Streamlining triage-required questions

[vampireslayer]

Our ER is trying to revise our triage template (computer charting) to remove any questions that are not needed at triage. Not saying we won't ask them EVENTUALLY, once the patient gets back into a room, but to avoid the backup that we've had, where people may sit out in the lobby for an hour before anyone ever speaks to them, we're trying to find ways to triage faster.

We've had nurses say certain questions MUST BE ASKED during the triage process, as per JCAHO (I think...and maybe EMTALA??). We're screening for suicide & abuse, of course, TB, fall risk, alcohol use, drug use, smoking. All that along with an assessment.

So what REALLY HAS to be done at triage, and what can wait until the patient gets a bed?

I really think the problem is that the new nurses (who shouldn't be in triage in the first place, but that's another story, staffing is stretched to the limit right now) can't do a quick focused assessment. Their triage takes way too long, and we get backed up. NOT because of the previously mentioned questions, but because they're assessing every little thing rather than doing a focused assessment. Obviously quicker assessments will come in time for all of them.

But for now, what exactly are REQUIRED triage screening questions, and what can wait until the person gets a room?

Can anyone give me a sample of exactly what is asked in your ER? Our assessment screen even has things like "behavior" and "appearance". That's appropriate if the person is suicidal or homicidal and the behavoir is "agitated" or "combative" or whatever, but 99% of the time, nurses will write "apearance is uncomfortable" (yeah, duh, they have abdominal pain of course they're uncomfortable) and "behavior is cooperative" (that doesn't help me, where as agitated or combative might). Same with respiratory...most nurses think it's crucial to chart ALL the Resp. fields "breathing is even & unlabored, airway is patent, breath sounds are clear bilaterally" while others are happy with "no deficits noted". We have LOTS of that, where some nurses are fine iwth "no deficits" and move on, while others insist upon charting "abdomen is soft & non-tender in 4 quadrants, bowels sounds present in 4 quadrants, denies n/v/d" even when the chief complaint has nothing to do with GI! And cardiac is another one that most people feel is crucial to at least chart "denies chest pain, denies SOB", they won't just chart "no deficits", and they won't skip the field altogether. Dermatologic "skin is intact, warm, normal color and dry" rather than "no deficits" or skipping that field altogether. We are "supposed" to be charting by exception but they feel they need to "CYA" by charting all of it...hence triage is taking a few minutes longer for each patient, which isn't a big deal until you get 15 people behind that haven't been triaged.

So what are our legal (or EMTALA or JCAHO) requirements on charting and screening in triage? And what are our liability risks for "no deficits" or not charting something at all? I've never been involved in a court case where my charting came up so I honestly don't know how to help the triage committee pare down the process within legal and liability constraints, and we have nurses who simply refuse to triage any way other than the way they've always done it, which is a complete and full assessment (with NEVER a "no deficits noted" comment)! Maybe they're being smart and I'm naive, and if so, I need to know that!

Any help would be appreciated as we try to streamline our process.

VS

[Altra, BSN, RN]

WHOA ...

I've used both electronic and paper systems and have not seen anything like this. Kinda ridiculous, if you ask me.

Triage needs to start as a blank slate, which an experienced nurse quickly whittles to a very focused assessment, with the possible inclusion of some other unrelated but important detail(s).

Are these nurses who chart on bowel sounds and lung sounds listening to all these fields? No wonder there's a problem.

There is no way that all that stuff needs to be asked in triage. Screening? If patient's chief complaint is depression or anxiety or hallucinations, then it's appropriate to ask in triage about suicidality ... but ridiculous if that's being asked in triage of a patient who presents with a chief complaint of abd pain.

Who designed your triage screen?

[CritterLover, BSN, RN]

joint commission may require those screeing questions be addressed, but they don't require that it be done in triage.

many facilities have these questions addressed in triage because it seems to be a reliable place to get questions answered and the screenngs done, thus increasing compliance.

i know that when i was in triage, it was me and a patient, 1:1, and i was asking a bunch of questions. "whats a few more?" seemed to be the prevailing attitude.

once the patient went to the back, there was so much else going on, that the screening questions can get neglected.

the triage form where i used to work included (from memory):

c/c

ht/wt

lmp

vs

breif pe (lung sounds, pulses, loc, edema, cap refill)

place to write an assessment note (also supposed to be brief)

use of etoh/drugs/tobbacco

abuse screen

suicide screen

culture screen

advance directives

primary language

pcp

assigned dx

triage level

there may be more to it. it has been over six months since i filled one out.

where i currently work, it is much shorter. pretty much c/c, vs, breif pmh, triage category.

it sounds like you need to get a lot of that assessment stuff out of your triage form. there is no reason to to do a full-on assessment in triage. you are guaranteed to get backed up.

as for the substance use/abuse screen type questions, i think it is really a balance between getting throug triage in a timely manner and ensuring that the questions are addressed. you need to figure out what is best for your facility. if you move those things to the ed assessment (rather than the triage note), will they get missed? if so, it might be best to leave them on the triage noted. if they will consistenlty addressed in the back, then maybe move them.

(regarding the abuse screen, it may also be beneficial to consider which place the patient is more likely to be alone)

[canoehead, BSN, RN]

We do subjective, objective, pain assessment, allergies, meds, ht/wt, vitals, past history, smoking/etoh/drugs, GCS, and that's it. We're JCAHO certified. Takes about 5minutes. Registration does the living will/advance directives questions.

