OPINION PLEASE-er triage situation-overwhelmed!

[Uptoherern]

:angryfire My newER director has recently told us that we are triaging "wrong". As an example, she said that a patient recently signed in as "lady partsl bleeding". The pt. waited in the waiting room for 1/2 hour, then left to go to another hospital and miscarried in the parking lot. Her point was, the triage nurse should;ve gone out to the waiting room and asked the pt if she was pregnant. So What? I should have been more assertive, but now I question was the pregnancy viable? Were there 10 people to triage before her? Were we on diversion? Were we holding multiple admits? were there 4 ""chest pain" patients in their 60's and 70's before her? Where was I supposed to put THEM? Was the charge nurse available to help triage? If we were absolutely full to the brim, what was the triage nurse supposed to do? AARRGH. waiting times where I am are 8-10 hours. sometimes even 10-18 hours at county hospital.. If we are full to the brim, what are we supposed to do? I must've blanked out at this discussion, although I was "greatly irritated" (read: really pissed off_) I, for some reason, couldn/t defend us at the time. the more I think about it, the more it irritates me. Any suggestions? Any good replies? I was not the nurse in question. I was in triage last night, and was ordering labs/xrays whatever I could to help speed up things. I do my job and I do it well, but sometimes we are just overwhelmed and we have absolutely no power over the situation. I don't need my "boss" to tell me how to triage. Let's see how SHE does!:angryfire

[cacwell]

understaffing

overcrowding

grumpy patients that just need a pcp and not the ed

no management backup

no facility backup

nurses in the medical icu refusing pts because "the patient's condition doesn't warrent the last bed"

holding inpatients in the er for 24 or more hours

charge nurses that could care less if an RN already has 3 seriously crit pts

these are just a few of the reasons why I'm moving upstairs.... I love the controlled chaos of the ED, I've been there for 3.5yrs, it's just that I don't feel safe.... I can't afford to lose my license because the hospital can't staff my unit.

At least in the icu I can only get 2 critical pts!

[Mermaid4]

Great poem..The thing is that no one anywhere can ever make a perfect decision for every patient. And I don't think anyone here is attempting to minimize the fact that an early pregnancy loss isn't important or traumatic. If I brought my child in for what I felt was something majorly important (and just being in the ER means most people at least feel that way), even I would be upset if he or she wasn't seen right away howEVER many serious patients were ahead...That doesn't mean that I am right, but that is the perception of most people. Human nature is human nature and it is unfortunate that all too often we can't please everyone....

[nursechick1]

The fact that you were overwhelmed in Triage and your ED was packed will not hold up in a court. The fact is simply that "you are a professional" and any judge will tell you " you should have known better". This patient in question was lady partslly bleeding. The questions to be asked:

1. pregnancy ? Last menstrual period? Could this have been an ectopic?

2. How much bleeding-How many pads used in how much time?

3.vitals stable?

4.postural vital signs obtained?

5.history.

You state that you were overwhelmed in the ED, then you MUST let your resource know, your manager know and if necessary the CNO know your situation and DOCUMENT, DOCUMENT, DOCUMENT. that is clearly your only defense. If all avenues are covered and documented properly and you did everything in your power to prevent this from occuring, as well as have the patient sign the form for leaving against medical advice, after having discussed it with the MD on duty then, and only then are you "covered". I realize what you are saying about being overwhelmed, but you are a professional, as so indicated by your license and you must act in accordance with the standards set by that license and by your facility. The fact that your facility was overwelmed will not matter in a court of law.

Iam a Legal Nurse Consultant as well as a very seasoned ED nurse and I would be the one to do chart reviews on this case. I know what needs to be in place on the chart before it goes to court.

Nursechick01 RN, BSN, LNC

[erShocker]

Congrats!!

You are todays sacrifce for the 'Customer Service' Diety!

(An evil diety that knows nothing nor cares about you, your dedication to thousands of other patients, or how hard you worked to get where you are now.)

You will now be tossed aside, as if you were a part worn out. The ironic thing is that the same 'management' priesthood will be confused by the 'nursing shortage' and wonder why they cant hire more nurses? (I mean, after all, there is no problem hiring managers!)

[zaleah]

I agree, I am a professional. And if you have the means of doing all that perfect stuff on every patient, all power to you. Posturals at triage? Sometimes on a good day;. and if I end up in court--they can have my license. I can make just as much money waitressing, and the 'customer' appreciates it!!!!!!

I do my best, I use the tricks of the trade, and I expect my clients/customers/patients to help as well. This is not a one sided relationship and I cannot control them.

[ncgeminirn]

I work in a level 1 trauma ED and triage here can be quite overwhelming. We have 55 beds, split between non acute and acute. As the triage nurse you can have anywhere from one to 30 people waiting in the lobby to triage at a given time. We use a 1-5 triage system and theoretically anyone who meets the protocol goes straight back.

