RN at triage window?

[RNintheER]

OK. Well we used to have one RN doing triage. Now we have two....sometimes 2 RN's sometimes an RN and an LVN. Technically, the RN at the window takes basic data, name, dob, pmd, allergies, and Chief Complaint. Then assigns a triage priority (1-5) puts a chart together and gives it to the nurse in the back. The nurse in the back is called a data collector to get past the sometimes LVN in that assignment. So the back nurse does vitals, asks PMH, surgical history, ht/wt/smoking history, etc. Then either rooms the patient or puts them in the lobby to wait for a room.

Our thing is that an RN and only an RN must remain at that window 24/7. We are busy and understaffed and sometimes we hardly get pee breaks!!!

I have seen other ER's where a registration clerk is at the window and you sign in with your complaint. No RN?

Does anyone know about this? It is frustrating me to no end! I believe they said its a DHS thing?

Our management is not so great though so who knows!

Thanks for any info!

[Wendy_RN]

I understand what you are saying, BUT that is not how it is done at any of the hospitals I am familiar with. A RN triages the patients, but the registration clerk is the first person to see them.

[MassED, BSN, RN]

I understand what you are saying, BUT that is not how it is done at any of the hospitals I am familiar with. A RN triages the patients, but the registration clerk is the first person to see them.

well then, don't know what to say about where you work... it was a JCAHO requirement to change it being that registration clerks don't have medical knowledge to determine severity or urgency with illness. It might be where you work where JCAHO hasn't caught up to them or your management or hospital hasn't decided to make the change....

even where I work now - it's PA's who are the first to see any person... it was triage nurses, always a lead RN who was the first person - but now with PA's they stream-line the process... but then, I'm sure JCAHO has changes and updates frequently.

[Wendy_RN]

It is not just the hospital where I work that does it this way. I don't know of any hospital around here that is organized the way you are describing. As I said in a prior post, the registration clerks are only getting the person's name, dob, and c/o. There is a RN at triage that is adjacent to the registration desk. JCAHO has been at our facility recently and we are compliant. Patient's do not sit in a waiting room with the medical staff unaware of their condition.

[MassED, BSN, RN]

It is not just the hospital where I work that does it this way. I don't know of any hospital around here that is organized the way you are describing. As I said in a prior post, the registration clerks are only getting the person's name, dob, and c/o. There is a RN at triage that is adjacent to the registration desk. JCAHO has been at our facility recently and we are compliant. Patient's do not sit in a waiting room with the medical staff unaware of their condition.

didn't write that patient's sit while medical staff are unaware - never brought up anything like that....

Well the issue must be with JCAHO, then, and in N.C., where I worked, this was the latest thing... as well as here in Massachusetts. Here's some info from JCAHO on issues that are being re-designed because they have been found to be root-causes of ER sentinel events. One of them being the triage process: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_26.htm

I'm still searching for more info with JCAHO and the triage process... and OP has the triage process the same as I described we had in N.C..... so, others have experienced this. Peace.

[frenchfroggyAPRN, MSN, LPN, RN, APRN]

I work in a small town hospital. A 4 bed ER. I (RN) see them in the triage area, get vs, name, dr., allergies, cc and most importantly consent to treat. I decide whether to send them up front to be signed in (insurance, address etc.) or take them directly to the treatment room.

[nurse97mommy2000]

Hello All. At our hospital when a patient comes in the front door of the ER the registration clerk is the first to see the patient. They get the patients name and c/c. If the c/o is chest pain, difficulty breathing or even if the patient is bleeding everywhere, etc.. the registration clerk calls back to the back and lets us know. Otherwise they page the triage nurse that there is a patient in waiting. If we have a drive up at the EMS bay then a nurse will see the patient first.

