mcvaragon

To Maisy ER RN, Our system was the following: During times when beds were available, an EMT/ Paramedic is at triage. They simply identify that the patient is here to see the ER Doc and either select a bed and/or call the Triage RN in the treatment area to see if there is a preference. The patient is quick reg'd out front and a bracelet applied. The patient is escorted to the treatment room by the greeter/escort and tech stays out front. The triage RN who floats in the back and provides an extra pair of hands between patients, either triages the patient or the primary RN triages them the same way they do an ambulance. We use an electronic tracking board and adhere to the ESI V level and only ask chief complaint, VS, pain and anything relavent to the actual complaint vs. the old fashioned PMH, meds, allergies etc... At 1000 another RN comes in and serves as a float RN/ 2nd triage RN so the 1st one isn't running around like a chicken w/ their head cut off. The RN:patient ratio is approx 1-4 on average and sometimes up to 5. We had 6 beds for FT and 35 other beds. There is 1 triage RN 24 hours a day and a second that floats out to triage from 1100-2300. The triage RN's go out front when there are no more beds available. The triage RN is also a float in the back, however, doesn't get too involved in patient care. They give a med, do a dc etc.. We see approximately 80,000 patients per year. I do agree w/ the comments above and think the roll out is critical. We did flow maps and kinda did a table top of the process... annotating possible areas where the process could fail and came up w/ solutions to those problems first. We tested it over one week and only did it for 6 hours at a time. the staff got to critique the pros and cons and then we went back to discuss the cons and how to fix. We also shared the wins related to flow, RN workload, patient and caregiver satisfaction. It won't work well w/o this... .you plan forever, launch it and it fails miserably and nobody wants to try it again vs. small test runs. Good Luck!

From reading your explanation above, your ER sounds like it is going beyond the basic triage bypass or quick triage scenario. The process that we use is that the patients go back until the rooms are full (rooms are reserved/blocked for EMS on our tracking board when we receive the radio call). The RN's have no more than 4-5 patients tops and our charge RN has no patients. Our protocols are pretty aggressive as well and we have a tech for pretty close to the 5 rooms. You're right in the fact that communication is key; nurses hate to be surprised and walk in to a patient who has been in their room for 30 minutes unnoticed by anyone. I've done this in many different roles: staff RN, Charge and Manager. And yes ENA and ACEP endorse and it is always easier for the physicians because they hand-off the admission to another doc while the ER RN continues care. Your process sounds like it was more intended to be like what Vanderbilt, Mary Washington etc.. use called Team Triage and/or Supertrack.... you can google it. But like I said, it sounds like a good idea gone awry. Hope they morph it so it is a little safer and the RN's feel more supported. Good Luck

I would suggest the following: 1. If you have shared governance, suggest they do an ESI Audit Tool. If you don't, bring it up to leadership. 2. I would ask that your leadership approach flow differently as unfortunately, many nurses choose answer "C" or ESI level 3. There are some hospitals that perform the flow a little differently: The 1's and 2's go straight back to main, the 4's and 5's go to the urgent care/ Fast Track. The 3's get protocols, some point of care testing, get re-evaluated and sent with the 1 & 2's or back with the 4's and 5's. 3. I would also remind your charge RN that just because a patient came in as a level 2 doesn't mean they remain there.... you could have turned around a CHF'er and now there a 3. Also, the little old lady who came in as a 3 for the perpetual "altered mental status" is now in the late stage of sepsis from her UTI so of course she has altered mental status and now she has no "pressure". We need to use our assessment skills and more importantly our "reassessment" skills. Always ask for help, even if it is just for 10 minutes to get you out of the woods. I know nurses hate to ask for fear of the 'dramatic eye roll and the deep sigh' or worse yet "I've got nobody to send you". but always ASK!