[MAISY, RN-ER, BSN, RN]

Meds, med/surg hx, tet-pneu-flu vaccine in last 5, allergies food or med, allergy to latex/rubber, vs, ht, wt, pain level,lmp, pregnant/wks? breastfeeding? PMD name, drink-smoke-drugs?, do you feel safe at home? Then generalized statement area of primary reason patient is being seen. If patient complaint involves sob, then I will listen to lung sounds. If patient complaint involves swollen leg, I will check pulse, temp, edema, size. Etc....

We also have an area in which we can highlight interventions: ekg, ice application, dressing, npo status, etc....

In addition, how they got there-ambulatory/bls/als-any interventions prior to hospital-oxygen, iv lines fluids etc....

Hope this helps.

Maisy

PS We are now trialing an advanced triage protocol for cp and abdominal pain patients using standing orders. So far it has been moving along.

[groh2009]

In triage: 1) chief complaint with history of s/sx and duration of s/sx, 2) medical hx,

3) surgical hx, 4) allergies, 5) weight, 6) actions taken before coming to ER, 7) pain level, 8) LMP, 9) vital signs, 10) acuity level.

We are to have our triage assessment completed in 5 minutes. A focused assessment in regards to chief complaint, pain assessment, triage history (JAHCO questions), and list of home medications are all completed once the patient is in a room.

[CanERRN]

ours includes the required "fall risk" as well

[ernurse1993]

We also have all those questions in the triage document, it is hard for some of our nurses to leave it incomplete. I say the nurse doing the primary assessment can ask all the mandatory questions when doing their primary assessment, hooking them up to the monitors and starting the IV's. We are very good at multi tasking. I just tell my patients, ok it is time for all the mandatory questions that we are required to ask them. Some pt's get mad others just go along with the questions.

[alkaleidi]

So what REALLY HAS to be done at triage, and what can wait until the patient gets a bed?

I honestly don't know what legally has to be done per JCAHO/etc, but this is what our triage screen has:

-free text box for chief compalint

-full vitals (t/p/r/bp/pulse ox)

-pain assessment (2 options: pain scale or full pain assessment... pain scale takes you to a 0-10 screen where you click the number, and is only supposed to be used for folks with 0 pain... full pain assessment takes you to a picture of human body, click where their pain is, takes you to a screen where you [[describe pain [sharp, dull, throbbing, burning, cramp, etc] and mark either radiation [to ______] or no radiation, intermittent or constant, and that you educated them on pain control, and set a goal (0-10) for their pain]] seems like a lot but it's a lot of click to mark a box and move on -- goes quickly

then...

-onset of problem

-who info is obtained from (pt, parent, relative, friend, amb record, NH record, police)

-allergies

-on medications or no medications (click one or the other)

-PCP

-medical hx (brings you to a list and you double click dx's to add to history)

-surgeries

-weight

-OB hx (LMP, G/P/A, etc -- very simple and concise)

-acuity (acute, emergent, urgent, non-urgent)

-triaged to... main ED, fast track, waiting room, or discharge from triage -- takes you to a screen that basically says "triaged to room ___", pt instructed/assisted to undress, transported via (stretcher, wheel chair, ambulatory)

I think that's all. I personally think it's pretty simple -- of course there are things that aren't necessarily necessary (i.e. OB hx unless having female sx) and in the free text box you can write as little or as much as you want. Some triage nurses are too vague ("pt presents with abdominal pain"), while some are a little better ("pt presents with abdominal pain x3 days off and on, exacerbated with food/liquid. pain started in ruq and has become generalized; abdomen firm and tender x4 quadrants, hypoactive bowel sounds x4 quadrants. nausea and vomiting for past 8 hours. unable to keep food or fluids down. vomiting at time of assessment.") or whatever... and some tell a life story. I've never heard anyone complain about our triage screen...

hope that helps!

[canoehead, BSN, RN]

ours includes the required "fall risk" as well

You can ditch the fall risk if you make a policy that everyone in the ER is a fall risk by virtue of being undiagnosed, and with a rapidly changing condition.

[KatieBell]

VS,

your template sounds more like an initial assessment. I've done triage with a variety of systems. I suggest your ED look at the plain old T-system triage. It does not include things like breath/bowel sound assessments nor assessments of cardiac rhythms.

Most of this sould be done as an initial assessment by the primary nurse. If the ED is backed up (as is often the case) I might do a focused assessment to try to confirm a suspicion (ie get an ekg in triage to try to confirm that this persons "racing heart" is an abnormal rhythm, not anxiety) but otherwise, most of this should be done by the primary nurse....

I have noted though that it takes me and my working pal about 7 minutes to triage someone, and that it takes some of the newer nurses more like 15 to do the same kind of patient.

[LilgirlRN, ADN, RN]

We use T sheets in out ER, you can google the T system if you don't use it in your ER. It asks all relevent questions depending on complaint. However on some complaints they ask personal questions where I don't get the relevance such as... male abdominal pain. If the man does not answer affirmatively that he's having trouble urintating, burning, stinging, or describes retention I don't get why I need to ask if he's sexually active if he just comes in with vomiting. If he had rectal pain I could even see asking about his sexual history. I do agree with "why do I need to know if he's been exposed to TB" in triage other than for my own protection. I suppose the best palce for your questions would be ENA, there's nothing those guys don't know about ER protocol. :)