Triage times (under 3 minutes)

Editorial Team / Moderator · Aug 24, 2016

How much information is gathered in your triage? Is it just vitals/chief complaint/assign ESI, or do they go into meds/hx/etc.? Is there someone like a triage tech doing vitals, or is it just the nurse?

MassED, BSN, RN · Aug 25, 2016

How much information is gathered in your triage? Is it just vitals/chief complaint/assign ESI, or do they go into meds/hx/etc.? Is there someone like a triage tech doing vitals, or is it just the nurse?

chief complaint, travel history, PMH, surgical history, alcohol, drugs, LMP, vital signs. No we do not do medication reconciliation in triage, that is primary nurse responsibility. The triage nurse does the vital signs in the triage room. I talk to them while I do their vital signs, which really saves time.

Editorial Team / Moderator · Aug 25, 2016

I talk to them while I do their vital signs, which really saves time.

This is important â€” I do the same which is why my triage times are fast, I stay focused and multi-task. I think some people have difficulty with this, and you might find the same. Maybe developing a triage tips and tricks presentation? And give them incentive to improve â€” we published a dashboard that had triage times by RN in our breakroom and also awarded small prizes to those who were number one each month ($5 Starbucks card, etc.).

I found that some nurses have difficulty redirecting that rambling patient who wants to talk about a sprained ankle from 1976. I continuously orient those people back to TODAY â€” what brings you TODAY? Let's focus on TODAY.

Then there are people who just don't belong in triage.

Lev, MSN, RN, NP · Aug 26, 2016

I think triage time can depend on what is going on and how detailed you want to go with your questions to figure out what the "real" problem is.

Some nurses include one sentence (or just a phrase) in the chief complaint. Others have details like denies xy&z. Sometimes you have to probe beyond the "story" to figure out how to accurately triage the patient. That can take more than 3 minutes.

Sometimes a patient can't talk.

Also, do you do assessments as part of triage - i.e. listen to lung sounds?

I don't think triage should take more than 10 minutes. Sometimes I spend 2 minutes triaging a patient, sometimes 15. It really depends on what else is going on. I have gotten patients with a 5 word chief complaint who had a ton more going on and should have been triaged higher. Maybe if the triage nurse had probed a little more they would have gotten back sooner.

My 2 cents.

emmy27 · Aug 28, 2016

I spend a lot of shifts in triage because I like it while most people don't. I have a pretty good system down- I ask the basic questions for our documentation in a specific order while I'm getting vitals so I don't forget anything, and I use a targeted approach to try to keep the "well, it all started back in 1986" rambles to a minimum.

In an ideal patient- one who knows their own history, has a clear idea of what they're there for, isn't in any way limited in their movement or communication- I can complete the triage in the time it takes the dynamap to get a blood pressure + about 1 minute for typing.

That said? Lots of patients- some days most patients- aren't that ideal, together patient. Sometimes there are communication barriers. Often there are knowledge barriers (like the patient who says they have no health history, but is allergic to a dozen meds and has a prior visit history as long as my arm). Sometimes the complaint they walked in for is not the most concerning thing you notice while triaging them (I'll never forget the woman who came in complaining of sunburn and started vomiting copious amounts of blood during triage and still was primarily concerned about her sunburn). Sometimes no amount of redirection will get them to hurry up and get to the point. Sometimes they take foreeeeeever to answer each question (WHY DO SO MANY PEOPLE HAVE TO THINK AT LENGTH AND UM UM UM OVER THEIR HEIGHT? WHY?). Sometimes you have to do some assessment to determine whether someone needs to be in a higher or lower acuity area, or if they need to be bumped ahead or can safely wait a while. Sometimes you've completed their triage for a sprained toe and they mention at the very end that they've been having crushing chest pain 10/10 since this morning.

The ideal triage is one that efficiently determines the correct triage level, clearly documents the state of the patient when you saw them in a way that would hold up if you had to give testimony about it years later, and safely guides the patient to the appropriate care. A two minute triage can't do that for every patient and if you're never over two minutes, I'd suggest you might sometimes be missing crucial details that could come back to haunt you or your patients later.

If patients are regularly backing up in the lobby, the problem is probably at least partly systemic- is there a way to improve efficiency of flow elsewhere? Is immediate bedding and bedside triage being used where possible? Can a tech obtain vitals while the triage nurse types? Can clear 4/5s be directed to a fast track area and triaged as part of their assessment immediately?

DayDreamin ER CRNP · Aug 28, 2016

I can triage our typical lobby patient in about 5 minutes. Our documentation software is template-based so we drop that triage template in and away we go....chief complaint, PMH, PSH, tetorifice, LMP, language barriers, fall risk, and suicidal assessment. We take vitals and ask height and weight (unless super slammed) and we do an EKG if the CC warrants such.

We might take a glucose check if needed, too.

