Triage Practices

[applesxoranges, BSN, RN]

I was a paramedic that triaged at my old facility. I am now an RN in a new facility. I am a little bit disturbed by the lack of triage protocols. Triage there is an eyeball at the front desk and you send them to the waiting room if there is no rooms from what I gather whereas a triage at my old facility was you took a patient in a triage room, get vitals, get some info, and then send them to a room or a waiting room. If there was no room, we did have some protocols in place such as an ankle pain can get an xray or a chest pain could have an EKG done with blood work (straight stick, no IV). We could get UA and pregnancies if someone had to pee to help speed it along so once the person is back there, we're not waiting on a specimen as it's already resulted. I always made females urinate if they were going to be in the waiting room if there was a chance of a radiological test, abd pain, etc.

What disturbs me is that the facility supposedly had at least two cases of people who were waiting in the waiting room with two active MIs for 40 minutes for one and over an hour for another. At least with an EKG/labs I would feel a touch more comfortable because we can start the clock even though no meds were given.

Another difference is that apparently if a person is suicidal, they're not watched untill they go to the back. They may sit in the waiting room and if they leave, they leave. Which is different from my other facility where they were sent straight back for an eval and the physician could decide from there.

Also, no ambulances ever go to triage at this facility even if it something like a boil on the leg. We sent ambulances to triage at my old facility often.

It's just scary. I thought my other job did some questionable things but triage sounds a bit more dangerous here. I thought they were an accredited chest pain center (I don't remember) but isn't there rules that you have an EKG in x amount of time? Like five minutes?

[wurms]

So when and where do patients get vitals, history taken, ESI code assigned to them? Is that all done when they get in a room?

Sounds very unsafe. How does management justify this system?

[applesxoranges, BSN, RN]

The vitals and history are done when they are taken back to the room otherwise they sit and wait. The ESI is assigned by eyeballing them and asking about the chief complaint at a desk/counter in the waiting room.

I didn't realize how bad it was till yesterday when my trainer and I were talking about the practices. I know I surprised them when I mentioned getting an EKG in triage during the interview. I don't know much about it but I am going to suggest a change through their one system. I don't know how well it'll go through.

It's not a big hospital. I don't know how many beds but it is approximately the same size as my other hospital but they are busier because they don't have as many hospitals near it. So their ER is twice the size of my old ER because there's less competition.

I like the people so far and I like the job. I am just not sure that the triage system is as safe as it can be given the rumors of the two chest pains (it's what employees say, I was not working there when they happened). I wonder if they are trying to do a pull-to-fill scenario? I don't know much on that style of triage.

I'm going to see if I can get away with not triaging for some time.

[Anna Flaxis, BSN, RN]

You can't assign an ESI level without a set of vitals.

This triage practice sounds very unsafe to me. I would think long and hard about working there.

[emtb2rn, BSN, RN, EMT-B]

What stargazer said. I promote a lot of 3's to 2's after getting vitals.

[Esme12, ASN, BSN, RN]

The vitals and history are done when they are taken back to the room otherwise they sit and wait. The ESI is assigned by eyeballing them and asking about the chief complaint at a desk/counter in the waiting room.

I didn't realize how bad it was till yesterday when my trainer and I were talking about the practices. I know I surprised them when I mentioned getting an EKG in triage during the interview. I don't know much about it but I am going to suggest a change through their one system. I don't know how well it'll go through.

It's not a big hospital. I don't know how many beds but it is approximately the same size as my other hospital but they are busier because they don't have as many hospitals near it. So their ER is twice the size of my old ER because there's less competition.

I like the people so far and I like the job. I am just not sure that the triage system is as safe as it can be given the rumors of the two chest pains (it's what employees say, I was not working there when they happened). I wonder if they are trying to do a pull-to-fill scenario? I don't know much on that style of triage.

I'm going to see if I can get away with not triaging for some time.

No bueno. It is not safe. wow....ESI is also tied to reimbursement. I have found facilities that do this are really not safe places. It is usually physician driven for they believe nurses should not be assigning medical tasks.

It takes the directors input, and physician cooperation, to get triage protocols in place. When was their last survey? I"d be curious to know wht they were dinged for....

