Pull until full triage

I was wondering how other emergency rooms do triage? We are attempting to do pull until full. We still have an assigned triage nurse, but are having difficultly with what the triage nurse needs to do. Currently we are having the triage nurse do vital signs and take directly to room. The nurses in the back that are receiving the patients feel overwhelmed and that the triage nurse isn't doing enough. We are trying to improve our door to doctor times and need to reduce our times by 8 minutes. Does anyone have any other suggestions or ideas? Thanks in advance!

[ChristineN, BSN, RN]

I also work in a small ER that brings pts straight back if we have rooms open. However, we have the triage nurse either do the triage prior to their coming back or do the triage in the room. Especially for chronically ill pts with extensive histories, long med lists, etc that can start taking up a lot of time for the primary nurse if they also have other pts already assigned to them.

[BrnEyedGirl, BSN, MSN, RN, APRN]

I work in a 68 bed Level I trauma ED,.we do something similar, if we have several open beds we do bedside triage. It appears to have decreased some of our times. Honestly, I work 7a-7p and usually by 11a we can no longer do this so I'm not sure how much it is really saving us.

[RNCEN]

We bedside triage nearly all our patients, and ultimately it is the primary RN's responsibility. That said, we typically have a team leader in each area (85 bed + hallways ER) to help, although they are frequently not available to triage. We work closely as a team, so help is never far away. Our ER operates with a triage team leader out front who directs patients to the 3 different acute areas and to minor acute based on a pre-designed grid system. Pt. assignment/placement may also depend upon what is going on in a specific area (IE, that area may get skipped if they have high acuity-such as concurrent MI/CVA/Cardiac arrest, etc.). We have 3-4 bed slots, and if you have an open room, you can bet you'll be getting a pt soon. It can be overwhelming, but it's what we do...our door to Doc times are very low.

[MedicalPartisan]

Yep. We call it triage bypass. In our triage there is registration, RN, and a tech. Registration will enter them in the system and the nurse will simply chart the complaint and acuity level, then the tech walks them back to a room and informs the obligated nurse. We do this until we've reached full capacity. Realistically this only occurs for a few hours (if that) early AM and that's about it. If we empty enough rooms we are supposed to bypass again but that never happens. We triage about 130-140 walk-ins a day (24 hours). 40 rooms. 5 are dedicated for low acuity patients seen by an ARNP or PA and another 5 are behind locked and guarded doors for behavioral medicine patients. 1 is a dedicated EKG room. 2 are trauma rooms. So we ultimately have about 25 rooms to work with and I think twice in the five years I've been there have we emptied in the middle of the day.

[Sassy5d]

Every day is different.

The problem I run into, if I'm triage by myself, take a pt back to room and do bedside triage, that leaves the waiting room empty, no staff at the window.

If I arrive them, room them and not triage them, it could be 20 minutes or more before a nurse can get to bedside.

My ER is at a battle with 2 things. The door to doc times and pt satisfaction. Essentially a 16 bed ER with a fast track. Many days, it's nearly impossible to keep up with the walk in's. The sign in sheets are a pile. They want them arrived right away. Cool. Except it could take 2 hours before a single pt gets back. Which kills door to doc time. But the pts view of er begins when they walk in. Letting the papers pile up lowers scores.

[jallen326]

Every day is different. The problem I run into' date=' if I'm triage by myself, take a pt back to room and do bedside triage, that leaves the waiting room empty, no staff at the window. If I arrive them, room them and not triage them, it could be 20 minutes or more before a nurse can get to bedside. My ER is at a battle with 2 things. The door to doc times and pt satisfaction. Essentially a 16 bed ER with a fast track. Many days, it's nearly impossible to keep up with the walk in's. The sign in sheets are a pile. They want them arrived right away. Cool. Except it could take 2 hours before a single pt gets back. Which kills door to doc time. But the pts view of er begins when they walk in. Letting the papers pile up lowers scores.[/quote']

Well in our ER we have 16 beds and are also instructed to pull till full. There is usually one triage nurse on the morning and if we get slammed very early then the primary and the charge nurse helps out with doing the triage until we get our 10 0r 11 am staff. At 11 our minor care rooms become open.

