I've finally hit my one-year mark as an emergency nurse, and now I'm allowed to triage. Our department uses the "nurse first" and an RN is the first person the patient sees as they're checking in. When the department is short-staffed and our rooms are full, it gets difficult to get patients back. We are the only hospital in town, and patients tend to get frustrated when they cannot be seen after 4 hours for a minor problem. My question is, how do you guys deal with the patients who beat on the windows, yell and curse at the nurses, and fall out in the floor into a temper tantrum? My patience is wearing thin, and I could definitely use some tips!
How do you triage your patients in your ER? How do you keep a steady flow as a triage nurse?
How do you control patients when your security isn't helping?
Specializes in Emergency Dept. Trauma. Pediatrics.
Is this of any concern at all to your admins? There are some very large systems out there that have been able to significantly improve wait times in recent years, using various measures and making adjustments in multiple steps of the process. This has its pros and cons, of course.
If you have been able to observe any specific factors affecting the situation at your place, you might consider seeing if mgmnt is open to a discussion about it (not a complaint, mind you, but an offer to study the issue or to research some aspect of it, etc.). For instance, say you observe that your rooms actually are emptying but then there's no one to clean them in a timely manner - there are several workable solutions for problems such as this and others. If this is something that appeals to you, I'd probably advise getting a little more solid triage experience under your belt before approaching anyone - and know your environment and the odds of positive reception before-hand!!
I am not a proponent of nurses stressing ourselves and effectively accepting responsibility for these situations which are out of our control. With that in mind, I keep things moving the best I can using any protocols which might be in place, make good solid judgments, keep a close eye on the people I've already triaged, re-prioritize as necessary, provide reassurance as much as possible, speak kindly as often as possible ("please let me know if you are concerned that something with your condition is changing") and beyond that, well...I put myself in emotionally-detached mode, to some extent. I love my job but I'm well past the point where voluntarily rolling on the floor has any effect on me. I'm very practical about it. Sometimes I recheck a pulse or a pulse-ox and then kindly state, "Your vitals are stable and I think everything's still okay here. I know it is frustrating to have to wait". When drama rules, it usually results in some patients who are not sick getting a bed before some patients who are. I avoid this as much as humanly possible because it violates patient safety and my personal sense of ethics. Overall, stay calm. People can smell/read our frustration, stress, and anxiety, and sometimes are provoked even more by it - thinking if they just push the envelope a little further, they will be successful.
Side note - it might not be a terrible idea, in the interim, to try to befriend some of the security personnel to see if that changes their responsiveness at all. This is a perfect situation for security input, as it CAN get out of control. Call them down, say "Sorry to bother you but I'm concerned that tensions are running quite high in the WR. Can you keep an eye on me for awhile so I can safely keep triaging people?" If you get anyone willing to help your cause, make sure to thank them and try to build a working relationship between your departments.
5 ER's I have worked in, 1 was a level 1 trauma center that was the busiest ER in the state, 1 was a level 2 trauma center and the only Trauma center in the state, another level 2 Trauma center that was the only one in the South East of the state and just doubled to 106 beds, and 2 were community ER's
All have varying systems when it comes to triage and fast track and so on, but all had the same exact core problems or similar that are always discussed in these threads.
Until we can figure out a way to stop having the ER's being the dumping ground and go to for everything, I don't see a solution anytime soon unfortunately.
Specializes in Psychiatry, Community, Nurse Manager, hospice.
It's a systems problem.
If your hospital gives a crap, start researching ways other hospitals have reduced wait times. Share them with higher ups and ask for implementation.
My hospital has an app for patients that estimates wait times at the ER before you come.
As far as dealing with the immediate issue, do your best to give an estimate of the wait time and always overestimate it. So if you think a patient will be seen in 3 hours, tell him 4 hours. If he's seen in 3 hours he will be happy at that moment, because it was better than the expectation you set up. When you tell a patient 2 hours, they are already berserk by 2 hours and 4 minutes. If you tell the same patient 3 hours, they are pleased at 2 hours and 10 minutes.
If your hospital gives a crap, start researching ways other hospitals have reduced wait times. Share them with higher ups and ask for implementation.
My hospital has an app for patients that estimates wait times at the ER before you come.
As far as dealing with the immediate issue, do your best to give an estimate of the wait time and always overestimate it. So if you think a patient will be seen in 3 hours, tell him 4 hours. If he's seen in 3 hours he will be happy at that moment, because it was better than the expectation you set up. When you tell a patient 2 hours, they are already berserk by 2 hours and 4 minutes. If you tell the same patient 3 hours, they are pleased at 2 hours and 10 minutes.
Good luck.
And are pissed when it takes longer than what you said. I never give a time, because I can't. I sometimes tell them the longest time someone has been waiting, and tell them it is not an estimate when they will be seen, as I cannot control what else comes in the front door or what EMS brings in.
An app to give wait times is a failure waiting to happen. People see 45 minutes, and expect to be seen 45 minutes from that time (not when they get to the hospital). Also I have seen some hospitals that give the wait time to be "seen", which can include just to be triaged. Very misleading.
Specializes in Emergency Dept. Trauma. Pediatrics.
And are pissed when it takes longer than what you said. I never give a time, because I can't. I sometimes tell them the longest time someone has been waiting, and tell them it is not an estimate when they will be seen, as I cannot control what else comes in the front door or what EMS brings in.
