Using MDs in triage

[gamegirlkimmy]

I have been reading alot of articles about how having an MD in triage increases the flow in the ER. The article states that most ERs overcrowd due to each step being dependent on the previous i.e. triage, registration, waiting room, rooming, MD eval, labs/xrays, MD re-eval, ect..... An alternative scenerio is this: Registration generates a "quick chart", The MD is present as the triage nurse gets the chief complaint and history and then gets the process started from triage with labs, Xray, or possibly even discharging pt from triage. According to the articles I have read patient flow is greatly improved, Door to seen by MD times are drasticly decreased, patient satisfaction improved, and JACHO is happy!

Anybody out there use anything similar to this? I would like feedback and any data you might have that would or would not support this.

[erjulie]

I've just been assigned to a committee to check this issue out, "rapid medical eval" in triage. Sounds good, like probably 30% of patients presenting to triage do not need ER or Minor Care eval and tx. I see that this would unload some of the load on ER, but how this would actually help us get beds upstairs and quit holding, I'm not so sure. Seems like (without having studied on it...) it's just another task to ad to ER without "disimpacting" the hospital...but will update you as our committee gets to work.

[CritterLover, BSN, RN]

while we don't have a doctor in triage, we do start our workup there. we have a list of protocols for most problems that need to be worked up, and as needed, we start iv's, draw blood, do ekgs while the patient is being triaged. the doc reviews the ekg, and if it is ok they can wait in the waiting room. blood goes to lab, and we can pull them out of the wr to a bed if anything comes back abnormal requiring immediate attention. then, when they get to a room, the basic work up should be back, allowing the doc to add what is needed or disposition as appropriate. the only part of the basic work-up that can't be done this way are xrays, because our xray dept won't take someone from the waiting room anymore. (by the way, we have a dedicated room just off of triage for the ekgs where there is privacy. it started this way because we somehow lost the monitor for this room, and that was one thing we could do with the space, but has really ended up working out well).

when i am in triage, i do warn people that i put an iv in that if they decide to leave and not wait any longer, they must have it d/c'd, or the police will be seeking them out to bring them back to either have it taken out or to verify that it has been removed. (and no, the police will not do the verification that it is out. they bring them back for us to verify it. people tend not to be very happy when this happens). often, if we are very backed up i will do just a vp rather than starting the iv to avoid this, unless they have really bad veins.

the last night i worked, we were extremely backed up for us, and two of the patients i triaged were older ladies with vague complaints and nothing significant on their ekgs. when the basic work ups came back, one had a crit of 20 and the other had a ddimer of over 1800. both got a room quickly when we got the labs back. others with similar c/o and nl labs waited over 8 hours, many went home, so it helps to get the people who truly needed to be seen back to a room.

is this common in other ers? things i've read on this board lead me to think it is fairly common, but i get comments all the time that "i've never had blood drawn in triage before."

while having a doctor in triage would lessen the glut in the waiting room, it really doesn't seem like a very good allocation of resources when what you really need is to do is get the people out of the beds in the back and dispositioned, to free up new beds. there is only so much you can do in triage/waiting room. and though this may sound callous, many of the people that would be discharged from triage will get up and leave anyway on a busy night, since they really didn't need to be there to begin with. why waste having a doctor see them? why waste your time having to discharge them from triage, one more thing to do up there? i really thought that having a doc in triage sounded like a good idea when i first read your post a while ago, but the more that i think about it, the more i think that it isn't the best allocation of resources.

[erjulie]

in response to critterlover, I couldn't agree more. We also do the protocols and work-ups, and still do x-rays. Start IVs etc. Last week, a kid was in a bed at the triage desk, line, labs, ivab, then off to OR for her appy. I agree that it's just more work for ER to fully staff another treatment area (triage). I fully agree that this is a hospital problem, not an ER problem (get those pt upstairs!) There's this doc in NY state who developed a protocol where every unit in the hosp (exception: ICU) gets a boarder in the hall when ER is in crisis. I can get his name and email if you are interested, I of course can't remember his name.

The answer, I think, is not to add more layers to the ER, but to get the pt where they belong.

We need to do EKG out front, too, our problem remains space in the triage area. That would help to alleviate a lot of anxiety out there. It's a very tiring topic, don't you agree?