Paramedic triage

[klerrn]

My hospital is considering placing paramedics at registration for initial triage, I'm not so sure I'm comfortable with that. Has anyone had any experience with this process, the potential liabilty, negligence etc ?

[MassED, BSN, RN]

in spotting emergent situations, yes, but placed as initial triage through registration for all ER patients, no.

[MassED, BSN, RN]

Depends where you are really. I'd be fine with it because where i live, all our paramedics complete a university degree including clinical studies and another probationary year at the end. They get about the same training as the nursing students really. The only exception being volunteer/private service crews and transport officers (who only transfer patients between hospitals). In fact i'd probably prefer the paramedic to the nurse since the entire focus of the medics training is emergency 1st aide / triage

But i understand that a lot of places have paramedics with less training (emt's) that only do short courses. Then i'd rather have a nurse. I think my rule is: If you've spent less than a year studying medical, i don't want you deciding how much of a priority i am.

Then again, i'm the kind of person that won't bother going to a hospital for anything short of a life/death emergency, so i want someone good at the desk

Paramedics do not get the same training as RN's do. Nurses have at a minimum of 2 years for their degree. Paramedics have, what, a year?? As far as intubation, extrication, and other emergent in the field situations, paramedics are the top choice. Not for triaging - we are trained to see the entire clinical picture, as RN's.

[MassED, BSN, RN]

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.

any EMT or paramedic could do a great job, given more training, would then be... an RN!!!!

[MassED, BSN, RN]

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'd give you a few thanks, but I could only click it once. Good points! I couldn't agree w/ you more.

[Lunah, MSN, RN]

Paramedics do not get the same training as RN's do. Nurses have at a minimum of 2 years for their degree. Paramedics have, what, a year??

My paramedic certification came with an associates degree. Two years of training, including hundreds of hours of in-hospital clinicals being precepted by RNs. Paramedics aren't just ambulance drivers. I know you didn't say that, but a lot of people don't understand what kind of training paramedics receive. Kind of in the same way that many patients treat nurses like glorified waitresses -- they don't see us as critical-thinking beings.

[MassED, BSN, RN]

My paramedic certification came with an associates degree. Two years of training, including hundreds of hours of in-hospital clinicals being precepted by RNs. Paramedics aren't just ambulance drivers. I know you didn't say that, but a lot of people don't understand what kind of training paramedics receive. Kind of in the same way that many patients treat nurses like glorified waitresses -- they don't see us as critical-thinking beings.

two separate roles with different, though equally important, skills, both making a great team. That's how it works in my ER. If there weren't differences, then we would have had the same training and the same national certification.

[Lunah, MSN, RN]

two separate roles with different, though equally important, skills, both making a great team. That's how it works in my ER. If there weren't differences, then we would have had the same training and the same national certification.

That's pretty much what I said on the second page of this discussion. I was just hoping to clarify for the masses that paramedic education is a little more extensive than many nurses realize. Yes, paramedics operate under protocols, but I guarantee we (most of us, at any rate!) do understand the rationale behind them, and we medics often provide more than "simple information" when bringing patients in the back door. But again, I'm not all about having paramedics in triage, either, as I said in my initial post in this thread. But I am all about understanding, mutual respect, and working together for the good of the patient.

[opus13]

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.

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.

With all due respect it sounds as if you do not fuuly understand paramedic education. Paramedic education focuses on critical thinking and assessment skills not just following protocols, which in most areas are called guidelines and allow for flexability, and these are not even looked at until you apply for medical control after graduation, this is because medics who cannot properly assess or think for themselves kill pts. Paramedics have a very deep knowledge within their scope of practice. A good paramedic program is an associates program or 16 to 18 month non degree program which runs straight through without any school breaks like a semester based program. This doesn't include clinical hour of which I did almost as many clinical hours as classroom hours in medic school I did 900 hrs of clinical just in ride time, ED MICU and CCU, not counting OB, burn, OR or pedi.

Now, as a new graduate nurse I can tell you that I didn't learn anything new in the areas of cardiology, respiratory, neuro, or pharmacology, other areas I learned much more in nursing school. In fact I learned more in my paramedic training about trauma than in nursing school. This makes sense since 80 to 90 percent of paramedic education focuses on these areas, we don't learn much about other areas except where the complications can kill you quickly or are major issues like D.M. or sickle cell.

As far a triage is concerned, orientation to a triage system is required regardless of you skill level, both RN's and Paramedics can due it equally well with exceptions based on the level of experience they each have. I've seen both do triage, some can and some shouldn't. In fact before one of the hospitals we transport to went computerized at triage we frequently did our own triage including assigning acuity and decide main ED, or fast track and would just check with the charge nurse for room or waiting room.