:grn:As for breaks and lunch, I work night shift and just for example, the other night I as a charge nurse was not in an assignment until 11pm. From 7p-11p we had every room full with people in the hallway and 10-12 in waiting. Mind you we are a 19 bed unit (5 Minor, 14 Acute). I had 5 nurses besides myself. We had 4 EMS trucks come in at 1900. I was running around like a chicken with my head cut off just getting the hallway and EMS patients settled. There was no way to relieve anyone at that time. At 11pm our census was the same and 2 nurses left (11a-11p) shift. I then took triage and was left with only 3 other nurses. At this time we also lost the 5 Minor beds due to not enough staff to cover, but did we loose patients?...NO!! We emptied the minor rooms, but the back rooms were still full and we kept 10-12 in waiting up until 5am. There was no way I could relieve anyone for anything, and the problem is, we have a nightshift supervisor, but they do not know or system nor do they want their name on the charts. Anyway, WHO had time to call them to let them know we needed to pee or eat. There is a lot of nights like this and even worse. Some times at 11p we are down to 1 charge nurse with 2 nurses that is 3 nurses to handle triage and 14 acute beds.

:sstrs:Sorry to ramble. Just got on a venting spree. But to answer the question, the registration clerk sees our patients first.

[Altra, BSN, RN]

where I work now - and where I worked one year ago in N.C. - they operate the triage process differently. JCAHO dicatates how it should be done - but they mess with it to suit their needs.

In N.C. it was like where you are - a medical person had to be the FIRST person to lay eyes on the person - either an RN (or likely an LPN) - since it was a "what's your name and c/c" - then registration did their thing and on to the triage nurse...

Here in Massachusetts, they have done away with that... up until 1 month ago it was a team leader RN that laid eyes on the patient, got a C/C - then the triage process... NOW it is this MS2 project (who knows what the heck that stands for) - but it was modeled after a level 1 trauma center in Maryland, I believe... so they think it's better and more effective. Here's how it goes: registration (I believe) sees the patient, gets the name... P.A. sees the patient and obtains a C/C and very little else (like PMH or meds, at least they don't CHART anything). So the patient is scooted to wherever they think is appropriate... peds ER, a staging area (ideally no one on drips here... like nitro), main ER, or a screening room (like the old urgent care). The nurse still does a triage when the patient is in the room. Which, can be done hours later, in my own experience. Once you are taking care of patients, you can't stop and obtain all of that info in a timely manner when you have 4 or 5 patients dropped on you, physicians seeing them... then implementing orders... and then to triage all of them. I miss the old way of doing things. It's not better for nurses, that's for sure. It's better aesthetically to the outsider looking in and seeing less congestion in the waiting room - though this hasn't helped that all that much. It's all about how it looks - I tell patients that it may help them get to me sooner, but it doesn't help me get things done quicker.

I agree with you that it seems that this new process is focused on "clearing the waiting room" but probably doesn't positively impact overall flow through the dept. very much.

One thing that stands out in this post and a few of the others ... obtaining VITAL SIGNS seems to be delayed. This seems problematic to me. As soon as a patient scoots their bottom into my triage chair, I start the conversation at the same time I'm putting on the BP cuff & pulse ox. A young adult c/o "pain in my right ribs" who does not appear acutely uncomfortable might seem like an express care patient until you get an SpO2 of 90% ... then ask and find out he has had recent frequent plane travel ... suddenly that's a high level of suspicion for a PE, an ESI 3 or even 2, and definitely certainly not going to express care.

I'd be concerned if I worked in triage where obtaining VS and getting a brief but focused story from the patient wasn't the first priority.

[Wendy_RN]

I always get vital signs first when I am in triage. I can do that at the same time the patient is telling me why they came into the ER. Vital signs are labeled such for a reason. I think the ER where I work does a great job of triaging the patients. Registration only sees the patients for a brief moment and then they are triaged. The registration process is actually completed after the person has been moved into a treatment room or has already been seen.

[RN+]

It is not just the hospital where I work that does it this way. I don't know of any hospital around here that is organized the way you are describing. As I said in a prior post, the registration clerks are only getting the person's name, dob, and c/o. There is a RN at triage that is adjacent to the registration desk. JCAHO has been at our facility recently and we are compliant. Patient's do not sit in a waiting room with the medical staff unaware of their condition.

Same as Wendy's facility,

Our PCT's/Admin types see the Pt's first but our nurses are usually sitting right near them. We passed JCAHO not long ago with this system so don't know what requirement you east coast types are talking about.

