The Front Line

I agree triage is a tuff place to spend 12 hours. Where I work you must have at least 2yrs RN experience and at least one of those in ER before you are eligible to take the triage class. You then spend three weeks with a preceptor before you're on your own.

I've been at the same hospital for almost 12 yrs now, and in all those years the issue of long waits has been the focus of some committee. We have made a bit of head way when we made this a hospital wide issue, rather than just an ER issue. Our committee now includes staff nurses from various floors, staff from radiology, US, Lab, house keeping and the house supervisors. The ER is the "front door" of the hospital for a majority of our patients. They start in the waiting room, move through lab, radiology etc and finally find their way to the unit/floor. If any point in this process is held up for any reason, the entire process is held up. If lab is short staffed and it takes an extra 45minutes to get results, then every person who needs lab is delayed, therefore pt's continue to wait in the waiting room. If a pt is waiting for a bed assignment, but our computer system is down, everyone waits. If we are short housekeeping staff, we may wait hours for that bed to be cleaned and ready for the pt. If the discharges on the floor are delayed for any reason, everyone waits.

Our committee has a data collection "sub committee" right now. We are timing different areas of care to see where the biggest "gap" is. We time how long it takes from when an order for a CBC is written, to when it gets placed on the computer, to when it's drawn, and when the results are posted. We do this for all orders. We time how long it takes from when an admit order is written, to get a bed assignment, for the bed to then be available, for report to be called and for the pt to actually be transfered to that bed.

Our house supervisor is frequently communicating with the charge in the ER. We know how many ICU beds are available, how many telemetry beds, how many male vs female beds. The charges in these departments are working to get discharges complete, transfers done and even moving pts to free up extra rooms.

We have started pre treatment in triage. We have protocols for female vs male abd pain, cough w/fever, CP, child fever etc. Of course this process only helps if all the other departments are flowing well. We can order CXR's from triage all night long and unless there are enough techs in radiology they won't be done until the pt is in a room.

This process isn't even touching on the abuse/misuse of the ER. We attempt to explain at triage that an "emergency" from a triage/ER point of view is a life/limb threatening injury/illness or an illness/injury that is likely to decrease your quality of life if not treated immediately. (We have a sign to that effect) Wanting a pregnancy test at 2am doesn't quite fit in here. We are keeping track of the "left without being seen" from triage. If it's a 2yr old with a fever of 102 X 1hr and they left after 2hrs in the waiting room, we really don't get excited about it.

IMO that is the hardest part of spending my shift at triage. The kids with fever, HA, chronic back pain, twisted ankle etc. These pts feel crappy and don't want to spend 4hrs in the waiting room. I get that,..I really do, but we really do have enough real emergencies that those people end up waiting hours to be seen. Many of them become angry, accuse the triage nurse of "not caring" and throw a fit about the wait. As a triage nurse I can't send a kid with a fever ahead of the CP just because her parents are tired and cranky and want to get some sleep! I'm not sure we'll ever fix this aspect of long waits. We are trying to speed up the time the true emergencies are waiting, and reducing the numbers of non-emergencies that are seen would help that,..but alas I don't know how to fix that!

I've heard of hospitals that have a "code ER" or something to that effect that alerts the floors and other dept's that ED is overwhelmed, this with an intent that the floors will make room for admits and send down extra staff (those who have had a short orientation). I think this would help in our dept because the floors and ICU especially, like to slow down throughput for their own convenience.

We have a code where if the ER isn't able to free up at least two beds appropriate for ambulance calls the charge, ER manager, and house admin get together and declare the ER is unable to provide emergency services, and the floors each take one ER patient up to the hall. They may be admitted patients waiting for a bed, or patients waiting for bloodwork that can't go back to the waiting room, but up they go within the next 5 minutes. We take them back once the crisis is over. Usually that night we can take them back, but some admitted patients get to stay if the floors don't want to bother sending them back. It works well, the docs have learned to push for it if things are backed up.

Financially it works because the ED docs continue seeing patients and generating revenue. Patients in the waiting room get through in a timely fashion, and the criteria made up for patients send to halls is pretty strict, no O2, no tele- they tend to be our most stable wait and see patients.