Rickbos

We used to use pagers but 2 or 3 times a day I would "beep" the next patient and wait & wait & wait, and "beep" again ....but nobody would respond. I swear someone's garage door in the neighborhood was opening and closing instead.

Its all determined by total amount of resources utilized as outlined in Emergency Severity Index Version 4: Everything you need to know 5 LEVEL TRIAGE SUMMARY ESI 1 Needs life saving interventions ESI 2 Needs immediate Rx but not life saving Rx ESI 3 Needs 2 or more resources but not a level 2 ESI 4 Needs 1 resource ESI 5 Needs no resources other than physician exam DEFINITION of RESOURCES Lab, EKG, x-ray, IV Fluids, IM/IV/Inhaler Meds, = 1 Resource Consult with Specialist,Simple procedures i.e.; suturing, ear/eye irrigation, DSD change, splinting/casting etc.= 1 Resource Procedural Sedation = 2 Resources What is not a Resource Finger stick BS, Urine Dip, Saline Lock, oral med, Tetorifice, PCP consult CRITERIA For ESI 3 Upgrade to ESI 2 ...........................Pulse ..Resp.. SO2..... Temp 100.4 180.. >50.. 100.4 (? Consider) 3 months- 3yrs.........>160 ..>40.. 102.2 (? Consider) 3 yrs-8yrs ...............>140 ..>30 .. >8yrs .....................>100 ..>20 ... Valid pain >7/10 if pain unresolved through triage intervention i.e. ice elevation tetracaine etc.

That is exactly how I feel about the safety aspect of having the charge nurse do triage and have a patient assignment. It is a set up for a bad outcome. Thanks for your answer.

Thanks....

Hi Does anyone work in an ER where the Charge RN is responsible for the whole ER for their shift, triages all patients, and also has a patient care assignment in the ER? If so what type of patient load do they take, how many patients a day does your ER treat, and how many staff RNs are there on duty besides the Charge RN?

Do you, as an RN, have to enter the patient name, DOB, ER doctor, and print out an ID bracelet & stickers as part of triage as part of your electronic triage?

We were proposing the patient upon arrival(if well enough to do so) fill out a carbon less copy triage form that has basic demographics(name, DOB, complaint, & med list). One part of the carbon less copy goes to registration and the other goes with the patient to triage . The registration staff would create a face sheet, patient labels, and an ID bracelet, while the patient is being triaged. The rest of the registration is completed in the patient's room. If the patient is not well enough to be seen in the triage room, everything s done in the room.

We are trialing a new triage system to hopefully improve flow that has the triage RN do a portion of the patient registration, apply the ID bracelet, do the triage assessment, and then place them in a room after triage(if available) and the registration process is completed by clerical staff. Do any of your triage procedures involve the triage RN doing patient registration, or is that done solely by the ER registration clerks? The triage RN feels it slows down their clinical assessment and it would work more efficiently if the ER registration clerk did a "mini" registration for arm band, stickers, and a face sheet with demograpics, simultaneously while the RN was triaging the patient. What do you do out there?

We must have upset some folks in the front offices because we never heard a word from any of them on ER Nurses Day..... Amazing, life goes on!

We use a patient generated triage form that has Name, DOB, Reason For Visit, PCP, Meds & Allergies. Because we are in a resort area, we ask for a telephone # they can be reached at while they are visiting so we can contact them if follow up is needed. This is signed by the patient, giving the patient some ownership in supplying accurate information, and is used as the med recon sheet as well as to aid with the registration process. PMH is not part of our triage form. We are not fully computerized so this is very helpful for initiation of treatment.

Somehow the emphasis with ER care has been put on giving the patient the "false sense" that they are getting treated better by rushing them back in to a room in the shortest amount of time regardless of their acuity. It is an attempt to increase Press-Ganey scores and in my opinion, this flies in the face of "real" triage. If a patient is triaged properly, they will get back to a room immediately if they need it, if not, they will go to the waiting room and go to a room when it is available and the ER staff in the back deems it "safe" to bring them back, not just because a room is available. This concept of "immediate bedding" seems to defeat the purpose of triage. If you fill up all the rooms on a "first come first serve" basis, regardless of acuity, what happens when you need a room for an emergent patient? Valuable nursing time is wasted moving a patient that could have been in the WR out, so you can move the sick patient in. Triage was designed for a purpose and we seem to be ignoring that purpose to get better PR.

