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Discussion

Treating in triage

I'm an RN in the ED of an urban hospital. On many days we may have 30+ people waiting to be seen. We already do second triage when the wait time gets to be about 3-4 hours. The nurses are allowed to order labs, xrays, CT, and other tests based on the patients complaints. That way when the patient gets to the back, most of the results are available. Now our medical director is attempting something he is calling third triage. He sees patients who are in the waiting room (usually sees them in the conference room) and writes orders. He expects the triage nurses to administer meds in the waiting room. We have a 4 hour window to administer antibiotics from arrival time. The other day he wanted me to give Levaquin to one patient ("We're getting close to the 4 hour mark"), and Nitroglycerin to another (We were on yellow and red alert, but so was everyone else and all beds in the back were full including hallway). I certainly don't want patients to wait for treatment, but I also don't feel safe administering medications when it is physically impossible for me to properly monitor patients while treating others. Anyone have any experience with this.

Thanks,

Holly

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So, you are now supposed to do triage, and treat patients? Yikes. At our hospital (similar situation to yours,with the wait time, secondary triage, and full full full), we do a secondary triage, but the only meds we usually give are paracetamol for fevers- mostly for kids who we do not want to have a fit whilst waiting. We have also strung up IV fluids for dehydrated patients in the waiting room. But we do not give nitroglycerin...or antibiotics. (I think I once gave Cipro to a girl who has a UTI, on an exceptionally bad day, but that was out of the ordinary) I can not see how you could be expected to do triage, and also be responsible for a patient load in the WR. Your medical director seems pretty gung ho, perhaps he would like to treat the patients and also be responsible for giving the medications!!

Sounds like trouble and a lawsuit waiting to happen. Before I would go along with this I would ask for formal documentation from the hospital that this is in their policy. Is this person who is writing orders an MD?

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Nitro in the waiting room without a monitor? :confused: You've got to be kidding. :nono:

We give Tylenol and Motrin for fever to kids by protocol, the rest you grab a doc and tell him what you need. Sometimes order labs and all when we are really backed up, or a film of an obvious deformity (again, go grab a doc and get him/her to write it), but that's it. You can't do the window and treatments at the same time.

that is very unsafe for the patient and your license. there is no way i would ever give cardiac meds without the patient on a monitor. this 3rd triage system also sounds like a creative way to abuse the RN's and make you liable for anything that goes wrong. our ED also has protocols for pediatric fever and hydration, but the buck stops there.

We have a 3rd Triage spot, but she doesn't actually triage. She (or he) does bed placement and our fast track. She'll take orders and give meds. Nitro? No way. Those all go back. She only treats the urgent care stuff.... runny noses, sprained ankles, etc.

We have a seperate waiting room for those that get orders from the fast track doc, so she hangs out in there with the patients. It's very stressful, because the patients are constantly eyeballing you and breathing down your neck. However, it cuts the wait times by quite a bit, and helps to unclutter the ED with minor complaints.

If someone in fast track were to develop CP or something serious, they would be "upgraded" and taken back immediately. No matter our wait times.. if a CP comes in, we find a bed for them. We may have to move another guy out in the hall, but we make it work.

Good luck, I hope this is what your hospital is trying to do, rather than have a nurse triage and do all of this at the same time... that wouldn't be too smart of them.

We do peripheral Xrays at triage only with a mechanism of injury/trauma, never a CT (that amazes me), and only medicate with Tylenol and Motrin (we have standing orders for Maalox and Benadryl...but I have strong beliefs against Maalox at triage). Benign hives might LWOBS if you give them a whiff of Benadryl and feel better...but I'll only have to call them back and it makes me more miserable to do paper and calls then to have them sit all day for hives.

There is a distinct line that should never meld between being the triage nurse and directly performing pt care. I wouldn't even give the Cipro to a confirmed UTI with no allergies and been on Cipro before for UTI. A UTI is a primary care complaint and if it's bad enough for the ER (like finally ascended and is a rip roaring symptomatic febrile pyelo) then they aren't at the bottom of ESI or "non-urgent" anyway.

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