Triage Practices

Dixielee, BSN, RN · Jun 15, 2004

I think it works well where I work, so let me try. Patient comes to front window and signs a sheet with general info, i.e name, complaint, time. The paper says if you are having chest pain or trouble breathing to notify the nurse immediately. The clerk inputs the patient info into the computer and hands the sheet to the triage nurse or puts it into the rack if the nurse is busy. We have 2 RN's and 1 tech in triage except 11-7, then usually just one RN and tech if still really busy. Of course if the patient is critical, the triage nurse or charge nurse will take them back immediately and they bypass triage all together. But, if more routine, the nurse gets the info sheet from the rack and calls the patient from the waiting room. Of course if you are not busy, you see them checking in and escort them into the triage area as soon as they sign in. Now the patient is in your ER computer, so you sit them down and start getting information, and check vital signs. If they have been there before they will be in the computer and lots of info will already be there like meds, allergies, doctors, history, etc and you just update them. If not, then you enter all info you can. If patient is not at that point deemed critical, they go to the main check in area where the usual demographic and insurance info is gathered. It is at this point that you send them to fast track or decide they go to main ER. If there is a bed in ER you take them back when they complete check in which usually only takes a few minutes. The clerk puts the arm band on them and hands you the completed chart. They may go to the waiting room if there are no beds, but if you take them back, you the triage nurse decides what room is appropriate, i.e. cardiac, pelvic, ENT, eye, general, peds, etc. and make the room placement and put the patient on the board so the nurse knows she has patient. If the nurse is readily available she is told about the patient, if not the charge nurse is told. Ths chart is put in the "to be seen" rack on the counter. Sometimes the nurse picks up the chart first for eval and sometimes the doc or P.A. picks it up first. Then it goes from there.

We try to keep one of the "major" rooms available for ambulances or walkin MI'S. Sometimes that is not an option, then you go the hall route, but we try to think ahead and not let that happen too often. Eacn nurse is assigned a set of rooms at the start of the shift, so you know up front which rooms are yours when a patient arrives. I'm sure I have left out a few steps, but that is the jist of it. Hope it makes sense.

tiredfeetED · Jun 15, 2004

I think it works well where I work, so let me try. Patient comes to front window and signs a sheet with general info, i.e name, complaint, time. The paper says if you are having chest pain or trouble breathing to notify the nurse immediately. The clerk inputs the patient info into the computer and hands the sheet to the triage nurse or puts it into the rack if the nurse is busy. We have 2 RN's and 1 tech in triage except 11-7, then usually just one RN and tech if still really busy. Of course if the patient is critical, the triage nurse or charge nurse will take them back immediately and they bypass triage all together. But, if more routine, the nurse gets the info sheet from the rack and calls the patient from the waiting room. Of course if you are not busy, you see them checking in and escort them into the triage area as soon as they sign in. Now the patient is in your ER computer, so you sit them down and start getting information, and check vital signs. If they have been there before they will be in the computer and lots of info will already be there like meds, allergies, doctors, history, etc and you just update them. If not, then you enter all info you can. If patient is not at that point deemed critical, they go to the main check in area where the usual demographic and insurance info is gathered. It is at this point that you send them to fast track or decide they go to main ER. If there is a bed in ER you take them back when they complete check in which usually only takes a few minutes. The clerk puts the arm band on them and hands you the completed chart. They may go to the waiting room if there are no beds, but if you take them back, you the triage nurse decides what room is appropriate, i.e. cardiac, pelvic, ENT, eye, general, peds, etc. and make the room placement and put the patient on the board so the nurse knows she has patient. If the nurse is readily available she is told about the patient, if not the charge nurse is told. Ths chart is put in the "to be seen" rack on the counter. Sometimes the nurse picks up the chart first for eval and sometimes the doc or P.A. picks it up first. Then it goes from there.
We try to keep one of the "major" rooms available for ambulances or walkin MI'S. Sometimes that is not an option, then you go the hall route, but we try to think ahead and not let that happen too often. Eacn nurse is assigned a set of rooms at the start of the shift, so you know up front which rooms are yours when a patient arrives. I'm sure I have left out a few steps, but that is the jist of it. Hope it makes sense.

WAS I just dreaming?? That sounds Great! You missed out the part about the white pickett fence! :)

Trauma Columnist · Jun 15, 2004

I work at a level one trauma center and we see about 200-250 people/day. We have a huge space issue. We have two experienced ER RNs at triage from 0900 to 0300 along with an EMT-P, a hostess and a transport. An RN greets patients to give the "across the room assessment". We don't use the waiting room unless there are no beds available. We use the ENA triage categories.

Dixielee, BSN, RN · Jun 15, 2004

I forgot to mention that we all hold hands at the end of the shift and sing Kum Ba Ya.....

veteranRN · Jun 15, 2004

In my personal experience, you have to be careful relying on signs that say "please notify nurse if you are having SOB or CP". I once went to an urgent care and sat in the waiting room for >1hour. My complaint? A heartrate of 38 (over betablocked). I never had chest pain but chest pressure. (I am an RN but didn't want to bother people because I truly felt it wasn't an emergency). Now aren't you glad I'm not triaging any patients :imbar

Dixielee, BSN, RN · Jun 16, 2004

Believe me, vetRN, we don't generally have patients that suffer in silence. Most put on the best show they have for the sign in desk and escalate as they work thru the system. Also the wait time from walk up to actually seeing an RN is very short, usually a matter of minutes. Now, waiting room time may be longer, but they have at least been initially seen. They tried to have a nurse stationed in the waiting room to recheck folks every 30 minutes but she ended up being a gofer for blankets, coffee, etc. and was just a whipping boy for the people waiting. That attempt failed miserably and fast. If someone looks really bad, they come right in or go to the back immediately anyway.

