea of setting time limits on reassessment by category, but I can see where it would fail when the t nurse is busy - and he/she probably is if there is a long wait in the lobby necessitating reassessment.
Other things about our triage:
***We only see walk-ins - Ambulance patients come in a different entrance and are directed by the charge nurse and triaged by the nurse that the patient is assigned to. Occasionally an ambulance patient is directed to the triage area due to "lack of acuity". Lots of people think that calling 911 is a quick way in.
***We have an immediate care area (5 beds staffed by a PA, RN and tech from 3pm to midnight) which takes a lot of load off the ER during the busy evening hours. I wish it opened at 9am since I work a lot of days and that's when it starts to get busy.
***The t nurse can order extremity xrays per a protocol and aerosols are sometimes started if the ER is full, but we don't have the staffing at triage to do EKGs or labs. Chest pains get priority placement anyway, even if it's to a bed in the hallway pending placement. Not ideal, but better than sitting in the lobby.
***We use a computer program called Logicare. We place the patient into the system so the charge nurse can see what's pending and work on placement. This eliminate a lot of radio traffic and often the room is on the screen by the time the triage assessment is complete. Due to new privacy laws, the system is being revamped so less "personal" info is displayed unless accessed by a password. Previously the screen might display Room 5 JANE DOE 36 F Vaginal Bleeding - at least until the screen saver kicked in and blanked the screen.
Triage is an assignement that some of the nurses like, and others hate. It has a lot of challenges and sometimes things get hostile out there, but it keeps your assessment skills sharp and there is a lot of responsibility to it. When they redesigned our ER, they installed bullet proof glass at the window and it has better security than most banks, but then we do all the psychiatric screenings for the county and there is always the concern that a patient will come back to settle a grudge.
Sorry to be so long, but I'm one of the nurses that likes triage!
Yes in our facility the nurse can order lab work...in triage and when the patient goes to a room. We have "pathways" they tell you what you can order per the patient complaint. For instance chest pain patients get:
EKG/CXR/CPK/Troponin/CBC/CMP/sometimes a PT/INR and Hep lock. We also can start SL nitro, nitro paste and give ASA.
We also have a seperate door for ambulance patients. Occasionaly those patients are placed in the waiting room to be triaged out front as opposed to the ambo entrance.
Its really very informative to read these leters for me since I have been working in Saudi, in a civilian hospital which receives about 180 pts a day in er and there is no triage system followed. We only had heard about it. And when we have emergencies it a total chaos with all catogary of patients demanding to be cared for first! but then we always have less no: of staff even for the emergency room and so having a triage system may not be possible?!. Any suggestions for such situations?
Rio, ASN, RN
In a Mass Casualty Incident the demand exceeds resources. The response to a MCI will vary depending on a multitude of factors. The one central componet of all MCI is the Triage of patients. Without a basic system of triage, (there are many), every surge of demand will cause confusion and chaos. Check out http://www.ena.org for resources and educational material. The ESI system is a well developed 5 tier approach to triage.
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