Triage: HELP-Initial Contact Registrar

nowplayingEDRN · Mar 18, 2004

I just moved. I am concerned over the Emergency Room Triage process here.

Written into the process is the patient's first contact is the registration clerk. The clerks have received a policy that states:

"Patients are registered in the order in which they arrive, except when the patient states or the registration clerk views the patient experiencing any of the following symptoms:

Chest pain, jaw pain, arm pain
Shortness of breath
Altered state of consciousness
Motor vehicle accidents
Pregnant with bleeding, cramping, Pain
Altered state of consciousness
Headache
High temperature with change in usual behavior
Allergic or diabetic reactions
Paralysis
Gunshot or stab wound
Behavior health issues or aggressive or violent behavior
Any other condition causing concern

The triage/ED RN will be notified immediately by the registration staff when a patient presents with any of the above symptoms. It is the triage/ED RN's responsibility to then determine if the patient needs to receive urgent care prior to registration."
END OF POLICY EXCERPT

If the triage RN is occupied with a patient, and another patient arrives that does not have one of the above symptoms, the registration clerk is to go ahead and register that patient. The patient has a seat and when they are finished with the current patient, the RN looks at the paperwork completed by the clerk, reviews the symptoms and determines who to take next.

I understand that EMTALA now allows the registration process to proceed if it is not delaying the medical screening. However, I have great concern over who is to determine it is okay to go ahead with this registration piece. For example, how is a registration clerk to know what is a diabetic reaction?

I am new and from a larger facility that had a tech assisting the RN out front making these decisions, not the clerk. I was hired to work Triage and this makes me nervous.

My questions are:
Is there a regulation preventing the registration staff from having this responsibility?
Is there a regulation that states specifically who should have the initial patient contact?

If so, where can I find this, so that I can present this to my supervisor? When I briefly mentioned my concern, I was told having the tech out front would be considered the tech was triaging and be an EMTALA violation....wouldn't a clerk doing this be more of a violation? HELP!!
Thank you for taking the time to direct and assist me.

Have you tried looking up the regulations for your state on the BON web site? That would be where I would start, also check with your local health department and investigate what the requirements of the law are, specific to your area.

I know that our facility works closely with the health dept on appropriate staffing and triage as well as with the state BON reqs.

Another good source of info would be your states local emergency nurses association.

Hope that some of this is of help to you. I would be concerned that a reg clerk is starting the triage process, too. In our facility, the reg clerk is not allowed to beging the reg process until the nurse has laid eyes on the person, obtained a complete set of VS and obtained what the presenting problem is (at a minimum).

Trauma Columnist · Mar 18, 2004

I work in a level one trauma center and we had this issue also. We solved it by having two RNs and an EMT-P at triage. The registrars now register in the triage rooms with portable laptops mounted on wheeled carts. It works so much better. Our goal is to have pts seen by RN first withing 1 minute of arrival. It also allows for the "rapid, across the room assessment" that ER nurses do. Putting two nurses at triage was expensive, but it only takes one sentinel event to do it! Good luck...push for two nurses at triage.

nanseatx · Mar 19, 2004

This is much the same system that is currently used at our ED. If the triage nurse is busy however, and any of the conditions listed are given as complaint, the clerk pages STAT TRIAGE and one of the nurses in the back, usually the charge nurse, comes out and assesses the patient. Even then, it hasn't been a very successful system and (thank god) we are soon to go to the Nurse First Triage System. We have recently had some bad outcomes from this practice and I would definitely not be continuing as a triage nurse here if we weren't changing the system. :uhoh3:

I just moved. I am concerned over the Emergency Room Triage process here.

Written into the process is the patient's first contact is the registration clerk. The clerks have received a policy that states:

"Patients are registered in the order in which they arrive, except when the patient states or the registration clerk views the patient experiencing any of the following symptoms:

Chest pain, jaw pain, arm pain
Shortness of breath
Altered state of consciousness
Motor vehicle accidents
Pregnant with bleeding, cramping, Pain
Altered state of consciousness
Headache
High temperature with change in usual behavior
Allergic or diabetic reactions
Paralysis
Gunshot or stab wound
Behavior health issues or aggressive or violent behavior
Any other condition causing concern

The triage/ED RN will be notified immediately by the registration staff when a patient presents with any of the above symptoms. It is the triage/ED RN's responsibility to then determine if the patient needs to receive urgent care prior to registration."
END OF POLICY EXCERPT

If the triage RN is occupied with a patient, and another patient arrives that does not have one of the above symptoms, the registration clerk is to go ahead and register that patient. The patient has a seat and when they are finished with the current patient, the RN looks at the paperwork completed by the clerk, reviews the symptoms and determines who to take next.