The Press Ganey pacifying "immediate bedding" management idea violates the original concept of triage.... "treatment as per acuity". If you want "first come first serve" go to the deli counter or McDonald's. If you want sound, efficient emergency care, utilize an accepted ESI system. "Immediate bedding" should not be done in ERs. The only thing it may accomplish is to give the false sense of being seen faster. It actually can delay treatment of high acuity patients that come in after you fill all your rooms because now you have to throw someone out, who didn't need to be there originally, to get the sick patient in. So Dr Press & Dr Ganey, how is that therapeutic for that high acuity patient? "Immediate bedding" is nothing but a PR gimmick and is detrimental to the delivery of efficient emergency care.

You are experiencing a lull because all your patients are summering in my ER on Martha"s Vineyard. Please put a return address on your folks so we can send them back to the correct point of origin when they are done here. Have a great summer, where ever you are.....

After watching the the 5 Level Triage DVD a couple years ago I made up this little cheat sheet to help me remember the ESI levels. This is solely based on the instructional dvd and really the 5 levels the author of the original question uses are right on. Hope this is of some help to you....Rick 5 LEVEL TRIAGE SUMMARY ESI 1 Needs life saving interventions ESI 2 Needs immediate Rx but not life saving Rx ESI 3 Needs 2 or more resources but not a level 2 ESI 4 Needs 1 resource ESI 5 Needs no resources other than physician exam DEFINITION of RESOURCES Lab, EKG, X-ray, IV Fluids, IM/IV/Inhaler Meds, Consult with Specialist, Simple procedures i.e.; suturing, ear/eye irrigation, DSD change etc.= 1 Resource Procedural Sedation = 2 Resources What is not a Resource Finger stick BS, Urine Dip, Saline Lock(must administer fluids to qualify for a resource), oral med, Tetorifice, PCP consult CRITERIA For ESI 3 Upgrade to ESI 2 ************ Pulse Resp SO2 Temp 100.4 180 >50 100.4 (? Consider) 3 months- 3yrs >160 >40 102.2 (? Consider) 3 yrs-8yrs----- >140 >30 >8yrs---------- >100 >20 Valid pain >7/10 if pain unresolved through triage intervention i.e. ice elevation tetracaine etc.

Thanks for your ideas. Since I posted the original message I have worked it out our ER registration folks to register the patient in a timely manner to eliminate the problem I originally had. All is well for now...thanks

If we continue to accept assignments that go beyond a nurse's ability to deliver safe care and do nothing to improve the situation, we are endangering the very patients you feel a nurse that chooses to go on strike, is abandoning. A strike is not something that a nurse enters into lightly. A lot has to happen before most nurses are willing to take to the streets. As for the abandonment issue, a 10 day notice must be given prior to the start date of any such work action. The hospital, in that time period, can bring in staff to replace the striking nurses or they could put some serious effort into dealing with the root cause of the nurses' reason for calling the strike. The management team can deal with it as they see fit and if they choose not to address the reason for the strike, the nurses that go on strike are not abandoning their patients. As you can probably tell.....I support the MNA's strike.

That would not be needed. I neglected to say that the labs we have standing orders for are strep screens, Urine for C&S, and UCG. We rarely send blood off from triage and that would involve a consult/order from the ER attending.

We have a triage policy that allows the triage nurse to send certain complaint specific labs off out off triage and x-rays on obvious deformities. We do not have electronic order entry and the printed patient labels do not get generated for as much as 20-30 minutes after the patient has been triage and the spec/need for x-ray has been identified. Due to this there is a long delay getting these tests initiated. The thought was to have the triage nurse keep collected lab spec and xray reqs in the triage room, wait for registration to complete the chart, get the labels, and send the specs/x-rays then. The problem is, there is 1 nurse in triage and the nurse has no way to know when the ER registration/chart is completed, and is busy triaging other patients. Triage gets slowed down if the triage nurse is constantly trying to get labels from charts of patients they triaged 30 minutes prior. Does anyone have any ideas how to expedite the process of these diagnostic tests or do we just let things bog down?