[turnforthenurse, MSN, NP]

We were doing pull till full for awhile but then stopped. The only time we do it now is if we have a bed available and we have an unstable patient (like a patient actively having chest pain who recently had an MI and also went into cardiac arrest) - we'll get the height and weight and bring them back immediately. Otherwise, the entire triage (ht & wt, vitals & CC) are done out in triage.

I can see where pull till full can have an advantage but at the same time, you risk filling your beds with patients that can end up waiting. What happens if you get an unstable patient that walks through the door but no beds available? Sure, you can initiate the treatment in triage by doing an EKG, line & labs, full assessment, order XRs, etc, but you still need a bed.

I'm curious to know what places regularly practice pull till full and have it actually work. And not just by increasing patient satisfaction and increasing door to provider times.

[Glutton-4-Trauma, BSN, RN]

We have been using immediate bedding for about a year in our ED. The patient arrives at the front desk requesting to be seen and the tech pages the triage nurse. The tech will then quickly register the patient while the triage nurse makes their way up to the front. The triage nurse is paged over a phone system, so all nurses in the dept are able to hear the page. The patient is taken straight to a room and is triaged at the bedside (vitals, ESI, med list, etc.). The triage nurse will then assign a primary nurse and handoff the patient. The primary nurses are expected to pay attention to the triage pages so that they can bed and triage new patients if the triage nurse is busy triaging another patient. The process works fine for the first few hours of the shift when census is manageable, but it becomes problematic when flocks of patients begin to flood the department at the same time. It is extremely difficult, if not impossible, for the primary nurses to drop what they are doing to triage new pts within the required time frame when they already have a heavy pt load of their own. We are being told that our numbers have improved drastically, which was the purpose of the new workflow. However, the process is exhausting and the nurses are twice as overwhelmed. We typically try to leave at least one trauma and/or one cardiac room open for high acquity patients, but this is not always possible due to the unpredictability of the ED. I hear that administration is pushing to make more changes to the process, none of which will benefit nursing staff, of course.

[ADeks]

We triage patients out in a triage room next to the WR after triage back out to WR. We will pull patient and do bedside triage if there is something emergent.

We also have a PA who sits in in triage. PA will ask additional questions, may do some quick assessment, and begin orders. We have a second nurse out in our second triage room who will start those orders. Things like line, labs, swabs, even meds. Also radiology will grab patients from WR and get tests completed while waiting for a room.

[zmansc, ASN, RN]

We triage patients out in a triage room next to the WR after triage back out to WR. We will pull patient and do bedside triage if there is something emergent.

We also have a PA who sits in in triage. PA will ask additional questions, may do some quick assessment, and begin orders. We have a second nurse out in our second triage room who will start those orders. Things like line, labs, swabs, even meds. Also radiology will grab patients from WR and get tests completed while waiting for a room.

So you have a full time provider doing nothing but triage assessments and writing initial orders? How big is your ER? What's your volume? Do they keep busy with just that, or do they do some fast track or other patients as well? 24x7? My ER is far too small to even consider this, but I'm curious on how it works.

Thanks.

[ADeks]

So you have a full time provider doing nothing but triage assessments and writing initial orders? How big is your ER? What's your volume? Do they keep busy with just that, or do they do some fast track or other patients as well? 24x7? My ER is far too small to even consider this, but I'm curious on how it works.

Thanks.

We have a PA that starts orders based on triage interview from 9a-9p. That same PA May d/c some of the less complicated patients from the waiting room basically. We do have a designated fast track 11a-11p, but that's seen by PAs and MDs. We are a high-volume, 46 bed ER. We get a lot from both doors so depending on what's going on in the back we have long door to doc times. So having the PA there cuts down. Plus I'm pretty sure it cuts the LWOTs because if they were seen in triage with the PA, if they were to leave it's now an AMA