Paramedic triage

JStyles1 · Apr 11, 2009

The State of Texas laws says that all patients triaged need to be assessed by an RN. But on a personal level I feel parameidcs are quite capable of the triage system. I think we can all work together well.

i concur. i think some states have laws that say assessment must be initially triaged by an RN, if its not a full JCAHO policy. I know at my level 1 ER we do not put medics in to triage pts.

i believe that medics do have the possibility to be able to triage; however, their assessment class/skills are a different set than an RN's.

emergencyrn06 · Apr 13, 2009

Basically, I think that if a Medic has enough training to scrape your butt off the asphalt and keep you alive on the way to the hospital then they can triage anything that walks through or is dumped at the ER door. I also agree somewhat with the post that said an EMT-B would be like having a CNA triaging. Yes, some basics are really good and know their stuff, same goes for some CNAs with ER experience. But come crunch time I'd rather have someone with more training on my team. Granted maybe there should be a short course the Medics should take to learn the ropes for triage in the hospital setting, but other than that I would be fine with it.

**canoehead, BSN, RN** · Apr 13, 2009

From ivanh3's post I see where some pitfalls would come in.

Having people wait 3-4 hours does throw a wrench in the works, and reassessing, and basic hospital politics. I still think any advanced EMT could do a great job, given some time and training.

Editorial Team / Moderator · Apr 14, 2009

I know medics who would be brilliant at ED triage, and others who wouldn't. In-hospital is definitely not like being "on the street" -- as both an ED RN and a paramedic, I can say that with certainty. Two different worlds -- yes, with some overlap, but I wouldn't expect a paramedic to be able to step into ED triage and function flawlessly in the RN's usual role any more than I'd expect an ED RN to step out onto the streets and function flawlessly in the paramedic's usual role. Both would require time and training, and I'm sure those places using medics for in-hospital triage require some training/orientation to that role, and/or, as Ivan had, an "RN backup."

Aliakey · Apr 22, 2009

I am a paramedic and I also work primarily in triage at a level II facility that sees about 200 patients per day.

In our triage, the EMT or paramedic completes the triage process (hx, vitals, c/c, etc.), initiate any immediate treatments based on written protocol (such as an ECG for chest pain), and will make a rough determination on the patient's severity and priority. Also, when things get hectic, the EMT or paramedic will also go ahead and obtain blood draws, medicate, temporary-splint, or whatever else can reasonably be done in the triage area (we have 5 treatment rooms available). However, in all circumstances, the RN must review the chart and sign to comply with set rules. Depending on who the EMT or paramedic may be and their proven experience in triage, they could either be trusted in their assessment and the chart signed with minimal questioning, or the nurse has the right (which is respected by the EMTs and paramedics) to start the 20-question process. We all get along great with a one or two person exception --- usually, those folks don't remain for long anyway. We all need each other, and that's well understood in times of overcrowding.

Taking a fresh-from-the-field medic into triage does require some additional education, as one poster said it right, we are not all that familiar with the details on some of the interventions and disease/condition states that would affect what actions are taken in the ED. I learned A LOT from working in the ED, and use it nearly daily when I am out in the field (seeing my partner's eyes glaze when I discussed a lot of the conditions of our patient with Tetralogy of Fallot was priceless the other day). But, paramedics (in our area in particular) may have significant experience or training in areas, such as 12-lead ECGs, that help some of the nurses that have a weakness in that area. For example, if we misinterpret an ECG in the field, our butts get reamed by the doc or in our case review, so we always have a painful incentive to keep our proficiency up, lol!

Just some thoughts from both sides of the game. The best thing for your ED is to have written protocols for both the RNs and medics to adhere to. That prevents 90% of any problems in triage, in my experience.

Intubate89 · May 1, 2009

Hi there,

I work at a level 1 trauma center, average census >300/day and frequently work triage which is staffed with a minimum of 3 RNs, sometimes 5 depending on the census.

I'm shocked at the responses of nurses who agree with EMT-Ps working at triage. In my state (CA), RNs must perform the initial assessment whether the patient is received by ambulance or walk-in.

Aside from that, I appreciate how medics work and function in the field but there exist fundamental differences between the professions. Medics are taught to follow and function according to protocols. Nurses are able to think outside the protocol. Yes, some experienced medics are more knowledgeable in emergency care than some nurses and medics perform assessments under very difficult circumstances. However, nursing is able to address a wider spectrum of patient care than medics. Even the educational requirements of the professions differs and nurses are exposed to so much more.

Assigning a triage number based on ESI is more complicated than following the algorithm. From my experience and education as an ER nursing educator, it makes me nervous to even consider a paramedic working the triage zone. Considering the liability alone, I firmly believe that paramedics can assist in the emergency department however, assessments and triage should remain solely a nursing function.

Displaced · May 1, 2009

Hi there,
I work at a level 1 trauma center, average census >300/day and frequently work triage which is staffed with a minimum of 3 RNs, sometimes 5 depending on the census.
I'm shocked at the responses of nurses who agree with EMT-Ps working at triage. In my state (CA), RNs must perform the initial assessment whether the patient is received by ambulance or walk-in.
Aside from that, I appreciate how medics work and function in the field but there exist fundamental differences between the professions. Medics are taught to follow and function according to protocols. Nurses are able to think outside the protocol. Yes, some experienced medics are more knowledgeable in emergency care than some nurses and medics perform assessments under very difficult circumstances. However, nursing is able to address a wider spectrum of patient care than medics. Even the educational requirements of the professions differs and nurses are exposed to so much more.
Assigning a triage number based on ESI is more complicated than following the algorithm. From my experience and education as an ER nursing educator, it makes me nervous to even consider a paramedic working the triage zone. Considering the liability alone, I firmly believe that paramedics can assist in the emergency department however, assessments and triage should remain solely a nursing function.