[MassED, BSN, RN]

Same as Wendy's facility,

Our PCT's/Admin types see the Pt's first but our nurses are usually sitting right near them. We passed JCAHO not long ago with this system so don't know what requirement you east coast types are talking about.

I'm sure there must've been documentation with rationale for JCAHO to come into that ER in N.C. where I worked to make those changes right then - having a medical person of some sort to get a name and what their complaint was....

in fact, now where I work - registration is the last portion of the process to see the patient. All ambulance and walk-in patients have registration roll into their room with their computer and get all of their info....

[Altra, BSN, RN]

I'm sure there must've been documentation with rationale for JCAHO to come into that ER in N.C. where I worked to make those changes right then - having a medical person of some sort to get a name and what their complaint was....

in fact, now where I work - registration is the last portion of the process to see the patient. All ambulance and walk-in patients have registration roll into their room with their computer and get all of their info....

Agree but -- we don't know what the rationale was, and we don't know what conversation led the administration of that particular hospital to interpret JCAHO requirements as requiring implementation of a change in the triage process at that particular moment.

The 2 ERs in which I've worked both have a registration clerk take the pt.'s name, DOB and chief complaint. This is in full view of the triage nurse, and part of our responsibility is to eyeball every patient as they literally cross the threshold of the front door to assess whether they require immediate attention, e.g, if they're elderly and leaning on the counter working to breathe as they're trying to provide their name -- I need to grab a wheelchair and interrupt that process. As soon as "PatientX, Age 70, Chest Pain" pops up on the tracking board, it's common sense that that patient needs to be triaged before PatientY, Age24, Sore Throat." Both hospitals have had JCAHO site surveys within the past 18 months and received full accreditation.

I read the JCAHO sentinel event alert you referenced earlier. I did note that it is from 2002, and in the 6 years since then there clearly has not been a wholesale change in the triage processes of all JCAHO-accredited hospitals in the way that "Dangerous Abbreviations" have been adopted pretty much across the board no matter where you are in the US.

[MassED, BSN, RN]

Agree but -- we don't know what the rationale was, and we don't know what conversation led the administration of that particular hospital to interpret JCAHO requirements as requiring implementation of a change in the triage process at that particular moment.

The 2 ERs in which I've worked both have a registration clerk take the pt.'s name, DOB and chief complaint. This is in full view of the triage nurse, and part of our responsibility is to eyeball every patient as they literally cross the threshold of the front door to assess whether they require immediate attention, e.g, if they're elderly and leaning on the counter working to breathe as they're trying to provide their name -- I need to grab a wheelchair and interrupt that process. As soon as "PatientX, Age 70, Chest Pain" pops up on the tracking board, it's common sense that that patient needs to be triaged before PatientY, Age24, Sore Throat." Both hospitals have had JCAHO site surveys within the past 18 months and received full accreditation.

I read the JCAHO sentinel event alert you referenced earlier. I did note that it is from 2002, and in the 6 years since then there clearly has not been a wholesale change in the triage processes of all JCAHO-accredited hospitals in the way that "Dangerous Abbreviations" have been adopted pretty much across the board no matter where you are in the US.

Altra - I understand your point. No need to debate this, cause it's just not that big a deal to me. I also have worked in two ER's and this "new" process is how it works (they USED to be you'd see the reg person first). This is not just in (north eastern) North Carolina, but also here in Massachusetts. I really could care less if we triaged on the roof, it whatever improvements actually made an IMPROVEMENT on the flow, then I would be all for it....

I have searched for more than a bit attempting to locate specific requirements by JCAHO for ER triage - and haven't found anything. I would challenge anyone else who might be able to find something on this to post it - would be some nice info.

So, needless to say, it must be up to interpretation by the facility (and as long as JCAHO deems it to meet the needs to maintain accreditation, then I'm sure that is how it stands). I can usually research the heck out of something and find some small pieces, but info on triage and who should be the first person a patient sees is just not out there.... I will go into a seperate college library and see if I can find anything on any of the journals....