I understand that EMTALA now allows the registration process to proceed if it is not delaying the medical screening. However, I have great concern over who is to determine it is okay to go ahead with this registration piece. For example, how is a registration clerk to know what is a diabetic reaction?

I am new and from a larger facility that had a tech assisting the RN out front making these decisions, not the clerk. I was hired to work Triage and this makes me nervous.

My questions are:
Is there a regulation preventing the registration staff from having this responsibility?
Is there a regulation that states specifically who should have the initial patient contact?

If so, where can I find this, so that I can present this to my supervisor? When I briefly mentioned my concern, I was told having the tech out front would be considered the tech was triaging and be an EMTALA violation....wouldn't a clerk doing this be more of a violation? HELP!!
Thank you for taking the time to direct and assist me.

nanseatx · Mar 19, 2004

This is much the same system that is currently used at our ED. If the triage nurse is busy however, and any of the conditions listed are given as complaint, the clerk pages STAT TRIAGE and one of the nurses in the back, usually the charge nurse, comes out and assesses the patient. Even then, it hasn't been a very successful system and (thank god) we are soon to go to the Nurse First Triage System. We have recently had some bad outcomes from this practice and I would definitely not be continuing as a triage nurse here if we weren't changing the system. :uhoh3:

I just moved. I am concerned over the Emergency Room Triage process here.

Written into the process is the patient's first contact is the registration clerk. The clerks have received a policy that states:

"Patients are registered in the order in which they arrive, except when the patient states or the registration clerk views the patient experiencing any of the following symptoms:

Chest pain, jaw pain, arm pain
Shortness of breath
Altered state of consciousness
Motor vehicle accidents
Pregnant with bleeding, cramping, Pain
Altered state of consciousness
Headache
High temperature with change in usual behavior
Allergic or diabetic reactions
Paralysis
Gunshot or stab wound
Behavior health issues or aggressive or violent behavior
Any other condition causing concern

The triage/ED RN will be notified immediately by the registration staff when a patient presents with any of the above symptoms. It is the triage/ED RN's responsibility to then determine if the patient needs to receive urgent care prior to registration."
END OF POLICY EXCERPT

If the triage RN is occupied with a patient, and another patient arrives that does not have one of the above symptoms, the registration clerk is to go ahead and register that patient. The patient has a seat and when they are finished with the current patient, the RN looks at the paperwork completed by the clerk, reviews the symptoms and determines who to take next.

I understand that EMTALA now allows the registration process to proceed if it is not delaying the medical screening. However, I have great concern over who is to determine it is okay to go ahead with this registration piece. For example, how is a registration clerk to know what is a diabetic reaction?

I am new and from a larger facility that had a tech assisting the RN out front making these decisions, not the clerk. I was hired to work Triage and this makes me nervous.

My questions are:
Is there a regulation preventing the registration staff from having this responsibility?
Is there a regulation that states specifically who should have the initial patient contact?

If so, where can I find this, so that I can present this to my supervisor? When I briefly mentioned my concern, I was told having the tech out front would be considered the tech was triaging and be an EMTALA violation....wouldn't a clerk doing this be more of a violation? HELP!!
Thank you for taking the time to direct and assist me.

Calfax · Mar 22, 2004

Certifying whether or not a patient has an emergency medical condition starts at triage but doesn't end until the physician or other provider signs off on the chart. EMTALA doesn't specify exactly who needs to do the screening exam only as long as it is done by someone "qualified". As far as I can tell, you can staff triage with an oompaloompa as long as they're "qualified" to determine whether an EMC exists. As to what constitutes qualification......see the exerpt below from the FAQ section of EMTALA.COM.

"The short answer is that any assessment which is done by any person other than a physician has a much higher risk of being found insufficient under EMTALA....the regulations provide that the hospital must make a designation of who is considered to be a qualified medical person for purposes of (1) performing the medical screening examination and (2) the certifying signature in support of transfer in the event that a physician is not available. It is doubtful, however, that CMS or the courts would give hospitals unfettered discretion to specify who can be regarded as a "qualified medical person" as provided in the regulations. It is very unlikely, for example, that an attempt to simply designate all nurses as "qualified medical persons" would be found to comply. On the other hand, tailoring the provisions to particular areas of nursing specialty, such as permitting OB nurses to examine patients who may be in labor, would probably be found reasonable. "

I agree with whomever posted that triage and the MSE are not the same thing...an EMC may not be emergent. A fractured forearm may need repair and may be an EMC....but the patient may wait 4 hrs in the waiting room before being seen. A patient claiming to have ingested cyanide may be taken straight back...but having been found to be fibbing.....emergent but no EMC exists. Also a patient with an EMC may change triage catagories

Can you have the clerk register the pt? Yeah. I think so...as long as it does not delay care or determining a MSC.