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?
Wow! I have never heard of a system like this one. This sounds really unsafe! I'm constantly worried about my license at our triage due to lack of beds and long wait times (18+ hrs) but yours sounds like a lawsuit waiting to happen! No protocol orders? No vitals? Consider very carefully about staying here... In my experience, the front door practices set the example for the rest of facility. If this is their standard of practice right from the get go, I would be worried about the rest... Good luck
Op- I just started at a new hospital also and I you sound like your describing this new job. I came from two other emergency departments who both did full triage-vitals, EKG, history, etc. this practice of assigning an ESI number with little if any information is terrifying and not just for the RN in triage. As a nurse in the main ER I get patients brought back and I have no information on them. If I can't get into see them right away because of other critical patients or ambulances they sit in my room. I've always practiced under the understanding that as the primary RN I'm responsible for the patients in my room. This triage system plus having 5 patients to one RN all priority 3 and up is so dangerous. Does anybody have any evidence or research that can be brought to management to help change this practice. We all know it's unsafe but I need the best practice research to actually put enough pressure to make any changes. Thanks! And I totally feel your pain OP.
This is a link for the ESI handbook. You can download it from here and also check out the algorithm, it involves VS!!! You can't place an ESI without Vitals!!! Hope this help!
In the UK we have 15 minutes from when the patient books in to complete a written/computerized triage, and vital, +/- EKG if its a CP. Ideally labs get sent in that time too, although that can be difficult when they have bad veins and it takes more than one stick to get them.
The computer logs the time its all done, so it HAS to be completed on time.
We complain like crazy about targets, but reading about your ER I am glad we do this.
There is no way an MI would sit in the waiting room, and we feel safe because we know what it happening to every single patient in the waiting room.
Are you in the USA? If so, I believe the CMS indicators call for an EKG on STEMIs within 10 minutes of arrival. Most EDs make sure that happens by encouraging staff to get an EKG on all patients with chest pain within 6 minutes. CMS is very tied to reimbursement. I cannot believe your department manager hasn't implemented something like this yet. You mentioned that you surprised them in the interview by discussing this. Perhaps they were thrilled about your experience and are hoping you can help change triage. We just heard from our manager that CMS is going to officially start looking at door-to-doc times. You can make a huge change in your ED--exciting!
We have that where I am in IL, but my concern is that it is so focused on CP that other urgent cases can get ignored as they don't meet the CP criteria.
In all the EDs I have worked there has been an emphasis on triaging those who arrive by ambulance asap, to free up the crew to go get some more!
But those who arrive alone, (often the little old ladies who don't want to trouble anyone), can get left sitting quietly in the waiting room. Those who shout loudest get triaged first, as the hospital is so nervous about getting a complaint or bad review.
IMO, those who arrive by ambulance have already been triaged/assessed by the crew, and the priority should be seeing those sat in the waiting room.
We've all seen the silent MIs, the one who show up with "indigestion", and get left sitting because they don't meet the CP criteria.
I even had one MI present with knee pain once, no CP symptoms at all, I mean WTH??
And there are always those non CP silent emergencies, like epiglottitis, and all the other airway emergencies, who don't scream to be seen first.
If you don't get vitals in the first few minutes you are running a dangerous game.
Skylark I agree 100% as having seen a patient complain of horrible sharp upper abd pain, get triaged a priority 3 ESI and then get back to me where I get her full medical history and see she's hypotensive with a history of AAA. Now if she would have been properly triaged with vitals, history, home meds they would have got her back right away. Instead she sat in the waiting room for 45 minutes. Stories like this just pile up every shift I work, I just really need concrete evidence to bring to management that compels them to change before people like her die in the waiting room.
Also what's the RN to pt ratio where you work? Because I feel like not doing a full triage and having a high ratio is really hurting patients. Just curious what the ratios are other places that triage fully or that pull to fill
Specializes in Pediatric ED;previous- adult Ortho/Neuro.
Wow, and already triaging when new to the facility? We haves bit of a process to go through before being triage "certified", usually 6-12 mos after hire, have to have ENPC an take a hospital triage class granted, I'm in a pediatric hospital. Definitely sounds like some changes are desperately needed for safety. Lack I protocols for X-rays, etc to exposure things isn't helpful either, but certainly less worrisome than the lack of an actual triage process altogether. Does your facility have any kind of Shared-Governance council to take your concerns to? If not, definitely talk to manager, or someone. Suggest some Benchmarking with similar facilities in your region, as well as looking at standards. Good luck, you have an opportunity to enact great change that will have a huge positive impact!
We are revamping our triage system and I'm still trying to argue that it isn't safe.
An RN sits at the very front so that they are the first person that is seen the moment a patient walks into the waiting room. From there, they write their info down and that RN gets them into the computer. They can ask some questions but that's in front of EVERYONE - HIPAA violation, anyone? Then they sit and wait until the triage tech is available to get the patient's VS, HT & WT. While the patient is in the triage room the nurse can ask additional questions but then you don't have eyes on the waiting room so it can be a challenge.
It is very hard to assign an ESI level without vital signs and at least some PMHx information from the patient. A lot of times I end up changing the acuity level based on the VS. Now this whole process is when we are full... otherwise, we are supposed to be doing pull til full. The nurse in triage registers the patient, they get their HT/WT/VS and then are brought straight back to a room where either the primary RN or charge RN will complete the rest of the triage and assign an acuity level. We used to have 2 RNs out in triage at all times but they are going away from that. When you have a line of people it can be difficulty to sort through their "written information" and something can very easily fall through the cracks.
As for our nurse to patient ratios, they're usually 1:4 during peak times.
traumadreams
15 Posts
Wow! I have never heard of a system like this one. This sounds really unsafe! I'm constantly worried about my license at our triage due to lack of beds and long wait times (18+ hrs) but yours sounds like a lawsuit waiting to happen! No protocol orders? No vitals? Consider very carefully about staying here... In my experience, the front door practices set the example for the rest of facility. If this is their standard of practice right from the get go, I would be worried about the rest... Good luck