Triage at the bedside

[MAISY, RN-ER]

We have been practicing triage at the bedside with the theory that the pateint is safer with the nurse than in the waiting room. The nurses have revolted and truthfully feel that this compromises not only patient safety but their licenses as the patient is placed in the room with unknown acuity and left until someone comes into triage. Our current system allows a triage float nurse and a dispo nurse; however if the system gets bogged down, too many ambulances come or a bunch of people arrive at the same time. Everyone is compromised!

We are looking for alternative solutions for presentation to our new director. I believe we need a plan B as no business would run with just one way of doing business.

PLEASE HELP! We can't take it anymore! There has to be evidenced base practice that will support not doing this crazy practice unless there is sufficient staff!

Thanks

[MAISY, RN-ER, BSN, RN]

I was really hoping to see some interest or response to this post. Only one person responded postively to the practice and I have not gotten any particulars from mcvaragon.

We are meeting to discuss the practice and I was hoping that someone could detail if the plan works well, what are the processes that make it a success?

Is anybody out there?

[chip193]

My :

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.

Let me tell you a little story...

First a little background about me and the department. I've been doing ED nursing for about 5 years, the last 2 as a manager of the ED, and prior to that I held every EMS title that you can imagine, right up to COO. I continue to work for a nursing agency on the weekend, which give me access to 9 nearby hospitals to steal ideas that work! Our department is in an isolated community hospital, does trauma (level 2), has 23 beds in the main ER, 11 in Express, and 3 in the psych ER. Our clinical outcomes are excellent (in the top 5% of the country, per Healthgrades), patient satisfaction in the mid-80s percentile, and employee satisfaction is at about the 75th percentile.

Anyway, about 3 weeks ago, we changed our entire triage process. Prior to the change, a patient would present to a desk in the waiting room where a registration clerk would enter the patient into the system and complete a search of the medical records system to find the right patient. We also had a "Liason" at that desk who, so long as she was not working with the family of a critically ill or injured patient, would keep an ear on what patients' complaints were and would advise one of the traige nurses (who each had their own "office") that a seriously ill patient had arrived. The problem with the system was that the Liason had no real training and would miss the "hidden" ill patients - the MI with the atypical presentation, the sepsis patient who was hypotensive but still talking, etc.

So we changed things. A nurse now sits at that desk and does a really, really fast evaluation of the patient. She then decides where to put the patient - Critical Care, General Bed, or Express Care (Fast Track). One of the Triage Nurses will escort the patient back to the area and do triage in the room. Seriously ill or injured patients are picked off from the waiting room and sent back immediately - sometimes with a triage nurse, sometimes with the liason (who we are planning to teach EKGs, VS, and monitor leads next week) - just like an ambulance patient. We had some "dump and run" issues that were readdressed Thursday, which seems to have taken the pressure of the rest of the department. This process was based on one at one of the hospitals where I spent a couple of weekends. They had serious issues (including replacement of the entire ED leadership and most of the nursing staff and having state regulators in the ED to make sure that the behaviors that caused these problems did not repeat) and this was similar to their new system which worked wonders with their MI patients (and getting patients to the cath lab).

So what do we have for outcomes so far? We reduced the average door to EKG time on patient from 22 minutes to 2 minutes. We have reduced the time of placement of the first order (usually labs or an xray) from almost 48 minutes to about 21 minutes. Our front end is more efficient - now its time for us to work on our back end - the admissions!

[MAISY, RN-ER, BSN, RN]

Thank for answering,

I have a couple of questions:

How many patients do you see every year?

How many triage nurses are involved in working up your patients?

What is your nurse/patient ratio?

And just for clarification, your greeter sends appropriate patients to either acute, medical and or fast track?

Thanks

Maisy

[chip193]

Thank for answering,

I have a couple of questions:

How many patients do you see every year?

How many triage nurses are involved in working up your patients?

What is your nurse/patient ratio?

And just for clarification, your greeter sends appropriate patients to either acute, medical and or fast track?

Thanks

Maisy

We see 65,000 a year, three nurses in triage - one out front, two triaging either in their offices or in the rooms (depending on whether there are rooms available). Ratio is 1:3 in the trauma/cardiac area, 1:5 in the general area, and 1:7 in psych/Express (combined). And yes, the first nurse makes bed assignment based on a very short interview. I should have mentioned that all 23 beds in the main ER are monitored, so an acute/cardiac oops isn't a big deal.