I hope this doesn't sound like a flame it's not meant to, it's just that your comments seen to reflect the common misconceptions of ems education. This is something ems has done to itself because of all the different forms ems comes in, volunteer, municipal, fire based and private, this lack of consistancy is one of my pet peeves. I believe ems education can and should progress but we are to busy fighting amongst ourselves to advance as nursing has done. Unlike nurses who may differ in how they practice but still organize to advance their profession, ems models fight against each other which prohibits advancement. Until some types of ems disappear or are regulated to first responder roles only there will not be any unity to push for education changes. I'll save my opinion on what type should be the model because it doesn't belong here and would just open a giant can of worms with flames everywhere.

Karl

[ivanh3]

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.

What a very ignorant and offensive thing to say. Paramedics don't understand rationale? On what do you base this? Please tell me you have some inner, working knowledge of how paramedics are trained. I am not saying all paramedics, but every paramedic I know who went on to nursing school says the same thing: I learned as much or more about patient care as a medic than as a nurse. Every single one. You see paramedics don't study "paramedic theory". We study patient care. We study A/P, patho, pharm, etc. We learn how to think on our feet. We learn how to outreach to the community. And a very big YES: we learn about the rationale behind many things. Do we own the patent on this? Newp. But guess what? Neither does nursing.

in spotting emergent situations, yes, but placed as initial triage through registration for all ER patients, no.

Again, that is just plain silly. FYI, paramedics DO triage successfully in many hospitals. I have seen it. I have done it.

Paramedics do not get the same training as RN's do. Nurses have at a minimum of 2 years for their degree. Paramedics have, what, a year?? As far as intubation, extrication, and other emergent in the field situations, paramedics are the top choice. Not for triaging - we are trained to see the entire clinical picture, as RN's.

You are right. Paramedics don't get the same training. I would say we get better training, but that is just my opinion. But it is opinion based on being both a paramedic and a nurse, and also knowing many paramedics who went on to nursing school. So please tell me: what part of the clinical picture do RNs see that paramedics do not? Please elaborate and be precise.

any EMT or paramedic could do a great job, given more training, would then be... an RN!!!!

Or just a better trained paramedic. When I was a paramedic working in the ED, I trained many RNs. So by your logic then at some point before graduation a nursing student knows as much as paramedic? Do you really believe that?

two separate roles with different, though equally important, skills, both making a great team. That's how it works in my ER. If there weren't differences, then we would have had the same training and the same national certification.

No we wouldn't. Why? Because of nursing political power. While I agree that the roles started out as separate, many paramedics work solely in the hospital setting. Why? Often it is better pay, benefits, schedule, and tuition reimbursement.

A previous poster didn't respond to a point I made earlier, but I think it bears repeating. Not so long ago new grad RNs were either discouraged or prohibited from working in the ER as a first gig. That changed only because of the staffing shortage and not because of some improvement in nursing education. In fact, at least one hospital in my area is not hiring new grad RNs in the ED because of cutbacks. If nurses learn so much in school then why can't they just come out and work as ED nurses? Why an additional 4-6 months of training? Full time. If you want to compare a new grad medic to an RN that has several years of experience then please do. Or...go to an ER that lets paramedics utilize their skills and compare those medics to RNs with a similar amount of time on the job. Tell me what you see then.

Ivan

[ivanh3]

This is something ems has done to itself because of all the different forms ems comes in, volunteer, municipal, fire based and private, this lack of consistency is one of my pet peeves. I believe ems education can and should progress but we are to busy fighting amongst ourselves to advance as nursing has done.

Karl

Karl, you make some good points. One major step for EMT education is the move by the National Registry to require EMT programs to be accredited by the NREMT. I believe this obligation has to be met by 2013. Up until I moved to Georgia a few years ago, I taught at a Colorado community college. Our program was very complete. Students were taught urine cath placement, NG/OG tube placement, etc to better reflect that a growing number of medics are working in the hospital environment.

Ivan

[MassED, BSN, RN]

What a very ignorant and offensive thing to say. Paramedics don't understand rationale? On what do you base this? Please tell me you have some inner, working knowledge of how paramedics are trained. I am not saying all paramedics, but every paramedic I know who went on to nursing school says the same thing: I learned as much or more about patient care as a medic than as a nurse. Every single one. You see paramedics don't study "paramedic theory". We study patient care. We study A/P, patho, pharm, etc. We learn how to think on our feet. We learn how to outreach to the community. And a very big YES: we learn about the rationale behind many things. Do we own the patent on this? Newp. But guess what? Neither does nursing.

Again, that is just plain silly. FYI, paramedics DO triage successfully in many hospitals. I have seen it. I have done it.