I have heard of this concept but have always felt it fell short of the intended purpose/function of an ED. EDs are supposed to deliver "prioritized" care to those with "emergent" issues as per the 5-Level ESI triage system used by most EDs. They do not exist to provide primary care for patients on a "first come, first serve" basis. In the present health care setting we all know EDs are the "primary care" providers for a large number patients but that does not mean we need to abandon the core principles of emergency care delivery to gain higher Press Ganey scores. The prioritization of each patient in the ED is essential to the delivery of ED treatment to those that most need it, and this cannot be accomplished correctly and efficiently with the "first come, first serve" approach. The separation of the "emergent" and "urgent" care patients must be done giving the beds to the most "emergent" and allowing the "urgent" to wait for treatment when beds are available and staff are able to attend to that patient's needs. By the way, I hope you noticed I still refer to the "patient" as a "patient", not "customer" or "client". I have found in 38 years of practice you can be nice to people, get good results, provide a safe environment for the patient and yourself, and enjoy what you are doing, without applying "marketing/corporate tags" or falling for every PR scheme dreamed up by some "office jockey" to make your administration look good. Remember, it is your license they are playing with, not theirs.

RNs do not administer Propofol IVP at my facility, just via drip with vented patients. We do use capnography when we do conscious sedation and that would have have verified/documented your apnea situation instantly. As for your physician's lack of patience, I can't say what should be done to him/her in this venue.

I did have an idea that was not put into play that addresses the "Frequent Flyers" you originally asked about. It was a "Frequent Flyer Card". The patient has to present it in Triage every time they come to the ER. You would punch it on the bottom and after 10 visits they are guaranteed a minimum of 20 oxycodone and get their next ER visit free. I really thought this would get us better PG scores. Can't understand why we didn't do that???

What ever happened to the good old days when you could say...."We're here to save your a_ _, not kiss it!" Yes, I know they are long gone. The former "patient" is now the "customer" and patient satisfaction fulfills the "bottom line" and, as with any business, the "customer" is always right. I do draw the line at "Do you want fries with that"....Seriously now, this is what we did. The ER I work in is in a seasonal summer vacation area and is an 8 bed unit. Our population goes from 16-18,000 to 110,000 in the summer. To lessen wait times a few years ago for the peak periods, we added a 2 bed 10a-10p Fast Track area for ESI 4 & 5 level patients. We also added a patient beeper system that gave the waiting patients a little flexibility to move around and it also preserved their privacy when called for treatment. Our small waiting room was equipped with a TV and patients had access to picnic tables just outside the WR, in view of triage. Triage protocols allowed some initial lab & X-ray to be ordered by the triage RN and this helped expedite treatment. These adjustments brought us 2 Summit Awards from the Press Ganey folks.

We are about to open a new ER and the plan is to keep some patients that presently would be admitted to an inpatient unit, prior to the new hospital. The reason the ER is coming into play now is that we are a critical access facility and can only have 15 med surg beds and 10 SNIF beds. The old hospital had 31 so when we go from 31 inpat beds to 25, the frequent excess (6 patients) is going to be held in the ER. These patients will be admitted to a PCP or Hospitalist and the intent is to have our ER RNs care for them plus our Emergent patients. The Joint Commission demands that these patients get the same standard of care that they would get on an inpatient unit. We feel without additional staff, most likely additional med/surg inpat RNs to care for the OBS patients, we will not be able to care for them or our emergent patients very well. How are you handling similar situations elswhere. Rick

I was wondering how many hospitals allow ambulatory patients & visitors to access the ER directly through the ambulance bay? I work in a hospital that for 35 years, has allowed the ambulance bay to be an open access point to the ER & the rest of the hospital. We are moving into a new facility and we want that practice eliminated in order to secure the work site for patient/staff safety and provide higher patient confidentiality. Does anyone know if there are any regulations that define or address this issue? I would appreciate any & all input.

I once heard one of my co-workers, with a straight face, tell a frequent flyer, drug seeking patient in triage........"Pain is natures way of telling us to slow down." followed by about 30 seconds of dead air.....