Triage TX Anyone Have Any Good Ideas?

rnwaller · Sep 23, 2007

Maisy,

You did not say how busy an ER you where in or if its a one or two nurse triage system. I spent a year on committee of this very question. Some quick answers. We initiate standing orders in triage including Xrays and bloodwork - IV starts are held off as who is responsible to monitor an IV in the waiting room and what if the patient leaves?

It is imperative to have the medical director behind this. It does progress to some more aggressive ordering for experienced staff with established relationships with the doc (ie. head CT, U/S for DVT etc..).

I hope this helps - feel free to ask me more.

MAISY, RN-ER, BSN, RN · Sep 23, 2007

Thanks for responding, we currently order xrays, ct, doppler for obvious dvt, ekg and labs (for inside). We were discussing situations like flank pain-urine dip-where would we put samples, can we ask patient to hold on to?(I say no), or NV line with fluids-how could we start with zofran or whatever before patient comes it? Even labs, we do million dollar workups-it isn't such a big deal to draw, but where do we put them, or extras while the patient waits?

I almost want to say we need to have a PA in triage-then some type of intake nurse to do labwork.

Really looking for someone with a plan in place that may be doing some of these things. Right now we are seeing approximately 70k per year, we are trying to treat and street for their benefits, as well as ours.

Thanks,

Maisy;)

CraigB-RN, MSN, RN · Sep 23, 2007

[i've been doing some research on this as part of a grad thesis. There are a lot of things to look into.

1st. Everyone needs to be in invovled. THe Docs right from the start. The Medical Director has to sign off on it.

2. You have to look at the law. In some cases it's semantics but in KS you can't follow protocols you can only follow standing orders. (protocols are what APRN's function under)

3. You have to know your patient population. One location has a high degree of walk off after they had pre-treated N/V pt's with IV, & Zofran.

4. Adaquate CQI. You got to keep an eye on things and make sure what you are doing is what you need.

5. Education/Training - You have to do tons of this, ongoing and constant to make sure people are following the rules. If not you risk the dreaded "practicing medicine without a license" tag

6. If you can, get a Doc to champion this concept.

7. Make sure you have a plan in place for what to do when you get "critical" lab results on one of those patients that are sitting in the waiting room. You don't want to have a patient with a know K+ of 9.0 sitting out in the waiting room for 4 more hours.

8. Look into a provider in triage. THere are places that are doing this.

9. Wait 6 more months and my thesis will be done.

lorita · Sep 23, 2007

Where I sed to work we hd protacols for this labs were jst BS, UA, HCG really only labs we ran ourselves any other had to be ordered by the doc. We could order x-rays on extremities only and of course give tylenol and motrin.

rnwaller · Sep 23, 2007

Your already on the right track. The system we used was two (or three) triage nurses. One continued traige and one started workups, including sending labs, ekg etc. (an ED tech can also be helpful) We had a chart rack and a specimen holder and this nurse followed results for these patients (had to show EKG to someone watch for critical labs etc.) For that busy an ED you need a doc/mid-level assigned as the "go to" person for triage. If I felt an IV was necessary I used the hallway near triage - I did not let IVs go to waiting room. We used Zofran ODT for quick relief. The charge nurse (or whoever assigns beds) would work with the triage team to know who needed the bed next.

I have had a normal EKG with positive cardiac enzymes results sitting in the waiting room so the mention of follow through for results is important. Some people will still leave, even though you are getting thi ngs done for them, so a call back system has to be developed if you get abnormal results requiring follow up.

We did urine dips/upreg etc.. but I never told patients results if they were going back to the waiting room - if they have the answer they were more likely to leave.

Motivated as we all are, sometimes there is just plain waiting.

Crash_Cart · Sep 24, 2007

What you need to do is start an ER Comittee or a Special Task Force to conduct research in areas of concern when implementing the idea of ER triage at your hospital.

Engage all staff for input and provide the comittees recommendations to the Medical Director for approval. This has way more clout than the idea of simply seeking the medical directors "nod of approval."

When the ER committees or special task force recommendations are typically rejected (usually the first time around) then the Medical Director is accountable to provide the comittee with a written and detailed response outlining the specifics surrounding the rejection.

Revise the original report and submit it with certain revisions made which addresses and satifies any list of "valid" objections. Be sure the report outline reasons "why" the comittee doesn't accept certain rejects in bullet format. Outline at least 10 valid reasons in opposition for each rejection response indicated in the Medical Director's written response.

Basically, the Medical Director can only reject the ER commitee's report so many times before he will either. A) Run out of any valid reasons to reject the report or, B) Have no choice but to agree to the outlined recommendations.

"3. You have to know your patient population. One location has a high degree of walk off after they had pre-treated N/V pt's with IV, & Zofran."

Make them pay a refundable "user fee" when they check in. This commits them to stay in the ER or they risk losing thier cold hard cash. $5 - 20 bucks or something. They get it back when they are discharged.

"9. Wait 6 more months and my thesis will be done. "

OK. Sounds good and I wish you my best of luck!

alkaleidi · Sep 26, 2007

We have physicians and PAs in our 3 main departments: triage, ER II (fast-track), and Main ED. In triage, an RN and MD see the patients, and many patients are discharged directly from the waiting room. :) I love that. If they make it past triage, they go to either ER II/fast-track where a nurse and PA are their care providers, or the Main ED where they have either a PA or MD and RN.

Having an MD in triage means a lot of sore throats and sinus infections get sent home either with an rx or with suggestions for OTC treatment. Hurrah! One of the smartest things I've seen in an ED.