What's your triage protocol?

Editorial Team / Moderator · Jun 30, 2016

We're doing pull to full/immediate bedding, but the triage nurses are doing it unless the primary is available. 30+ beds.

I don't anticipate that your current system will last long, it sounds counterproductive.

MedicFireRN · Jun 30, 2016

I don't anticipate that your current system will last long, it sounds counterproductive.

Well it's been a miserable few weeks with no sign of change :arghh:

turnforthenurse, MSN, NP · Jun 30, 2016

We were doing this at a hospital I used to work at and it didn't last long. Then they only started doing it if someone really needed to go to the back like RIGHT NOW.

emmy27 · Jul 1, 2016

We have been using the method you describe at my current ER for a while now. It's not usually a huge issue, because the techs place them on the monitors and get the initial vital set for the receiving nurse, and because we rarely start a shift with many beds available, it's rare to actually wind up triaging many of your own patients (maybe one near the beginning of the shift). We also use good clinical judgement- I was in triage the other day and when an SVT and a stroke each came in with beds available, I didn't just straight back them and leave them for their nurse to find, I went back with them, got their triage and protocols started, and called a doc. We also triage true 4/5 "fast track" patients in the lobby so the nurse or medic in fast track can get them in and out without having to stop for triage (and to ensure they're actually 4/5 before we put them in fast track). We all have easy access to the tracker on our work screens, so we can easily see when a new patient has been placed even if we're in another room. I imagine it would be riskier at a facility that still uses paper.

I worked at a different ER that did straight bedding but also "swarm" triaging, where when a patient was placed, it was paged overhead and everyone available rushed in and got their triage and protocols started. This was stressful at times (it sucks when you're busy and you still need to help swarm) but it really got things done fast and increased our sense of teamwork and the feeling that you could count on your coworkers to have your back, and it guaranteed that those times you get in the room and find your brand new patient in terrible shape, you're not completely on your own- a couple of people have the understanding of the situation right from the start.

Just blindly putting people in beds and hoping someone finds them sounds terrible, I hope that's not really what you guys are dealing with.

DarknTwistyERRN · Jul 2, 2016

Our techs are getting vitals and weights as patients check in. If we're slammed at triage and have lots of rooms open (and RNs aren't bogged with critical patients), we'll pull to semi-full. We try to avoid sending patients back untriaged after about 11am because we're wall-to-wall by then. We end up having three nursing triaging with another at the check-in desk and two techs to do vitals/EKGs and take patients back to the rooms. Starting at 11am we also begin RTA (rapid treatment and assessment) which involves a quick assessment by a midlevel during triage and they order labs/radiology which is begun while the patients waits for a room. It makes their wait more "productive."

Lev, MSN, RN, NP · Jul 3, 2016

Patients who walk in are triaged by the triage RN and then sent to the waiting room, sit in triage, or sent back to a room. We have 46 beds in the main ER and 7 fast track rooms which can be more if the observation unit has rooms. Techs get weights and vitals. If the patient who walks in (or more likely is pulled out of a car) needs to be seen ASAP they are taken directly back to the room with warning to the RN who notifies the doc.

LadyFree28, BSN, LPN, RN · Jul 3, 2016

We had something similar; we have a sorter nurse and a triage nurse who is supposed to stay out front. The sorter nurse is ONLY supposed to assign ESI levels; the triage nurse may triage pts that are not able to readily be roomed.

The disconnect that was occurring was that techs were not getting vitals (because we didn't have any some days), high acuity and lack of staffing; in which the doctors complained that having the triage nurse out there doing nothing while the "primary" nurse was rooming patients, getting triage, taking them to/from testing, while having three other ESI 2's was not making the flow improve.

Now with enough medics and support staff helps make the situation more efficient-vitals and weights are done, the nurse can just get the essentials for triage and do their assessment and get the doc if ESI 2 and get the patient started, spending no more than 5 mins on stabilizing the pt, then monitoring them while waiting for test results to come back, etc while handling the rest of the assignment.

siegolindoRN · Jul 5, 2016

Mount Sinai Health System uses the "Split Flow" patient flow improvement process. It utilizes separating ESI 1/2 and high level 3 (abd pain with co-morbidities) into acute areas and ESI low 3 (abd pain NO comorbidities), 4 and 5 into an evaluation area. It also places 2 triage nurses in walk in however they were not used in the traditonal sense. Triage was split into an A and B, A encompassed 5 data points (2 for ID surveillance) and B included v/s, domestic violence, SI, etc questions. Everyone that came in got a triage A but only during "full" times was B utilized or when the RN could not identify an appropriate ESI given the CC. The "meat" of triage hx, allergies, etc were left to primary nurse to complete. I will say that when flow was steady it worked well but buckled when we had bolus' of 3 or more patients at any single time. We regularly saw close to 200 visits per day and constantly had issues with missed v/s, allergy banding, testing etc. On days with visits approaching 250 or better, it was just painful all around. Although neither regulatory agencies nor insurance providers have set time stamps for most ED visits,(outside of CVA/MI), ED administrations have self imposed "goals" of limiting the time from complaint to evaluation by provider (MD, DO, PA, NP). These systems of bedside triage are spawning from those decisions and it places an unnecessary burden on the clinical staff, causing low moral, dissatisfaction, high turnover, low retention and inadequate orientation (to name a few).

emtb2rn, BSN, RN, EMT-B · Jul 5, 2016

We pull until full, but the triage nurse will have a quick (10-15 second) conversation with the pt to determine if it's an esi 1 (which can & does happen). If immediate bedded, the tech will get vitals & ekg in the room. If really sick & immediately bedded. i'll call the doc covering the area the pt is going to & give them a heads up

MedicFireRN · Jul 6, 2016

Yeah, if we had more techs I could see it being more practical; but we often only have 1 tech; on a good day we have 2 techs for the entire ED from 11a-11p.

Roy Fokker, BSN, RN · Jul 9, 2016

Mount Sinai Health System uses the "Split Flow" patient flow improvement process.

We do something similar as well. ESI 1 and 2 get slotted for the Main ED. ESI 3 is split between vertical (ambulatory/no-co morbidities/low risk) and horizontal (non-ambulatory/high risk/possible admit etc.)

Vertical ESI 3 goes to a re-worked "fast track" area (staffed by a PA/NP, Doc, 4 RNs and a tech for 18 beds). ESI 4 and 5 go to "Rapid care" (staffed by a NP/PA and an RN {and a tech if you're lucky}).

Out front, triage nurse is only supposed to gather a very brief assessment. By the new book, the ONLY VS to be collected are a pulse-ox and heart rate, along with a height and weight. The patient is then placed in a treatment area and then the primary nurse completes the full triage (rest of vitals, history, allergies, meds, chief complaint).

The only exception to this is if the patient is to return to the waiting area due to lack of beds (in which case, only a full set of VITALS is completed. The rest of triage is still completed only when patient is placed in a room.)

While I admit that it certainly speeds up triage, I am always leery about placing a patient without checking a full set of vitals; especially blood pressure.

But in a few short months, there will no longer be distinctions between "Main" "Fast track" and "Rapid Care" because.... POD Nursing is here!

cheers,