Triage protocols. what does your ER use?

needsmore$ · Jul 14, 2005

Similiar to mommatrauma- we use the ESI ratings. We apply LET at triage, Tetracaine eye complaints, Motrin PRN, xray injured extremities. We also splint/ice etc. -(this is for the minor acute fast track crowd) .

Others include clean catch UA (unless full bladder needed for pelvic US) for abd pains.

If there are long waits for available beds- we have done quickie ECGs, benadryl PO, ASA- but these orders are all obtained by the triage nurse from the doc/(NP or PA for MACU) after the pt was assessed by the triage nurse. This is why it is rucial that the triage nurse be one of the most experienced/trained staff person-- many times you rely on a gut instinct- especially if you have MANY waiting that normally you would take back sooner if beds were available. I have applied nasal O2 at triiage if pt's sats were 91-92 but otherwise not ACUTELY ill- (pneumonias, early CHF's, etc.)

We also recheck waiting room patients every 15 minutes for change in condition-we keep a triage/waiting room log for this. Every hour we recheck VS as well.

Intervening for pain control is becoming a JCAHO hot item- that's why we have standing protocols fromMACU for the use Motrin or if something else is needed we call and get order for Percocet-- but make sure these people aren't walking out on you if you go that route--some sort of release/sig needs to be signed by the patient prior to getting the med (I'm working with Risk on that one--also featured in the recent JEN issue)

A lot to develop- good luck

Anne

sgent · Jul 14, 2005

Great discussion...

At least one thing that our behavioral health ppl were not happy about was how we were triaging patients that came in complaining of suicidal ideation. Due to that, those patients are now considered a lvl 2 for getting a bed, but the MD sees them as though they were lvl 3-4. We had a sentinal event (one patient left the ER, committed sucicide 3 days later).

lilmissg2 · Jul 21, 2005

Could you tell me more about your standing orders for pain managament (possibly even post/send me a copy). We are trying to update our standing orders currently ~ thank you

IClaudius · Mar 10, 2011

We've had alot of trouble getting approved a nurse-driven protocol for Motrin or Tyl in triage because of the administrations concern over JHACO's acceptance of such protocols. Does anyone have experience with this?

Aggie RN, ADN · Mar 13, 2011

Why would the Joint Commision have a problem with that? They're the Devil's agency I swear.

psu_213, BSN, RN · Mar 14, 2011

ACTIVE VOMITING (SEE ABD. Pain)
Start I.V.
Draw Labs
Phenergan 12.5 mg I.V or
Phenergan 25 mg I.M.
Phenergan Supp. Pediatric Dose 1 mg/kg
Type back & consider Abd. Pain Guidelines

If find it interesting that you use phenergan for active vomiting. This is not meant to question your facilities guidelines...just curious as to what other ED's use.

Rickbos · Mar 14, 2011

Its all determined by total amount of resources utilized as outlined in Emergency Severity Index Version 4: Everything you need to know

5 LEVEL TRIAGE SUMMARY

ESI 1 Needs life saving interventions

ESI 2 Needs immediate Rx but not life saving Rx

ESI 3 Needs 2 or more resources but not a level 2

ESI 4 Needs 1 resource

ESI 5 Needs no resources other than physician exam

DEFINITION of RESOURCES

Lab, EKG, x-ray, IV Fluids, IM/IV/Inhaler Meds, = 1 Resource

Consult with Specialist,Simple procedures i.e.; suturing, ear/eye irrigation, DSD change, splinting/casting etc.= 1 Resource

Procedural Sedation = 2 Resources

What is not a Resource

Finger stick BS, Urine Dip, Saline Lock, oral med, Tetorifice, PCP consult

CRITERIA For ESI 3 Upgrade to ESI 2

...........................Pulse ..Resp.. SO2..... Temp

100.4

180.. >50.. 100.4 (? Consider)

3 months- 3yrs.........>160 ..>40.. 102.2 (? Consider)

3 yrs-8yrs ...............>140 ..>30 ..

>8yrs .....................>100 ..>20 ...

Valid pain >7/10 if pain unresolved through triage intervention i.e. ice elevation tetracaine etc.