triage process

[turnforthenurse, MSN, NP]

Okay y'all, walk me through your triage process. I'm trying to look for ways to improve it.

We are supposed to be utilizing pull til full at all times but I work nights and most of the time I come into a full ER where pull til full isn't possible. There is an RN in the lobby at all times on a computer. Patient comes in and they fill in their information and the form also asks some questions like LMP, allergies, pain scale and how long these symptoms have lasted. You can't ask questions in the waiting room because it's a HIPAA violation but at the same time our policy is that an RN is to be out in that waiting room at all times, no excuses. The patient then gets their vitals taken and height and weight documented by the tech and if our rooms are full, they go back out to the waiting room.

The problem is that sometimes these patients fill out these forms with little to now information. One person wrote a one-worded CC and didn't elaborate. And since the nurse is in the WR you cannot ask questions because everyone would hear and it's a HIPAA violation. I feel like we're not getting good triages because of this system and sometimes the history and/or VS will change the ESI level. We have patients that seem like they would be meant for fast track actually need ER beds because of this system because information is missed. We're supposed to have a flow nurse to help with this but because of staffing we do not have one 99% of the time.

So with that said... walk me through your process!

[emtb2rn, BSN, RN, EMT-B]

We will pull til full as well. Pt gives their cc to the registrar (vomitting, vomiking, low bp, high bp, chest pain, abd pain, etc.), is weighed & brought back to the empty room. While this is supposed to expedite door to doc, the docs don't like that vs are often not available until after they've seen the pt. plus there might be a delay in the ekg if the receiving rn is with another pt & the tech is with another pt & the other rns are with other pts - see a trend?

Now once we're full or it's after 1500 (depends on charge or phase of the moon) we revert to triaging in triage. As before, pt gives cc to registrar, then weight, vs, cc, allergies, ekg if indicated. ESI level designated & pt brought back to room or hallway or if ER full and pt is stable, back to the waiting room.

[That Guy, BSN, RN, EMT-B]

We have a nurse and tech in the waiting room and 3 triage rooms. The nurse/tech will ask the persons name/DOB and Chief complaint. In a public setting this is NOT a HIPPA violation. When we ask the meds/hx/allergies, we do that in a triage room for increased privacy. Vitals are done there and so are protocols if we are full ( usually are ). Then back out to the waiting room for a bed.

[Dragonnurse1, ASN, RN]

Unless the RN is with a patient she sits at the front desk and observes the patient when they come into the ER (walk in's). The patient gives registration their information and the RN gets the complaint sheet. The patient is taken into triage and vs, allergies, meds and a more thorough complaint is taken. The RN then either calls the charge nurse to see if a bed is available or the patient goes back into the waiting room. Fevers are treated in triage for pediatric patients. There are standard protocols for many types of patients. Chest pains go to the Chest Pain Clinic immediately, sutures go to Minor Surgery, that sort of thing.

If the waiting room starts to fill up then the patients are re-triaged to monitor their situation. If their vs are getting worse then they may go to the back but be in a hall or we start doubling up the cast room and minor surgery. We use the halls a lot at night if we are busy.

[RN_rescue_ninja]

If we are full, we will have an RN in the waiting room who will be putting in orders for protocols and carrying them out, so that most of the work is done by the time they get to an actual room. Also, having the RN there helps ensure no one dies out there and that proper attention is given. I felt a lot of sadness the other night for this pt who was out there in the waiting area for 8 HOURS with 9/10 pain - he had stage 4 lung ca mets somewhere...broke my little nursey heart. But what can you do sometimes? Sometimes everyone out there is really sick.

[Kalipso]

I worked in a tiny 50 bed hospital with a 14 bed ER. They built us a triage area out in the lobby, it isn't completely sound proof, but as far as I'm aware HIPAA demands that an attempt at privacy be made. That doesn't mean you actually have to succeed. So it's like this the patient comes in to the main desk where the registrars ask their name/dob/cc. They put this in the computer and they have a list of cc that are "red". We all wear a vocera which is like a cross between a PA system and a telephone. If the patient has a cc that falls in the "red" list the registrar calls "New adult red" (or ped) and we can all hear it through our vocera. The triage nurse/charge RN gets out there ASAP to lay eyes on the patient and triage. If it is later in the day when we actually have a nurse specifically for triage the same process still happens. She sits at the end of the registrar desk which faces the lobby, but they have improved it with a glass wall that goes from the counter top to the ceiling for privacy but it is still open on either side. The triage nurse knows that when a 'red' patient is called he/she must stop the current triage and go get the 'red' patient. If there are two reds or she can't get away from her current triage she uses the vocera to call for help from the back and then the charge nurse or a free nurse is suppose to go and help. When we are slow we are suppose to 'pull until full' also but I tend to sit out in the triage area and fully triage the patient prior to taking them to the room unless they look really uncomfortable or unstable and I think they need an EKG. It takes 10 minutes to fully triage the 'average patient' 15 if they are one of those with 3 pages of meds. This way the doctor isn't coming in to the room trying to talk to the patient while I'm trying to finish getting their history and since most of the time we meet the doctor at the door to their room I can give the doctor 'report' about the patient which is nice because they get a quick idea of what is going on and can start asking symptom specific questions instead of pulling what they need out of a long winded patient to get a picture of their story.

Pitfalls of this system is that occasionally a patient comes in with a cc that the registrars feel fall in the category of their 'red' list when it really isn't. Like a patient saying "I'm having a hard time breathing." and difficulty breathing is on their red list. But the patient is having a hard time breathing because their sinuses are stopped up. Not really a red, but I can hardly blame the registrars they don't have medical training. It kinda ****** me off when the other nurses get mad at them for it. Also it can get sticky on a bad day when to many reds walk in at once...but what ER doesn't have those days?