You are right. Paramedics don't get the same training. I would say we get better training, but that is just my opinion. But it is opinion based on being both a paramedic and a nurse, and also knowing many paramedics who went on to nursing school. So please tell me: what part of the clinical picture do RNs see that paramedics do not? Please elaborate and be precise.

Or just a better trained paramedic. When I was a paramedic working in the ED, I trained many RNs. So by your logic then at some point before graduation a nursing student knows as much as paramedic? Do you really believe that?

No we wouldn't. Why? Because of nursing political power. While I agree that the roles started out as separate, many paramedics work solely in the hospital setting. Why? Often it is better pay, benefits, schedule, and tuition reimbursement.

A previous poster didn't respond to a point I made earlier, but I think it bears repeating. Not so long ago new grad RNs were either discouraged or prohibited from working in the ER as a first gig. That changed only because of the staffing shortage and not because of some improvement in nursing education. In fact, at least one hospital in my area is not hiring new grad RNs in the ED because of cutbacks. If nurses learn so much in school then why can't they just come out and work as ED nurses? Why an additional 4-6 months of training? Full time. If you want to compare a new grad medic to an RN that has several years of experience then please do. Or...go to an ER that lets paramedics utilize their skills and compare those medics to RNs with a similar amount of time on the job. Tell me what you see then.

Ivan

Ivan, I respect the fact that you were a paramedic prior to becoming a nurse. RN's, as well as paramedics, are no more ready fresh out of school to work in the ER as paramedics are ready to quickly intubate in the field. I would never suggest a newly graduated RN to start in the ER, even if they feel they are able and ready. They are not.

You seem to want to debate the fact that you believe paramedics are above RN's, and I won't do that with you. Each has their place. If Paramedics were adequate to triage, staff and manage total patient care in the ER, then what is stopping hospitals from hiring them to those positions, may I ask?

"According to ANA’s 1992 Position Statement, "Other regulatory entities have been pressured to lower agency staffing standards, for instance by allowing emergency medical technicians to function in the emergency room without registered nurse supervision or by substituting unlicensed personnel for licensed nurses. These unlicensed persons have not completed nursing education programs, or met other licensing requirements. In many instances, substitution of unlicensed personnel for licensed nurses clearly violates state nurse practice acts. At the very least, it is not in the interest of the health, safety, and welfare of the public".

"According to Mary Jagim, RN, president of the Emergency Nurses Association (ENA), "The use of paramedics in the emergency department would fall under the ENA Position Statement of use of unlicensed personnel in the ED, which is that the registered professional nurse is an essential element in the provision of quality, safe, and cost efficient care whether involved in patient care, or in directing non-RN caregivers."

http://home.earthlink.net/~douglaspage/id77.html

http://www.ena.org/about/position/pdfs/usenon-rn.pdf

[ivanh3]

you seem to want to debate the fact that you believe paramedics are above rn's, and i won't do that with you. each has their place. if paramedics were adequate to triage, staff and manage total patient care in the er, then what is stopping hospitals from hiring them to those positions, may i ask?

"according to ana's 1992 position statement, "other regulatory entities have been pressured to lower agency staffing standards, for instance by allowing emergency medical technicians to function in the emergency room without registered nurse supervision or by substituting unlicensed personnel for licensed nurses. these unlicensed persons have not completed nursing education programs, or met other licensing requirements. in many instances, substitution of unlicensed personnel for licensed nurses clearly violates state nurse practice acts. at the very least, it is not in the interest of the health, safety, and welfare of the public".

"according to mary jagim, rn, president of the emergency nurses association (ena), "the use of paramedics in the emergency department would fall under the ena position statement of use of unlicensed personnel in the ed, which is that the registered professional nurse is an essential element in the provision of quality, safe, and cost efficient care whether involved in patient care, or in directing non-rn caregivers."

http://home.earthlink.net/~douglaspage/id77.html

http://www.ena.org/about/position/pdfs/usenon-rn.pdf

you ask the question and then you answer it: what stops hospitals? nursing political bodies/lobbyists. i find it ironic that you would quote a 17 year old ana statement. it was wrong then. it is wrong now. paramedics are not unlicensed. all working paramedics are licensed. they were licensed in 1992. they are licensed now. there is no study, not one, that shows that patient outcomes with hospital based paramedics are less (or more) favorable. that makes me wonder about the motivation behind statements like that. are they truly about patient safety or is job security the issue? i expect it is somewhere in between. it is wrong for groups like these to lump paramedics in with nursing assistants/patient care techs.

i am not putting paramedics above rns. so let me be clear about what i am saying. i am saying that with the current state of both nursing and emt education, that either of these two pools of talent can equally succeed in the hospital setting given the same type of new grad or transition training. now this is based only on my experience, but i can't find a single reason to think that i am wrong, and no one has been able to demonstrate to me anything other than position statements which do not seem to backed with any study either.