Chip

[mcvaragon]

From reading your explanation above, your ER sounds like it is going beyond the basic triage bypass or quick triage scenario. The process that we use is that the patients go back until the rooms are full (rooms are reserved/blocked for EMS on our tracking board when we receive the radio call). The RN's have no more than 4-5 patients tops and our charge RN has no patients. Our protocols are pretty aggressive as well and we have a tech for pretty close to the 5 rooms.

You're right in the fact that communication is key; nurses hate to be surprised and walk in to a patient who has been in their room for 30 minutes unnoticed by anyone.

I've done this in many different roles: staff RN, Charge and Manager. And yes ENA and ACEP endorse and it is always easier for the physicians because they hand-off the admission to another doc while the ER RN continues care.

Your process sounds like it was more intended to be like what Vanderbilt, Mary Washington etc.. use called Team Triage and/or Supertrack.... you can google it. But like I said, it sounds like a good idea gone awry.

Hope they morph it so it is a little safer and the RN's feel more supported.

Good Luck

[mcvaragon]

To Maisy ER RN,

Our system was the following:

During times when beds were available, an EMT/ Paramedic is at triage. They simply identify that the patient is here to see the ER Doc and either select a bed and/or call the Triage RN in the treatment area to see if there is a preference. The patient is quick reg'd out front and a bracelet applied.

The patient is escorted to the treatment room by the greeter/escort and tech stays out front.

The triage RN who floats in the back and provides an extra pair of hands between patients, either triages the patient or the primary RN triages them the same way they do an ambulance.

We use an electronic tracking board and adhere to the ESI V level and only ask chief complaint, VS, pain and anything relavent to the actual complaint vs. the old fashioned PMH, meds, allergies etc...

At 1000 another RN comes in and serves as a float RN/ 2nd triage RN so the 1st one isn't running around like a chicken w/ their head cut off.

The RN:patient ratio is approx 1-4 on average and sometimes up to 5. We had 6 beds for FT and 35 other beds.

There is 1 triage RN 24 hours a day and a second that floats out to triage from 1100-2300.

The triage RN's go out front when there are no more beds available.

The triage RN is also a float in the back, however, doesn't get too involved in patient care. They give a med, do a dc etc..

We see approximately 80,000 patients per year.

I do agree w/ the comments above and think the roll out is critical. We did flow maps and kinda did a table top of the process... annotating possible areas where the process could fail and came up w/ solutions to those problems first. We tested it over one week and only did it for 6 hours at a time. the staff got to critique the pros and cons and then we went back to discuss the cons and how to fix. We also shared the wins related to flow, RN workload, patient and caregiver satisfaction. It won't work well w/o this... .you plan forever, launch it and it fails miserably and nobody wants to try it again vs. small test runs.

Good Luck!

[MAISY, RN-ER, BSN, RN]

I appreciate the reply, we see approx 75K or more per year. This has been rolled out, without a back up plan and without input from the nurses. No evaluation, then re-evaluations has been performed. No vision or plan has been shared with the staff.

Overall, the concept is good-the result has been less than satisfying to the staff and we truly believe patient safety is being compromised as are the nurses and their licenses. Our nurses are working with at least 5 patients. There is a large nursing home, transplant, and cancer population that uses the facility. All very sick, all needing a tremendous amount of care. Of course sprinkled in are the MIs, CHF, SOB, CVA occasional traumas and whatever else.

We feel the facility is supporting this because now there is only one name attached to the patient, the receiving RN. No longer can that RN say the greeter knew, the charge nurse knew, or even the doctor knew, only after the patient is assessed is there any real information available. Unfortunately for the patient and the nurse if they are tied up it may be too late for that patient!

Thanks to everyone, keep them coming. Will be sharing.

M

[chip193]

I appreciate the reply, we see approx 75K or more per year. This has been rolled out, without a back up plan and without input from the nurses. No evaluation, then re-evaluations has been performed. No vision or plan has been shared with the staff.

Overall, the concept is good-the result has been less than satisfying to the staff and we truly believe patient safety is being compromised as are the nurses and their licenses. Our nurses are working with at least 5 patients. There is a large nursing home, transplant, and cancer population that uses the facility. All very sick, all needing a tremendous amount of care. Of course sprinkled in are the MIs, CHF, SOB, CVA occasional traumas and whatever else.