asapstat · Jun 16, 2004

your department is completely computerized. Do you document yoiur triage note manually or via computer. We have EDIM but are notusing it fully. the nurses are documenting hand-written notes. We just started point of entry computer log in ( patient puts name, DOB and CC) and most patients are not too successful at doing this, and we still maintain a hand written log book as a cross reference . I like the idea of being able to pull up previous data, esp. allergies and meds. Otherwise your system is very much what we have in place now. We are looking to (of course) cut waiting times and improve pt. satisfaction. One idea is to have a registrar as the greeter, thus a quick reg. could be initiated as the patient enters. Our level 4 and 5 patients are registered at the bedside now, and are brought back to the main ED right away. We also suggested having a registrar in the Fast Track area and do bedside reggies there. We have only 1 RN in triage area, doing vitals and interview etc. Most of the time during the day, we have a volunteer as a greeter, but because of HIPAA they can only ask name and DOB, so we have to go back to the log book and write in CC and destination. Sometimes we have an LPN "in the front" and then it goes much quicker.

What info do you consider absolutely necessary to obtain in triage?

Do you do bedside triage, ie bring the pt. back to the assigned area and complete triage data there? and would it be the triage RN or the nurse assigned to the area to complete triage ? Currently all our ambulance pat. are triaged by the Rn assigned to the area.

Do you utilize an "internal triage" RN.

Thanks for your input,,,much appreciated.

Dixielee, BSN, RN · Jun 16, 2004

I will try to answer your questions. The computer system is called First Net. Currently we are only using it in triage but it will be integrated into the entire chart eventually. We are getting ready for a huge renovation, doubling the size of the ER, so maybe the changeover will take place then. We do have big plasmaboards with patient info on it. There are no names, but it tells what the chief complaint of patient and the room number, the nurses intials, etc. We are discreet with the CC on the board. We put VB instead of lady partsl bleed, SHOB instead of SOB for shortness of breath so folks don't think we are just being rude, FB instead of foreign body, etc. so we don't embarrass anyone. Most of the time laypeople wouldn't know what our abbreviations mean anyway. It will eventually be used for tracking as well, as there is a place to put if the patient goes to x-ray with times, etc. It also tells us how many patients are in the waiting room, and lists how long each patient has been in the system.

As far as absolute info in triage. We get vitals, PCP name, height and weight, LMP if relevent, pertinent medical history, allergies, list of meds including vitamins, herbal preparations, etc., current immunizations, head circumference in infants and of course, chief complaint. With the med list we also include what if anything the patient has tried relative to this complaint, i.e., pain meds, antacids, laxatives, etc. You can get almost all of that info in a few short questions while the BP machine is doing it's thing.

If someone needs to go straight back, the triage nurse accompanies them and starts the triage process, usually hooking them to a monitor and usually the primary nurse will take over before she can finish. We don't have an internal triage nurse but do have a charge nurse who usually does not take a patient load and is available to help. Currently, if an ambulance comes in, we just do the old paper triage note and transfer it to the computer when we have time later. We do have a few portable computers, but it is faster just to use the old fashioned way at this point. Otherwise we chart our triage note directly into the computer in the triage area.

The computer system is more thorough than the paper notes. It takes you thru more phases including method of arrival, i.e. private auto, ambulance, etc. and specifies which ambulance service. If you check yes that the patient is having pain, then you must quantify using the 1-10 scale, then it takes you to an area to describe the pain and tell exactly where..throbbing, sharp, upper left abdomen, etc. It can also be time consuming typing in all the meds and doses if they are not already listed. You could end up writing a book if you are not careful.

Overall it is a good system. We have been using it less than a year so we are getting use to it still. I would like to see laptop type computers instead of the big rolling models that add just one more large piece of equipment into an already crowded space.

I hope this helps. I think our system works great. The last job I had before this one at what I affectionately refer to as the hospital from hell....did not have much of a system at all. The charts were a jumbled mess scattered all over the ER and you never knew where your patients or your charts were. I have never been so glad to exit a place in my life than when I left there. Good luck, you will find a balence somewhere that works for your unit.

Sarah, RNBScN · Jun 17, 2004

1. Pt. takes a number, admitting clerk buzzez for our attention and an RN first screens the pt. for SARS then triages the pt.

We follow the Canadian Triage Acuity Scale level 1-5 (1 life threatening needs to be seen stat by MD, 2 - emergent needs to be seen by MD with 15 mins, 3 - urgent needs to be seen by MD within 1/2 hr. , 4 - needs to be seen within 1 hr., 5 - needs to be seen within 2 hrs.). It is really easy to follow and we have advance medical directives that are in situ to be used for example: Chest pain - protocol for ASA, 15 lead ECG, IV NSS @ TKVO, Labs.

Triage nurse is responsible for reassessing patients while waiting in our waiting room.

I have attachments if anyone is interested in seeing our flow sheet.

Have a nice day.

Sarah

asapstat · Jun 17, 2004

thanks so much for everyone's input. We have another meeting tomorrow and I will bring back this info and look forward to reading more responses.

RNin92 · Jun 20, 2004

We see about 100 people daily.

We also use the ENA's ESI triage system-5 tiers-works great

We have an RN and a medic in triage until 0300, then just the medic.

We used to have the registrar get the quick demographic info first...until we almost lost a 12 y/o with "shoulder pain"...that would be his spleen rupture.

Triage nurse didn't triage him for quite awhile...he had been listed as "non-emergent" when we used to also use a 3-tier system...No more...

Your are seen by a health professional when you hit our doors.