Triage

Honestly, if the rooms were full and we needed one for something major...we'd put the other patient on a bed in the hall. Never kids or someone who was confused/disoriented or someone who presented with vomiting/diarrhea.

We have a triage competency that everyone must go through. The triage nurses use an algorithm to send people to the main ED or minor care, and assign their acuity. The triage nurse can also start advanced protocols if we are busy in the back. Depending on how buys the triage nurse is she can send people to x-ray, draw and send blood on a preg vag bleeder etc.

I work at a similar size ER. We have been having a high census lately and long wait times..>4hrs is common. We have a pretreatment area,.just a couple of recliners,..we have protocols for common things like N/V, pediatric fever, suspected pneumonia, CP, preg/vag bleed etc. After the pt is triaged the triage nurse orders a protocol and the pretreatment nurses start the IV's, draw the labs and order xrays. The pt is then placed back in the waiting room. The only meds we give in pretreatment are Tylenol, ibuprofen and the occasional Zofran. This helps speed up the time the pt spends in the room,...assuming we can get bed assignments for admits,..but that's another thread..:)

Funny you mention that - our EC is about the same size as yours, and we just completed a comprehensive "lean" redesign of our triage flow about six months ago, which I've been studying since we're planning to start leaning the rest of the EC as well.

We have a whole ton of Advance Treatment Guidelines that can be initiated either by triage or by the back staff; based on clinical assessments, we can order labs, 12-leads and certain imaging (mostly chest and C-spine X-rays, but I've seen head CTs be "advanced" also), order Respiratory Therapy consults, hang fluids and administer some meds (PO NSAIDs, aspirin, SL nitro, IV Zofran, IM epinephrine, INH albuterol and a bunch more I can't recall off the top of my head). We also started using an "RN greeter" at the check-in desk who would eyeball each incoming patient and assign a pre-triage priority. Between that and some physician efficiencies we introduced (we were first in the hospital to go live on EMR/CPOE, the EC physicians all have tablets for charting, and so forth), we dropped our door-to-RN time by 90%, and achieved similar improvements in room-to-ECP times. It's not uncommon now for the ECP to beat the RN into the room when someone comes back from triage.

I work in a hospital with about 30 ER beds which seem to be full for longer and longer these days. Lots of CYA medicine being practiced here. We've recently opened a room with a couple of recliners in it for pts who are ready for dc except they may need to finish fluids. If we have no beds we order xrays, treat fever, have a room where an EKG can be done etc.

I'm blown away by the fact that a 45 bed ED sees 300 patients a day.... you're kidding, right??? That's a monster!!! What's the staffing like?

I'm blown away by the fact that a 45 bed ED sees 300 patients a day.... you're kidding, right??? That's a monster!!! What's the staffing like?

My department isn't too far off the mark - we have 40 beds and average about 250 encounters a day. Each "team" of ten rooms is staffed with three nurses and a tech, and each nurse is responsible for three rooms and up to two hallway pulls (1:5 ratio). In addition, we can call up to two floats, who mostly cover our "acute medical" teams for breaks, resus activations and the like.

So, the staff model looks something like this...

Team RN - 3 x4 teams = 12

Float RN - 2

Triage RN - 3

Ambulance Bay RN - 2

Charge RN - 1

ANM - 1

Total Staff: 21

(I've included the charge and the ANM in nurse staffing because they frequently pitch in to cover team RNs if we're being slammed, have multiple resus at the same time, have a pile of "RN transport" patients and so on. On days, there's also always a nurse administrator in the department, who will also lend a hand if we're that hard up.)

We are attempting to do bedside triage...it is a nightmare the nurses are running around in circles. we have a greeter...they eyeball the patient and send them back..we do not have a fast track so it's a free for all....we have 38 beds..we start out with 9 nurses..1 greet, 1 charge..the others take patients. then at noon we get 3 more nurses. I don't know what's going wrong but this bedside triage is not working for us and I don't know why..we lack teamwork, it's a mess....any idea's

We are attempting to do bedside triage...it is a nightmare the nurses are running around in circles. we have a greeter...they eyeball the patient and send them back..we do not have a fast track so it's a free for all....we have 38 beds..we start out with 9 nurses..1 greet, 1 charge..the others take patients. then at noon we get 3 more nurses. I don't know what's going wrong but this bedside triage is not working for us and I don't know why..we lack teamwork, it's a mess....any idea's

triage or prescreen from the front end - why are nonurgent patients not seperated from the other, more serious (or more of a work up) type patients? It should, ideally, be seperate, otherwise the higher priority patient will always trump the nonurgent patient. Triaging CAN be done at the bedside, but there does need to be some teamwork, which you wrote is lacking. Unless you get all 5 patients at once, and a few of them happen to have CP, you can do it. Triaging each patient only takes a few minutes. You can go add more detail later, but initially, you can jot down the basics and go from there. Good luck!

Our pt's are not triaged based on ESI levels because the manager is not on board with that....we have a RN greet.(cake job of the day! waste of an RN I believe)...looks at the pt and has the CNA place them in a room...no vitals, ekg nothing...the greet RN calls the charge RN and said I placed a CP in rm 1, I placed a abd pain in rm4 , toothache in rm 3...ect, we can see any type of pt in any of our rooms they all have monitors; then the charge RN calls the RN and says...can you take the pt in rm 1...then the RN goes in the room and does a quick triage...name, cc, wt, ....then later goes back and does the full triage..the doc can get in there pretty quick but then the RN can't seem to get the IV's started...complete the triage...meds...before they have 2 more patients...we have several LWBS and AMA daily, or pt sat scores are low...our staff is soooo very unhappy...I don't know what to do to help them..

Our pt's are not triaged based on ESI levels because the manager is not on board with that....we have a RN greet.(cake job of the day! waste of an RN I believe)...looks at the pt and has the CNA place them in a room...no vitals, ekg nothing...the greet RN calls the charge RN and said I placed a CP in rm 1, I placed a abd pain in rm4 , toothache in rm 3...ect, we can see any type of pt in any of our rooms they all have monitors; then the charge RN calls the RN and says...can you take the pt in rm 1...then the RN goes in the room and does a quick triage...name, cc, wt, ....then later goes back and does the full triage..the doc can get in there pretty quick but then the RN can't seem to get the IV's started...complete the triage...meds...before they have 2 more patients...we have several LWBS and AMA daily, or pt sat scores are low...our staff is soooo very unhappy...I don't know what to do to help them..

sounds like the manager needs to implement a new "triage" plan. What about your medical director? Sounds like it's pretty messed up. I would be irritated too. I would think that you could handle your own patient load and triage yours appropriately, based on an ESI system, even if your manager doesn't like it.(what's with that, anyway?) At least you would have the higher acuity patients needs taken care of first, the lesser ones can wait. Sounds like a cunundrum, though!! Good luck!

By the way, that is RIDICULOUS to have an RN greet (we have them too, but we TRIAGE them) and vital signs, at a minimum are done. What about the requirements for an EKG done within 10 minutes (or less) for someone w/ CP?

I can see why staff where you work are unhappy. Maybe you all should come together and make a plan of an ER system that would work?

We were told to like it or leave....

We just remodeled our ER so it's new, big and beautiful....I just wished we could take better care of our staff and our patients...I don't know what it will take to make a change...we have already lost several staff members in the last 2 months...very sad...