We feel the facility is supporting this because now there is only one name attached to the patient, the receiving RN. No longer can that RN say the greeter knew, the charge nurse knew, or even the doctor knew, only after the patient is assessed is there any real information available. Unfortunately for the patient and the nurse if they are tied up it may be too late for that patient!

Thanks to everyone, keep them coming. Will be sharing.

M

Hi Maisy,

It sounds like the problem isn't so much with changing the process, it seems to be the lack of input from the folks in the trenches.

When we do something new (that we invent - remember, there are still directives that come from above!), we trial it for about two weeks on the original plan (unless it is a complete disaster) then have a meeting with everyone who has been affected by the change and iron out a new/better way to do it. Two recent examples were when we went to computer entry of home medications and when we changed the triage process. A couple of weeks after we started the home medications, we met and scrapped the whole process, and rebuilt it from the ground up, in the meeting. We noted a problem with "dump and run" from the triage meeting. We changed the process right there with the staff and have buy in.

I also need to clarify what the Nurse First (my Director's little nickname for the greeter!) does. When the patient presents to the front desk of the waiting room, the patient will talk with the registration clerk to get entered onto the tracker. While this is going on, the Nurse First can ask a couple of questions if she needs to for bed assignment. She does not do vitals, allergies, meds, domestic violence screening, etc. That is done in the room by either the triage or primary nurse.

Chip

[needsmore$]

WE also bring patients back right away if the ED beds are open--Like many EDs, we combine our triage process with the initiation of registration or the formation of the ED chart.

Triage is a process. If the nurse assigned out front feels the patient needs to go back immediately and sends the pt there-either she accompanies the pt or calls the charge nurse as the EDT is wheeling them to their room. The 'chart' is initiated later as the assessment/interventions are initiated simultaneously

We are fortunate in that we do help each other out-even though we have our own assignments (4 pt/nurse),AND we do staff a float nurse to help--for just this reason-- in fact, I believe EDs should have that "float-unassigned_ nurse spot--someone well experienced that can jump in to help with triage or with procedures in the back. they should NOT be utilized to cover a 'sick' call--their assignment is just as vital as any other assignment

We see 38K/year.

[Michele1377]

OMG - this is exactly what we are going through in our ER right now - I know this is an old thread, but if anyone out there reading it can help me out I would appreciate it. I have been asked to speak at the next labor-management meeting and would like to have something to back our nurses position up.

Michele

[Scout12]

We just started "pull until you're full". My worse day with this was when I had 2 ICU holds, a chest pain, and they put a severe "new onset headache" in my last room and no one told be about it! Do I think it works, NO. All our NP's who did Triage now just walk the patient back to a room and start a short Triage. This leaves the waiting room without a Triage Nurse and only a person at registration! I'm just hoping I don't loose a patient because I don't know they were put in my room.

[gardengal1, ASN, RN]

We are smaller hospital, 19 beds, 28,000 ER visits/year. We have 2 ER techs (most are nursing students or paramedics) who get name/birthdate/presenting complaint and sit at a desk in the waiting room. They have written criteria beside them - shortness of breath, chest pain, vomiting - all go back immediately and one of them takes them to an unassigned room. They have also been trained which rooms are appropriate for the presenting complaint. While they are moving the patient, they vocera the triage nurse to meet them in Room X. She triages them in the room, tech assists with undressing, monitoring applications/EKG and then goes back out front - often taking 5 minutes or less. When triage nurse is almost done, she voceras the nurse being assigned and asks her to come into the room. Verbal report is given, primary RN now assumes care. It is not very often a patient is left alone when they initially present, other than the triage nurse to leave the room, ask another paramedic to go start an IV on this patient and she goes immediately back out to her triage room. More minor complaints are triaged in the triage room and then placed into an unassigned room. If she is not available when a chest pain comes in, ER tech has already vocered her, she has assigned a room via vocera and she then calls receiving nurse on vocera, instructing to meet this patient in Room X with "chest pain". ER tech does not leave the room until the assigned nurse physically comes into the room which is usually a very short period of time. By that time, pt is on the monitor, vitals have been taken and EKG is done. Our triage nurses can do a basic health history in the computer in about 3 minues. Complete assessment or any additional health history is up to the primary nurse.

Staffing ratios: ESI Level 1 1:1, ESI level 2-3 often 2-3:1, ESI level 4-5 can be 5-7:1 sometimes more.