Triage at the bedside

BrnEyedGirl, BSN, MSN, RN, APRN · Feb 9, 2009

Wow,..I've read some similar threads, of places who are trying to skip the triage area and immediately place pts in beds. The ER where I work isn't currently doing this as most of the time we don't have enough beds to actually do this. We are in the process of building a much larger ER and I'm worried that this may be the way of the future for us.

I can't see how this would work. As an RN assigned beds in the ER I'm not always able to drop what I'm doing with in 5 minutes and go triage my pt. This could be disastrous in certain situations. How many times have we seen the shoulder pain turn out to be and acute MI? Or the cough and sore throat be an actually resp emergency? Even the simple ankle pain could be bad if the pt has no pedal pulses! That's why we have triage!

I really don't have any answers for you. Will be interested to hear what others have to say on this.

MAISY, RN-ER, BSN, RN · Feb 9, 2009

If we have an open bed the patient goes to it regardless of acuity. How can you know how sick they are? Additionally, we are not set up for immediate response as our ER appears that is was laid out by someone on crack! Long hallways-everyone far away! Furthermore we have clinical technicians that are stretched out in the department and shared by many, no one to undress the patient, place them on monitors, get vitals or anything else.

One day, I had "help" from a couple of nurses to send patients upstairs, however, I got four patients at the same time UNTRIAGED! A SOB (>100yo and with it), a new onset afib, an active cp and a miscarriage; this was in addition to my SBO who needed dilaudid every 2 hours and cried the rest of the time! The doctors saw all four while I still had the ones waiting for upstairs (wanting and pulled to the hallway), the belly pain who was the neediest person I'd ever had, and all of these new patients! When I went into rooms everyone although seen by physicians were fully dressed! All four doctors wrote orders on people I didn't even know!

Imagine the safety issues involved-the rapid afib resolved on it's own as I didn't have time and didn't see the cardizem drip or bolus ordered because airway comes first! Scary scenario and very real to our new world. It might not be so bad if we only had 4 patients, but that isn't the case! I have had up to 8 SICK patients, and I am tired of it.

So again, any ideas I am looking. I can't believe we are doing this, but PG is up! People love going right in...they just don't understand how dangerous it is.

ScrappyED, BSN, RN · Feb 9, 2009

If the wait is really long out in triage and we have lots of open rooms our ER does bring them back but each nurse brings back only one pt at a time as they can handle it.

If the wait is very long and we don't have several open rooms we send a second nurse out to do a "second triage". This nurse has to take down info manually and then walk back to a free computer to enter the info but at least the patients are triaged more quickly.

It is dangerous and irresponsible to fill up all your rooms with unknown acuity pts if their nurse doesn't even have time to assess them first. What if the pt codes in a room by themselves, door shut (because of HIPPA), not hooked up to a monitor (lack of enough techs) and no family (they dropped them off at the door and ran)? Not to mention the fact that just when you fill up all your available rooms with nurses who don't have the time yet to take care of the pt is when the back door becomes flooded with ambulances.

We only bring back patients immediately if we have several open rooms and several extra "floating" nurses who don't have traumas currently. Sometimes our flow-co/charge nurse will bring back a pt or two and triage them for us. Maybe suggest that to your manager

Altra, BSN, RN · Feb 10, 2009

We have been practicing triage at the bedside with the theory that the pateint is safer with the nurse than in the waiting room.

My :twocents: :

Someone decided to do this not because it's "safer with the nurse than in the waiting room." Nope. This has been implemented to give the appearance of clearing the waiting room.

I can get on board with the idea that if there are rooms empty, then new patients do not truly have to be "triaged" in that they will all go to rooms immediately. This can work successfully if an available nurse can go & get the patient as soon as they pop up on the screen, walk them to a room, assess them and get things started. Where this seems to be breaking down where you work is that it seems to be the triage nurse who is leaving triage to walk patients back to a room and then leaving them there. This opens both the patient and the waiting room to considerable risk.

cookienay · Feb 17, 2009

We have recently began doing this, and frankly I believe it to be a good practice. We have 4:1 ratio and see over 200 patients a day (usually around 75k a year). If I am in triage and have patients lined up and see several empty beds, they are going in there. However, if beds are opening up 1 at a time, then triage is completed in triage. Likewise, if by some miracle, there are only a couple of patients in the waiting room, I will complete their triage before taking them back. Chest pains go straight back. With our computer system, you always know when a patient is in your bed from triage.

It is not necessarily about patient satisfaction,though it does help, it is about getting the patient to the treatment area sooner. It is about doing the right thing for the patient. I do charge, triage, and staff nurse. And in all 3 roles, I believe it to be the right thing to do. The key is communication. We have developed ways to communicate if a patient needs immediate attention, or is having chest pain. Perhaps if your facility develops such protocols this could work?? Good luck and keep us posted!

cyadontwannabeya · Feb 18, 2009

wow ..I would be just as frustrated as you are if I had to deal with 8 acute patients in the ER at one time, 4 of which I did not even get report or triage on. Maybe the answer is only 4 to one pt ratio in the ER. I know I could handle it then, however unlike California some states do not believe in actual pt acuity they only see $$$$ signs. I'm with RN,CEN. They want to get all the whiners out so as to make room for more.

mcvaragon · Feb 25, 2009

I have bypassed Triage at my last 4 ED's..... it is a best practice and perhaps your new Director should show the evidence based practice to the staff.

