need help-revamping my ER system and need guidance

[jinglebellz]

Hi! I manage a level 3, 20 bed ED. I am revamping our triage system to a 5 tiered system. That isnt the issue. The issue I am currently having is how to devise a system that will identify the priority for the pts to be seen by the docs. Currently our system is such...

The pt is triaged and given a level-the pt is then registered at front desk-then paper work is brought to charge for bed assignment- once pt is placed in bed, chart is placed in to be seen chart rack BEFORE secondary assesment is completed- MD picks chart up and sees pt......

OK the breakdown is when the MD picks up the chart from the to be seen chart rack. We do not have a system that helps the MD identify who is more critical and needs to be seen IE a level 3 before a level 5. It is just a vertical chart rack where the charge puts the charts in no real order to be picked up by MD.

1. I want the secondary assessment to be completed PRIOR to MD seeing pt.

2. How can I idnetify levels for the docs? I thought about a revolving chart rack with level at top... but I am not sure it would work.

How are other ER's doing this process. Would love some new insight.

Thanks!!

[Larry77, RN]

Ours is simple like yours...we just place the most critical chart at the front...we also have computerized charting for everything except the doc orders (which is what is the "chart"). So our docs can see the triage note and level on the computerized T-System before they see the patient.

Before our computerized charting we had every patients chart split in two with nursing notes on one clipboard and doc orders on the other, the nursing notes would stay with the nurse so he/she could do their secondary assessment while the doc orders went in the rack.

[matcgrad]

Before we went to computerized charting we used a dry erase board. It had room#, chief complaint, assigned nurse, ESI level, and time of arrival. It also had a columns for the doc to sign up, labs, xrays etc.

[jinglebellz]

Yeah, we have that now. The issue I am having is 2 fold...

1. The secondary assessment is not being completed because the chart goes to the to be seen rack by the charge nurse before the assigned nurse gets to complete it. Then the doc picks it up and it never gets finished.

2. The charts are being picked up out of order and not according to acuity because they are being placed in the to be seen rack and some docs pull from bottom, some pull from top and some flip through a pick what pt they want to see.

So I am trying to figure out a way that the secondary assessment is completed prior to being seen and a way to put them into some kind of identifiable order in the to be seen rack.

Thanks for the info though:)

[Displaced]

When a patient is put in a room, a carbon copy of the triage note is placed in a rack and the actual chart is placed on a counter near the patient's room. Our rack is labeled with two big stickers that say, FIRST (on the right side) and LAST (on the left side). The carbon copies are placed in the rack by order, but if needed patients can be bumped ahead. We always leave the first spot empty for patients that need to be bumped ahead. As we start to get near the end of the rack, the copies are all moved forward to make more room for future patients. If we run out of room, we just start doubling up in rack spaces.

We use a 5 level triage system, level 1 are not put in the rack, a doc sees them right away, 2s are bumped ahead most of the time, 3-5s wait their turn.

[crb613, BSN, RN]

We use computerized charting & a tracker board. When it goes down...we go back to paper. It works like this.

1. pt seen in triage given an acuity....we use colors blue=fast track, green= non-urgent, yellow= urgent, & so on.

2. pt registered

3. pwork from registration & triage goes in a rack for ward clerk to assemble & place in rack to be seen. This is done only.......... when a nurse is available to assess pt.& the nurse assigns the room. Unless pt acuity warrants it.....then they come straight back & room is made.

4. chart is made with color of acuity & put in rack to be seen ( rack is labeled by room name).......nurses notes are kept by the nurse not on the chart

5. dry erase board with all rooms...name of pt in color of acuity....doc & nurse that is assigned to pt.

When pt is dced/admitted chart is broken down & all parts then go together.

Works great for us & is very organized....sounds like your docs are the problem.

Hope this helps!

[Altra, BSN, RN]

Just a question -- before the implementation of the acuity system, what mechanism was in place to alert the docs that, "hey -- this guy doesn't look so good"?

[argos]

You really should invest in electronic charting. Registration can wait if there is an empty bed in the ed. Registration is important but not a priority and can be done at the bedside. Some other folks had some good ideas about color coding clip boards for acuity level. The chart rack system is so stone age and unsafe. What if the charts get switched somehow? I recognize there are financial limitations that may not allow for computer charting but it is the most organized way to manage pt charts.

[cuffie]

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