As most ED's we are always at max capacity, it is not unusual to have a 2-4 hour wait time to be brought back if you are non acute. In triage as many replies have stated we ask LMP, # of pads/hr, pregnancy status, any pain and where. If the pt is using more than 2-3 pads/hr the pt is taken back d/t risk of hemorrhage or hypovolemia, in most cases the pt appears hemodynamically stable-maybe tachycardic.

It is the triage nurse who sees these pts first and must in five minutes decide a likely diagnosis and possible treatments/interventions needed. Anyone who questions your triage decision needs to be in the hot seat for awhile. We all know pts can crump right in front of you. And honestly if I had a chest pain waiting or crush injury I would triage them first over a lady partsl bleed unless I was told by the check in attendant that the pt is bleeding everywhere or appears to be "sick". Nobody triages perfect all the time and everyone else in the back will always second guess your decision. You have to have (or develop) a thick skin and remember you are the first nurse this pt sees, your gut instinct will lead you to the right decision; and from experience this comes with time and after many "bad triage decisions".

Good Luck!

[grannynurse FNP student]

I had to recent ER experiences, in which a traige nurse was used. How would you have acted? A patient presents with wheezing, a known history of asthma and sudden left leg swelling, from her groin to her toes. She presents to a CNA who is responsible for notifying the triage nurse.

Grannynurse:balloons:

[canoehead, BSN, RN]

granny- is this one of those "hypothetical" situations that happened to you and you feel you were mistreated by an uncaring, unknowledgeable, young upstart?

Not interested in even starting the discussion.

[vampiregirl, BSN, RN]

Looking at the original post, it is not even clear if the patient in question was assessed by a triage nurse, just that this patient presented in the ER. If the patient wasn't actually assessed by the triage nurse, then it would seem to me that the actual problem is the entry into the triage system and not with the triage itself. JMHO.

[nursechick1]

Granny

If she presents to a CNA first who then summons the Triage nurse, kiss your license goodby because you are to see a triage NURSE first, no matter what. The facility is liable for every botch that happens if that is the way they run their ED.

[erjulie]

I think this is a common problem in many ER's across the country. Just last week we had patients waiting to be seen for 6 hours. One of our regular dilaudid/phenergan cocktail craving junkies was in for the third time that week with back pain again and when he was told the wait would be at least six hours he left and went to another hospital and caused a big stink. Guess what our manager did? Called him up personally on his cell phone and apologized and told him that she hopes this does not stop him from comming to our hospital to be treated. Give me a break. I don't know what the answer is. The hardest thing is when you have at least six patients in the ED who are admitted and cannot go upstairs for hours, not because there is no available beds, but because it will put the nurse/patient ratio over 1 patient. I am sure most ER nurses can agree that there have been many times we have up to twelve patients by ourselves and nobody cares. We cannot tell the walk ins that they have to come back when the next shift gets here because we don't have enough nurses to care for them. I love my job in the ER but it just seems as if so many policies that apply to other units are foriegn in the ER.

this just enrages me...the simpering pandering crap the manager/director/"leadership" shovels at these patients. It does nothing but undermine the work of the triage/bedside staff member who probably has every good medically sound reason in the world for not placing the patient in a bed immediately. This is de-moralizing to staff, and reinforces the bad behavior of the abusive patient. I am getting awfully sick of patients being "customers" with all the bad connotations that brings on....we provide a service, yes, but it's not a freakin' McDonalds. Yeah, I spent 6 hours in triage today with 6 hour wait times. Couldn't clear beds 'cuz nurses upstairs were "in report"- ah, for the luxury of "report"!:angryfire

[Uptoherern, RN]

To clarify, again, the patient was never seen. She signed in and then left. I don't know how long she was waiting. We try to have someone do a second triage station, but unfortunately, we are not staffed for this and everyone was swamped. How are you supposed to triage someone within 5 minutes of their arrival to the ER when 15 people show up at the same time? IMHO, the three elderly people with sign in complaints of chest pain probably needed to be seen before the lady partsl bleeding complaint. As for the legal nurse with the triage suggestions, I know HOW to triage, and I know WHAT questions to ask........ That is not the point. We work as fast as we can, but wading thru triage of others with complaints that sound more serious takes a while, and she chose not to wait. She left on her own. My original beef with mgmt was that she thought the trage nurse that night should have gone out to the waiting room and asked her if she was pregnant. What good does that do? IF ALL the rooms are full, and everyone is running full speed, and ambo's are lined up like a choochoo train in the hall.........are we supposed to sit her in a chair at the nurses desk? There is NO ONE available to help her at this moment. We try! WHAT do I do with the information, if I have NO resources...... we are packed full like sardines. This is what irked me. Charge rn is busy, nursing supervisor is busy, this is evening shift........no director, no mgmt around.

Sometimes it seems as if these people are all lemmings, and instead of running as a pack to jump over a cliff, they are all running into the er waiting rooms. aaaaaaaaaaaaaaaaaahhhhhhhhhhhhh!