1- Triage is a process and not a place.

2- There is never a time that a "patient" is safer in the waiting room.... observed by nobody than they are in a treatment area. Additionally, whomever assigned them owns them if they are unstable.

3- We've polluted the act of Triage by asking a bunch of QA questions 'at triage' and then call it triage. The ESI-V Level asks none of those questions.

4- It does require communication, good communication. Nurses complain about patients being put in their rooms w/o notification whether you follow this new triage process or not.

5-Patients in the waiting room are a huge liability for the NURSE. We've all seen the shows. There are regulatory requirements related to how often you have to reassess patients, as well as patients in the waiting room.

I've been doing this process for 6 years and would never go back to the old way. Additionally, big deal if the nurse can't get to them for 10-15 minutes.... chances are if you look at the time just to get to the triage RN because they are asking all of the QA questions... it is more. Before we started, it was taking 45 minutes just to get to the triage RN.

What needs to be managed is the nurse's anxiety.... we hate to feel behind and we hate when someone is in our treatment room staring at us because we're not in there. What is actually 5 minutes feels like 20!

I would definitely look up some of the best practices that ENA and ACEP have out. While there is a big push for this.... it has been around for years.

JessicRN · Feb 25, 2009

We have a new system for triage it is called Rapid assessment. Rapid assessment consists of 5 non monitored beds,2 RN's and a PA and a greeter who registers the patient and puts them in the rooms without telling the RN what is wrong with them.

(it is the belief that we can look on the board on the computer to see what the diagnosis is. ) We triage all the patients and if they are 4's and 5's they stay with us. If they are a 3 but only need IV hydration we take them as well we bring pedi patients to a regular bed and triage them there. We take all the overflow until a bed is available and no one is allowed to remain outside. This occurs between 10am and 10pm. Anytime after that the patient is brought in by the secretary or charge nurse and placed in a room to await triage. Again press ganney scores are the best in the nation. We are waiting for a death praying it won't be me. Because one of us could be in pedi with a patient and the other could be starting an IV when a chest pain comes in and is placed in one of the rooms untriaged (we already had one it was a pt sent by his MD for "an EKG" turned out it was a pt sent for an abnormal EKG (inferior MI) ).Hey It looks great from the outside .

MAISY, RN-ER, BSN, RN · Feb 26, 2009

I have bypassed Triage at my last 4 ED's..... it is a best practice and perhaps your new Director should show the evidence based practice to the staff.
1- Triage is a process and not a place.
2- There is never a time that a "patient" is safer in the waiting room.... observed by nobody than they are in a treatment area. Additionally, whomever assigned them owns them if they are unstable.
3- We've polluted the act of Triage by asking a bunch of QA questions 'at triage' and then call it triage. The ESI-V Level asks none of those questions.
4- It does require communication, good communication. Nurses complain about patients being put in their rooms w/o notification whether you follow this new triage process or not.
5-Patients in the waiting room are a huge liability for the NURSE. We've all seen the shows. There are regulatory requirements related to how often you have to reassess patients, as well as patients in the waiting room.
I've been doing this process for 6 years and would never go back to the old way. Additionally, big deal if the nurse can't get to them for 10-15 minutes.... chances are if you look at the time just to get to the triage RN because they are asking all of the QA questions... it is more. Before we started, it was taking 45 minutes just to get to the triage RN.
What needs to be managed is the nurse's anxiety.... we hate to feel behind and we hate when someone is in our treatment room staring at us because we're not in there. What is actually 5 minutes feels like 20!
I would definitely look up some of the best practices that ENA and ACEP have out. While there is a big push for this.... it has been around for years.

So far the only people who find this a totally positive thing are the patients who are unaware of the danger they face, the hospital, and the physician's group. My worst fear occurred recently, death.

I have been researching many articles and the only ones in favor thus far are involved with consultation businesses, hospital supported, or written by physicians. While I agree there are some positives to this practice, there needs to be much planning, proper staffing and a culture that supports its nurses. We also need to change our triage and treatment practices to enable this type of system.

I am sorry I must continue to refer to the fact if it isn't safe for an ICU/CCU nurse to carry more than 2 patients, I should NEVER BE CARRYING TWO and then some(untriaged-dumped in rooms-not worked up-acute)

You have no profile listed, what do you do exactly? What is your role in the ER? If I were the professional float, triage, charge, or a myriad of other positions BUT NOT THE STAFF NURSE, perhaps I wouldn't mind either!

M

EllieOhioRN · Feb 26, 2009

We have a quick registration system in triage which enables the patient's complaint and MR# to be posted in the room they have been assigned. If one has CP or stroke symptoms they go immediately back and get fully registered at the bedside. EMS gets registered as well at the bedside. Each team has their own registration person and this helps quite a bit. It works quite well for us.

MAISY, RN-ER, BSN, RN · Feb 27, 2009

mcvaragon, i would be interested in your prior experiences w/bedside triage. what the staffing,layout, and triage system was that the various hospitalsused. obviously you thought it worked, i want to understand why.

m