An app to give wait times is a failure waiting to happen. People see 45 minutes, and expect to be seen 45 minutes from that time (not when they get to the hospital). Also I have seen some hospitals that give the wait time to be "seen", which can include just to be triaged. Very misleading.
We are seriously getting into sketchier territory with this stuff. I was driving through MO I think it was and saw a billboard (this was about 3 years ago they are even more common now) but it was basically call ahead reservations for the ER. Like it's a Texas Roadhouse call ahead seating. Like what message is this sending? Hop online to reserve the time that works best for you so you can not wait as long as someone else. Whatever time is most convenient for you.
If your emergency is one that you can make a reservation for a time that works best for you, you're not having a freaking emergency.
If your emergency is one that you can make a reservation for a time that works best for you, you're not having a freaking emergency.
Ours has that option, but the charge nurse can "turn it off" for 4 hours at a time if the ER is busy. I have one charge that logs in every 4 hours to do this starting at 7AM.
It changes nothing though. The still have to get triaged (in order of arrival unless "really" sick) and will wait based on acuity. Problem with this is some make an appointment that really are sick and should come in when they make the appointment, delaying care that needs true emergency care.
Specializes in Psychiatry, Community, Nurse Manager, hospice.
And are pissed when it takes longer than what you said. I never give a time, because I can't. I sometimes tell them the longest time someone has been waiting, and tell them it is not an estimate when they will be seen, as I cannot control what else comes in the front door or what EMS brings in.
An app to give wait times is a failure waiting to happen. People see 45 minutes, and expect to be seen 45 minutes from that time (not when they get to the hospital). Also I have seen some hospitals that give the wait time to be "seen", which can include just to be triaged. Very misleading.
The app has been very successful, because it's accurate and because we've reduced wait times significantly in our ED.
We don't have people waiting 4 to 5 hours anymore. People usually wait 15 to 45 minutes, sometimes more.
It may not be possible for you personally to estimate a wait time but there are algorithms that can.
Specializes in Psychiatry, Community, Nurse Manager, hospice.
And are pissed when it takes longer than what you said. I never give a time, because I can't. I sometimes tell them the longest time someone has been waiting, and tell them it is not an estimate when they will be seen, as I cannot control what else comes in the front door or what EMS brings in.
An app to give wait times is a failure waiting to happen. People see 45 minutes, and expect to be seen 45 minutes from that time (not when they get to the hospital). Also I have seen some hospitals that give the wait time to be "seen", which can include just to be triaged. Very misleading.
Triaging should always be done within 15 minutes. The app tells you how long it takes to get a bed, not to get triaged.
And for the posters who said you're not having an emergency if you can call ahead and make a reservation, that is true, I totally agree.
That problem is caused by lack of urgent care facilities, or lack of access; irresponsible primary care facilities who tell pts to go to the emergency room when they don't want to deal with something because its after hours or to cover their asses because the person answering the phone is not a nurse.
The app tells you how long it takes to get a bed, not to get triaged.
Depends on the hospital system. Some places have a "provider in triage" (PIT) who "sees" patients as they are triaged and will start some basic stuff from the waiting room. Voila, they have been seen per the time measure. Gotta read the fine print!
Depends on the hospital system. Some places have a "provider in triage" (PIT) who "sees" patients as they are triaged and will start some basic stuff from the waiting room. Voila, they have been seen per the time measure. Gotta read the fine print!
We started this and, of course, our door-to-doc times plummeted.
Specializes in Emergency Dept. Trauma. Pediatrics.
So funny enough this popped up on my FB today in the memories so I thought I would share since I was just referencing this very post. lol
June 27, 2014 ·
So I'm pretty sure I've lost all faith in the health care system (not that I had much left) but let me back up.
Driving through MO I can always count on being entertained by the various billboards. I'm cruising along and read one asking if I'm ready to meet my maker?? Hmmm, the next one asks if I stopped a baby from being murdered today? S**t!! Obviously I'm damned and going straight to hell, that's ok though because the next sign is telling me where to get the cheapest liquor in Mo.and oh wait, there is a sex toy shop coming up too!!
Clearly I'm going out with a bang, go big or go home I always say.......
But here comes a sign that drains all humor from my face. It reads "tired of long Emergency Room waits?? Now you can bypass the wait times. Go online before you come in and put your name on the list and when you expect to arrive. You'll get first priority"
Seriously???? Are you effin' kidding me??? Now the ER is like Texas Roadhouse with call ahead seating??
News flash, if you're having an effin' emergency, you won't be concerned with going online to reserve your spot. Why? Because it's an effin' emergency.
Pretty sure when Hank is having his heart attack he doesn't stop and tell his wife Rita to go hop online and save them a seat. No he's calling the ambulance.
Well s**t, the ambulance just left to pick up the lady that decided at 0300 a cyst on her lady parts was an emergency and required the life saving ambulance. I hope she went online first to reserve her spot.
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~Mi Vida Loca~RN, ASN, RN
5,259 Posts
5 ER's I have worked in, 1 was a level 1 trauma center that was the busiest ER in the state, 1 was a level 2 trauma center and the only Trauma center in the state, another level 2 Trauma center that was the only one in the South East of the state and just doubled to 106 beds, and 2 were community ER's
All have varying systems when it comes to triage and fast track and so on, but all had the same exact core problems or similar that are always discussed in these threads.
Until we can figure out a way to stop having the ER's being the dumping ground and go to for everything, I don't see a solution anytime soon unfortunately.