We no longer triage

[Guest219794]

We have this new system in the 25 bed in which I work.

No triage. Charge rn goes out, and get's pt's as they come in. Has a brief conversation on the way to a room. We are adversising a fast door to doc time, and docs often get to the pt before the nurse.

We will fill our beds, sometimes with minor stuff. Pt's in a bed have a much greater expectation of service than a pt in a waiting room, taking a lot of nsg time on minor pt's.

The docs can only move so fast. We get the "seen" quickly, but I don't think we get them out any quicker.

Anybody else use this system? Does it work?

I'll put it politely by saying I'm not a huge fan.

HH

[Rickbos]

I have heard of this concept but have always felt it fell short of the intended purpose/function of an ED. EDs are supposed to deliver "prioritized" care to those with "emergent" issues as per the 5-Level ESI triage system used by most EDs. They do not exist to provide primary care for patients on a "first come, first serve" basis.

In the present health care setting we all know EDs are the "primary care" providers for a large number patients but that does not mean we need to abandon the core principles of emergency care delivery to gain higher Press Ganey scores. The prioritization of each patient in the ED is essential to the delivery of ED treatment to those that most need it, and this cannot be accomplished correctly and efficiently with the "first come, first serve" approach. The separation of the "emergent" and "urgent" care patients must be done giving the beds to the most "emergent" and allowing the "urgent" to wait for treatment when beds are available and staff are able to attend to that patient's needs.

By the way, I hope you noticed I still refer to the "patient" as a "patient", not "customer" or "client". I have found in 38 years of practice you can be nice to people, get good results, provide a safe environment for the patient and yourself, and enjoy what you are doing, without applying "marketing/corporate tags" or falling for every PR scheme dreamed up by some "office jockey" to make your administration look good. Remember, it is your license they are playing with, not theirs.

[brillohead, ADN, RN]

One of our local hospitals advertises "no-wait ER". It's a Level One Trauma Center that sees approx. 60,000 patients/year.

When you walk in, you're ushered directly into a small triage room (unless you're obviously in need of emergent care, such as blood gushing out of an artery ). The nurse takes your vitals, puts your name/address/reason-for-visit info into the computer, and prints out your pretty bracelet. You are then directed to either the "Fast Track" department or the "Emergency" department.

My only experience is with the Fast Track side of things (my family only seems to need emergent care on the weekends when the doctor's office is closed, and we don't have any Urgent Care places here that participate with my insurance). You get placed in a curtained area with one chair and one gurney. The doctor is assigned only to that one department (separate staff for the Trauma side of things), so he usually sees you within 10 minutes of when you entered the curtains. While you're there, a clerical person comes and completes the rest of your information, confirming insurance, place of employment, etc.

The last time I was there was on a Sunday evening. I had conjunctivitis that went way beyond "pink eye" -- nasty green gook that was basically oozing out of my eyes so fast that it would replace itself as soon as I wiped it away. I entered the ER, got triaged and sent to Fast Track, saw the doctor (who literally cringed when he first looked at me... it really was some nasty crud!) who diagnosed eye/ear/sinus infection, then waited for a while, saw the clerical person for insurance info, waited a little longer, got a Rocephin injection (doctor was extremely concerned with the speed at which the infection had developed), waited a little longer, then got my written prescriptions (eye-drops and oral antibiotics) and discharge papers. Door to door time was probably about 90 minutes, which is probably about how long it would have been if it had been a weekday and I'd been able to see my doctor at his office.

[Altra, BSN, RN]

Hey, that sounds like a good idea. That way, people are less angry and won't take it out so much on the nurses. People tend to shut up when they are around authority.

All these years of nursing evolving into its own profession ... but some want to hide behind physicians with "authority."

Personally, I am very comfortable with being accountable for my own decision-making, made within my scope of practice and backed up by solid science. On occasion, this will ruffle the feathers of a patient/family member without knowledge of triage practices. So be it.

[Joe B1]

I can't say I'm wild about that sort of process. It's been tried a few places I've worked and it works about as long as it takes to fill up all your beds. There also ends up being a lot of musical beds when you have pts taken to the fast track that need to be in the more acute area.