[BrnEyedGirl, BSN, MSN, RN, APRN]

I'm trying to give them the benefit of the doubt here,.....when you say pts go to the waiting room before vitals,...how long are you talking 3-4 minutes while registration gets them registered or 45 minutes until a room is open? I agree with the others you can't possibly give an accurate ESI without vitals and really hx for that matter,....my ED pulls til full, but we never leave anyone out there longer than 3-4 minutes and any time critical diagnosis gets either immediately triaged or back to a room. While ESI is tied to reimbursement, part of that charge is getting a doc to these people sooner, you can't do that without a picture of what is going on. If you walk in to my triage with CP, pale, diaphoretic etc I don't need to get vitals or hx, you get straight back, EKG, IV, O2, monitor, vitals et Nitro before the doc even makes it to the room,...and and ESI of 2 for all the speed!

[R!XTER]

Sounds super unsafe. I would try to avoid being put out in triage with that system (or lack of system). Triage holds tremendous liability for the triage nurse, and it sounds like you are being set up for problems... If your management is receptive to suggestions for improvement, definitely to try to improve the system. Maybe get together a team of nurses who would be interested in helping you improve the process, and write up a realistic plan for safe triage and present it to your managers. Good luck and watch your back!

[nurse2033, MSN, RN]

What an opportunity! There is a lot of room for improvement. You should take this forward as much as you feel comfortable.

[DayDreamin ER CRNP]

We have 4 triage rooms and usually have 2-3 triage RNs and two techs in triage. We also have a "work hall" behind our triage area for our NPs and work hall techs.

When a pt comes in he gets registered with just a brief peek by a "pivot" nurse who ascertains the CC. Once the patient is in the system he is then taken by a tech or nurse to a triage room.

Ideally, the techs each patient in and gets him on the monitor for a set of vitals and gets an EKG if the patient's CC is cp or SOB or something to warrant an EKG. The nurse usually follows in behind a minute or so later when she is finished with another triage patient.

It does help if the tech and just keep cycling patients in and out of the triage rooms with vitals so all the nurses have to do is go from one room to another.

We get a pretty brief look at the patient and what his CC is, history, surgeries, LMP, allergies, fall assessment, and a few other minor questions.

From this info, the patient is assigned an acuity and either placed directly on a bed or back in the waiting area.

We do have a fast track area for cough, cold, suture removal, etc.

Occasionally, an ambulance is sent out to triage if that EMS calls with a triage-appropriate patient. Those pts have to at least be seen by a charge nurse before rolling out to the front tho. We don't just go by what they report.

We have a 5 minute EKG goal which we meet about 95% of the time. We also have a 20 min or less triage time. We also direct bed if we have open beds in the back. We started doing that about 2 years ago and it has saved a lot of triage time for us and we don't often get backed up now. When we do, we have one nurse on the trauma team that is assigned to come catch us up if she doesn't have a L1 trauma patient at the time. Rarely do we have to utilize this person. And we consider 6 or more untrained patients as "backed up."

I'm on the triage team and have seen some HUGE improvement to our system over the past 2 years. We still have room to improve but we have come a long way!

[applesxoranges, BSN, RN]

You know how registration is usually at a counter? That's the triage nurse here. The triage nurse gets the complaint and basic info like name and birth date. They do not do vitals. They do not get the assessment. That is all done in the room even if it takes 1 hour, 2 hours, 3 hours to get back. No ambulances go to the waiting room no matter how silly the complaint is. The ambulance is privatized so they will sometimes wait at the hospital with a patient on their cot for 45 minutes.

It's scary.

[ChristineN, BSN, RN]

You know how registration is usually at a counter? That's the triage nurse here. The triage nurse gets the complaint and basic info like name and birth date. They do not do vitals. They do not get the assessment. That is all done in the room even if it takes 1 hour, 2 hours, 3 hours to get back. No ambulances go to the waiting room no matter how silly the complaint is. The ambulance is privatized so they will sometimes wait at the hospital with a patient on their cot for 45 minutes.

It's scary.

This does not sound safe. I find it hard to believe that the docs aren't pushing for a proper triage