No. Nurses also follow protocols/rules/policies. You say tomato, I say tomato. Yes, nurses can address a wider spectrum of care, but in triage, deciding if the patient is going to die now, later or eventually due to anything but the chief complaint is something both can do.

Intubate89 · May 1, 2009

I beg to differ. Triage is simply more than deciding if someone is dying or not; it's not that cut and dry.

We can argue the issue until the cows come home but ultimately, I'm glad that my state affirms what I strongly believe.

getoverit, BSN, RN, EMT-P · May 1, 2009

Intubate89,

I agree, triage is more than deciding life or death.

where I begin to disagree with you is on the spectrum of patient care. While nursing is definitely able to handle a much wider scope of patient care issues than paramedicine, I think that boils down to initial education. Nursing school prepares us to have a ground-level working knowledge for entering the profession. ER nursing takes a certain skill level, mindset, attitude and it has to be taught (to some degree, depending on the nurse). Where as paramedics are trained from day one to handle emergencies, most paramedic programs require ACLS/PALS/BTLS proficiency in order to graduate and I'm not aware of any initial nursing programs that have that requirement.

That being said, many ERs have a triage class that nurses take. I don't see how >90% of triage would be different if a paramedic had gone through the class along with the nurses. Especially in a true emergency. I don't expect a paramedic straight out of school to know about strange blood disoders, but they can recognize whether or not someone needs to be seen immediately as opposed to waiting for the more critical patients to be seen first. That's not to be equated with just scraping people off the street.

I have a much bigger issue with paramedics who say "I'm basically a critical care nurse already"...and I think "buddy, I doubt it."

for Aliakey, I can relate to your experience with describing tetralogy of Fallot. I had a similar thing with some guys at the fire dept when we had a kid with cecal volvulus.

I would be curious to know any actual statistics that have been compiled about paramedics in ER triage and missed a critical condition, as opposed to times that it has happened to an RN. And I have no pre-conceived ideas about what the data would show, I'd just be interested to see what the numbers are. If anyone knows of any studies like that, it would be great if you could link us up.

LLLLiiiFFEsaveer · May 1, 2009

I have not read any of this, but i can say...This is nothing!!!

ivanh3 · May 1, 2009

Hi there,
I work at a level 1 trauma center, average census >300/day and frequently work triage which is staffed with a minimum of 3 RNs, sometimes 5 depending on the census.
I'm shocked at the responses of nurses who agree with EMT-Ps working at triage. In my state (CA), RNs must perform the initial assessment whether the patient is received by ambulance or walk-in.
Aside from that, I appreciate how medics work and function in the field but there exist fundamental differences between the professions. Medics are taught to follow and function according to protocols. Nurses are able to think outside the protocol. Yes, some experienced medics are more knowledgeable in emergency care than some nurses and medics perform assessments under very difficult circumstances. However, nursing is able to address a wider spectrum of patient care than medics. Even the educational requirements of the professions differs and nurses are exposed to so much more.
Assigning a triage number based on ESI is more complicated than following the algorithm. From my experience and education as an ER nursing educator, it makes me nervous to even consider a paramedic working the triage zone. Considering the liability alone, I firmly believe that paramedics can assist in the emergency department however, assessments and triage should remain solely a nursing function.

I find it very offensive that you think paramedics can't think outside of the box. Why would you say that? Based on your experiences as a nurse or paramedic? Every paramedic I know makes a living thinking "outside of the box". I have worked on both sides of that ER door, and I have seen creative thinking on both sides of it. To say that paramedics are more protocol driven is just silly. The ER environment is every bit as protocol driven as the pre-hospital environment. That includes triage. As both paramedics and RNs build on experience they bring more of the "art" to the process, but make no mistake: you deviate from protocol and something goes wrong its your butt, no matter what your title is.

Lets talk about those educational requirements you are so proud of. What exact RN training are you referring to that makes nurses so adept at triage? When you say things like "nervous" and "shocked" it shows your lack of understanding of paramedic training. Many paramedics work solely in the hospital setting. They do just as well as RNs where ever they are utilized. There is no evidence to suggest otherwise. It wasn't that many years ago that new grad nurses were highly discouraged (even prohibited) from starting in the ER. Why would this be if this education you are so proud of is so great? Because they didn't have the experience right out of school. I have many friends who are RNs that graduated from many types of programs, and the vast bulk say the same thing: we learned how to be a nurse during our new grad programs.

You want to be "shocked" then that is on you. I am not, by any stretch, saying that paramedics are superior to RNs, but I have no problem saying this: I will put any new grad paramedic up against any new grad RN, and given the same new grad training I feel there will be no difference in patient outcomes.

Ivan

MassED, BSN, RN · May 5, 2009

I would be against this - they are not nurses. They can provide simple information, but as far as ordering and understanding rationale, no. They are not appropriate replacements.