My thinking is that we do triage for a reason, to make sure that pts with more urgent issues are taken care of first and in the most appropriate area. This "no wait ER" idea is a pure play to survey scores, which are statistically worthless given the sample size used. I don't know of any ED that is suffering from lack of pts, so it sure isn't to attract more of them.

[ernrs2b]

we are getting ready to trial "immediate bedding". We have an initial nurse do a quick screening to see whether the patient can go to urgent care and assign a bed to the main ER or urgent care. the patient arrives in the room, a "mobile triage team" which include a provider (MD,PA,NP), triage nurse and tech will do the triage and initial orders/assessment. when the beds are full, this team returns to triage and evaluates/discharges from the waiting room. We are hoping this helps our wait times. I agree, you can't predict what will roll in the door at any time. If there's a code, you find a bed. No different than any other day in the ER. We live in a drive thru kinda world, we have to cater to that unfortunately!

[LilgirlRN, ADN, RN]

We're about to start doing this too.

There is an ER nearby that gives out beepers like they do at Outback. When you're beeper goes off they take you to the back!

It's like I told my charge nurse, if you have to wait for a table in a restaurant for a little while you don't really mind the wait. However, if they take me to a table I expect to see a waiter soon. If I look over at another table that arrived after I did anfd the waiter is there then I'm gonna get ****** off and leave! Same goes for ER beds.

I really love the suggestion of allowing the doc to do the triage.

[Guest219794]

My issue is the time to "triage".

We made no alterations to our system. the charge nurse walks the pt back, and might catch a serious problem. Or not. So- I have 3 patients, and get a fourth. I have orders on 1 pt- iv, labs, and a gtt. It's going to take me at least 20 minutes to get it all from the Pyxix, start a line, lable tube, set up a pump, then document all that.

so, the pt sits 20 minutes. during that time, i got orders on my other two patients. Am I supposed to delay their care?

This system was introduced without any guidelines. It is being managed by people who have never seen it done well. the consensus from experienced nurses is we are heading to a sentinel event.

[Footballnut]

Sounds difficult at best. I like my charge nurse to be running the department, not walking patients to the back. We still have an RN greeter and do immediate bedding. We get a set of vitals on the way to the room (or fast track) unless the patient cannot tolerate to sit for a 1-2 minute set of vitals. That way when I am stuck in another room someone knows if my patient's vitals are unstable and lets me know. And the MDs who are seeing the patients quickly like the vitals too.

We have a backup system for when the beds are all full. The fast track staff puts all the triage information in and the doc there sees the patients and starts orders. It's kinda like having a doc do triage. The patients are in and back out in the waiting room in 10 minutes. Labs, xrays, ECGS and whatever are being done while they wait. No IVs or long nursing procedures or the system bogs down. If the fast track staff identifies a critical patient we have to kick a non-critical patient out of the main ED for them. Doesn't happen too much and other patients that qualify for the main ED still have to wait in the waiting room for a bed to open up. Usually a quick look out front by the greeter nurse gets most of the critical patients. The whole department has to flex to keep things moving for these times when the census is going crazy. Even the greeter nurse can put a little more "greet" into the picture (like starting carepaths) if they don't have a long line to greet and the patient has no place to be seen at the moment.

I think it is hard on the staff. I think we are doing more work in the same or less time. But our times are faster and our patient satisfaction scores are higher. I consider it a bonus if the fast track staff has put in my triage. I also haven't heard of any marginal patients that sat in the waiting room a long time to see the triage nurse. It just depends if you want your serious/critical patients sitting in the waiting room or on a bed in the department. At least they generally see the MD way faster. Communication and a handoff report from your greeter (or charge nurse who walked them back) are essential if you do immediate bedding.

Sometimes I drop what I am doing to take care of the new patient. The other day I got two ambulances right after I got orders for an IV and meds for a patient in pain. Poor pain patient had to wait while I dealt with 2 new patients.

All the best as you work through the process of refining this. It takes time and growing pains.

[Lunah, MSN, RN]

We've implemented bedside triage in our ED, as of a couple of weeks ago. My jury is still out, but is kind of cranky about it. We'll see how it goes. I understand the reason for it -- to shorten the door-to-doc times -- but still. Our triage process was pretty smooth before, and I'm a fan of the "if it ain't broke, don't fix it" philosophy. But I'm giving it a chance.