mid-levels in triage

CraigB-RN, MSN, RN · Mar 4, 2008

It can be both a lifesaver and a royal pain in the you know were. Make sure you have very specific policies about what their role is and what things you can do in Triage and send patients back to the waiting room, IE, IV medications, PO and IM pain medications. This is one of the current fads in emergency services. At first I was all for it, now I"m not so sure that it is actually doing anything other than buffing door to provider times. You have to make sure that you don't fill up your triage rooms with people being treated so you can't triage patients.

Crocuta, RN · Mar 4, 2008

My facility does not have any formal mid-level triage process in place, but we still do some triage area treat and release. It usually happens when our treatment rooms fill up and the mid-level is waiting for lab results on all of his patients. They are really great about coming out and taking a look through for quick eval and release patients. Tooth pain, simple out of med problems, minor sprains, etc. It helps more than you can imagine if you're the triage nurse - it's that many less people staring at you.

We've done it a few ways, and through trial and error have come up with a few ground rules.

First, if you're the triage nurse, and you have patients to triage, don't get sucked into being the nurse for the mid-level. Your triages stack up and then you end up playing catch up. The best arrangement has been when we've been lucky enough to have an extra nurse who can come out with the mid-level and work with them. Second best is when the nurse assigned to the fast track area comes out with them - it runs the risk of something being delayed in the back though.

Second, find a dedicated area for your mid-level to set up a clinic. We have two triage bays and a registration bay. When everything is running normally, our ED tech brings the next patient back, does a set of vitals and prepares the paperwork in one bay, then switches to bay 2 to start the next patient while the triage nurse assesses the patient in bay one. After the triage nurse is finished, the patient is escorted over to the registration bay to have a talk with those folks before being returned to the waiting room. When I get my mid-level out to triage, I commandeer the registration bay as a clinic and set the mid-level up over there, out of the way and feed them the appropriate charts. We just modify our process by having registration come to the patient in the triage bay after the nurse is finished. It slows things down slightly, but not nearly as much as tying up a triage bay with the mid-level. I use the extra time to sprint back to the treatment area and assess my room status. On the upside, we move faster overall because we eliminate patients from the waiting room without using a treatment bed.

When we do this, the mid-level might get through 1 to 5 patients before they have to head back to their area to finish up patients they are already seeing.

If we had more mid-levels, I'd push for a dedicated set up for certain times of the day, but we don't have the mid-level staffing for it right now.

KatieBell · Mar 10, 2008

I understand froma friend of mine that in one hospital the Mid-levels are not providing clinic care, but are actually able to siply tell the patient they have had a medical screening and that they do not require emergency care, and are able to make them an appointment either withtheir Doctor for that day or the next, or with the local clinic. According to my friend, this has really decompressed the ED, but I am not exactly sure which facility this was occuring at, as she is a traveler.

ERbunny · Mar 16, 2008

I understand froma friend of mine that in one hospital the Mid-levels are not providing clinic care, but are actually able to siply tell the patient they have had a medical screening and that they do not require emergency care, and are able to make them an appointment either withtheir Doctor for that day or the next, or with the local clinic. According to my friend, this has really decompressed the ED, but I am not exactly sure which facility this was occuring at, as she is a traveler.

This was one of the goals when we first added mid levels to triage, however, this part of the program has been put on indefinite hold.

My finding is that they tend to slow up the process in some cases. We always had advanced protocols for us to get labs and x rays done, so when that is all they do, it just adds another step to the process. We have guidelines as to what can and can't be done in triage, but some of them will stretch it and want to expand the role. Well, no one may be waiting for triage when they start tying up a nurse(and a room) doing procedures, by the time they are finished we are now backed up and people are waiting a dangerous time without seeing an RN.

Be sure your midlevels understand that the purpose of triage should always be triage, not "let's get them through quickly". And that it is still the triage RN who is in charge of it, not the midlevel.

We have worked out some of the kinks since starting this program, but its success still depends on who is assigned, and even after 6 months, most of the RNs absolutely hate working there.