We are lucky in that we have "triage teams" that consist of an RN, tech and NP that work in two rooms and another set of the same in our other two rooms. A pivot nurse sits at the desk and helps direct patients and do an E-fast assessment on neuro complaints. She also assigns an order to prioritize patients based on what the patient signs in with. A pt with a complaint of chest pain will go before the back pain pt.

Our door to triage time goal is under 10 minutes but we could go as long as 20 when we have a surge.

Having experienced triage nurses does help to keep the complaints simple and concise. We don't really care about what happened 10 years ago. We do a pretty good job of keeping the triage to the point. I've ticked more than a few people off when I tell them that we are just concerned about today's complaint. Having an NP in triage has helped, too. He/she can get some orders started and the patients at least feel like they are "getting things done."

skylark, BSN, RN · Sep 6, 2016

In the UK everything is timed, and its expected that the patient will be triaged, have labs drawn, ECG completed and xrays ordered within the first 15 minutes after registration. Unless they are a hard stick, its mostly achievable, so maybe this is a good guideline to encourage?

Unless you triage rapidly, how will you know about that silent MI sitting out there in the waiting room?

Where I am working now, (Illinois) we have a standard where the EKG must be done in the first 15 minutes, so it follows that they will have been triaged first to establish that they need the EKG. Unless of course they are standing at the desk clutching their chest and sweating!

Don't most hospitals have standards for door to EKG time? This might be a starting point for moving people towards faster triage times?

applesxoranges, BSN, RN · Sep 6, 2016

I average about 8 minutes but we also do meds in our reconcillation. It varies how much info is in the rec. The new hospital I am not sure how long it'll take me.

**canoehead, BSN, RN** · Sep 10, 2016

While watching people triage, I find that the hunt and peck typers cant talk/listen and document at the same time. It slows them to a crawl.

hardworkinmama · Sep 26, 2016

I am one of those slow triagers. I don't mean to be, but I'm always second guessing my plan for the patient. I'm worried that I'm going to put someone in the WR that should have gone back or vice versa. Unfortunately with our pt volume, WR times are over 8 hours frequently & that really affects my decision.

I would love any tips on how to triage more efficiently. I find that sometimes when I multi-task during the triage I end up having to ask questions again or recall the temp on the thermometer lol so I'm definitely open to suggestions on how I can improve!

emmy27 · Sep 26, 2016

My method is this- I try to keep the steps the same and in the same order for each patient, that way I always know what I'm going to do next and I don't leave anything out. I can also ask all the quick short-answer questions as soon as the patient walks in and write their answers down as they speak. By getting all those out of the way before asking the patient relatively open-ended questions about why they're here, I can keep things focused and also be typing everything else up if they turn out to be an incurable rambler.

So it goes like this, usually:

"Hi, have a seat, I'm emmy27 and I'll be triaging you today. Full name and date of birth please? Are you allergic to anything? Oh, what happens when you take that? How tall are you? How much do you weigh? Do you smoke, drink, or use drugs? When was the first day of your last menstrual period? Do you have any medical history? How about surgeries?"

This all takes (usually) under a minute to get through, and while I'm doing it I'm also putting the bp cuff and pulse ox on while they're telling me their name and dob, and getting the thermometer ready. I write down their answers on their sign-in sheet as I go, and take their temp last (so it doesn't interfere with their answering), and write that down as soon as I get it. So within one minute of them walking in, I can sit down in front of the computer with 90% of their answers already in front of me. This has proven helpful many times when something went wrong with the computer and I had to finish entering the triage later, or when somebody with a stroke/MI/GSW walks in in the middle of a triage and I wind up distracted with that before I'm able to enter the triage in the computer.

*Then* I ask the patient what their primary complaint is, and if they're not giving a concise answer I use specific questions and redirects to get them to focus ("When did that start? How would you describe the pain, sharp or dull?" "Have you had n/v/d with that abd pain?"). Patients don't know what information is pertinent and so they'll often over or undershoot (either "I just feel sick." or "Well it all started back in 1993...")

As far as second-guessing where you're putting them, it helps to think through what the likely resources needed will be (just like in ESI training- somebody who likely needs every treatment and diagnostic in the department is gonna be a higher priority) and what the worst case scenario is, and whether there are warning signs (history, vitals out of range, just a bad gut feeling when you look at them), and how they compare to the other people you know are waiting. It's good to glance at who's still in your waiting room between patients so you don't forget about them. Usually it's pretty clear if you just consider who you've seen today which among them is your top priority for going back next, which with limited resources is your real question. They all have to go back eventually, you just have to figure out who needs to be seen *first*. It's okay to change that order if you notice changes in the patients, too, and if you're really on the fence about somebody, you can call them back in to recheck their vitals and assess their pain later- you don't have to make a call and then live with it for eight hours if they're deteriorating. And if they're not deteriorating, congrats, you made the right call.

If you haven't had ESI training, talk to your educator about it- they have an excellent online module that's really, really helpful in learning to think systematically about triage.