We start the dopa/levo if patient is critical and request the central line. Chances are if you don't, you won't have a line for long and a mess on your hands. Conscious sedation is conscious sedation..... it's the drug and not the dose. If they are calling it a "fugue state' they are just trying to get out of a consent. Pedi sedation, depending on what is given (IM Ketamine etc...) we give it (the doc does). It's a risk/benefits issue. There is not reversal agent for Ketamine and you give supportive measures (bag 'em... etc....). We do give propafol in the ED "procedural"... it is not deep sedation/used to induce general anesthesia. Once again, it is our docs who give it as they must give the bolus and the nurses only the drips. Hope this Helps!

I have bypassed Triage at my last 4 ED's..... it is a best practice and perhaps your new Director should show the evidence based practice to the staff. 1- Triage is a process and not a place. 2- There is never a time that a "patient" is safer in the waiting room.... observed by nobody than they are in a treatment area. Additionally, whomever assigned them owns them if they are unstable. 3- We've polluted the act of Triage by asking a bunch of QA questions 'at triage' and then call it triage. The ESI-V Level asks none of those questions. 4- It does require communication, good communication. Nurses complain about patients being put in their rooms w/o notification whether you follow this new triage process or not. 5-Patients in the waiting room are a huge liability for the NURSE. We've all seen the shows. There are regulatory requirements related to how often you have to reassess patients, as well as patients in the waiting room. I've been doing this process for 6 years and would never go back to the old way. Additionally, big deal if the nurse can't get to them for 10-15 minutes.... chances are if you look at the time just to get to the triage RN because they are asking all of the QA questions... it is more. Before we started, it was taking 45 minutes just to get to the triage RN. What needs to be managed is the nurse's anxiety.... we hate to feel behind and we hate when someone is in our treatment room staring at us because we're not in there. What is actually 5 minutes feels like 20! I would definitely look up some of the best practices that ENA and ACEP have out. While there is a big push for this.... it has been around for years.

I've been there, done that.. got the T-shirt (and the shoes). I can say that I loved every minute of it. I flew Aeromedical Evacuation and worked in a large Air Force Medical Centers. There are only a few large hospitals left in the U.S and overseas. It depends on where you want to go. The benefits you can't beat, the pay is better than new grads and most is not taxed. You may end up going where they put you in the hospital.... however, they are just as concerned with nurse recruitment as they are in the civilian world so I wouldn't lose sleep. Additionally, and you'll find this hard to believe; if they want you to do a job.... they actually "train you" and that includes leadership training if you go that route (which you will). There aren't a lot of cons that I can think of... maybe where you get stationed. however, you have some wiggle room when you request an assignment. Good Luck!

This is interesting.... Let's start off by saying that healthcare "is" actually a business. The days of hospitals being run by nuns or insurance companies paying whatever the hospital bills them are over. Stupid JCAHO and the state. The hospital actually "pays" to be audited by JCAHO so that Medicare will then do business with them and pay them for the care delivered. The state comes in a makes rules b/c medical errors KILL. Regarding having the nurse do nursing; what does that mean... it would help to have a definition. If nurses were educated related to the business side and understood how their personal and professional practice makes or breaks their bottom line..... would they perform differently? The only reason that nurses have been allowed to under-perform is the threat of "nurses are going to leave if this continues". I've heard that F O R E V E R! So, when care is delayed, a patient could have been discharged hours ago, things aren't communicated effectively.... .that's money down the drain and your tech right along with it.

What would I have my tech do? I would have the tech be the primary on ALL of the tasks within their scope. Unfortunately, many ER RN's have become task oriented. The techs see the RN ONLY doing tasks, plus meds and hopefully an assessment. Therefore you have the statement by a few techs that "I can do everything a nurse can do accept give meds". The RN's should be assessing, reassessing, educating, collaborating, anticipating and driving the plan. The RN should be secondary on the tasks. Unfortunately, this has not happened and thus you have the role confusion (or resentment depending upon whom you speak to) of the difference between a tech and a nurse.