Advice for Triage Nurses

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I’m no doubt at some risk of annoying a fair number of readers, probably not a great idea for a new blog, but no one said it was going to be easy.

According to the Merriam Webster Online Dictionary, Triage means among other things, “the sorting of patients (as in an emergency room) according to the urgency of their need for care”.
Unfortunately, Merriam et al, don’t include the word rapid in their definition, which would have helped me out a bit. Ah well, I’ll soldier on anyway.

The problem is that triage in Emergency Departments has become something that is far from rapid. I understand that nurses, like everyone else, face ever increasing work loads without ever increasing staffing resources. I know the feeling. For some reason, triage has slowed to a pace that is about the same as evolution. Really, I’d swear that last week I saw the EMT in front of me develop opposable thumbs and the ability to walk upright while he was waiting for the nurse to finish triaging his patient.

It’s not uncommon for triage to take ten or more minutes. I don’t mean we wait for ten minutes, I mean that from the moment I say hello to the nurse until he or she is ready to assign us a room, or more and more frequently try to find a bed or counter top to put the patient on, it’s ten minutes.

Some of the nurses blame the ubiquitous computer based triage systems, but the absolute slowest ED in the city is still using paper. EMS folks have an advantage in that we see all of the EDs in our area, not just one. We can compare hospitals and know where to go and where not to based on a number of criteria. For that reason, we know where the triage is good and where it isn’t.

When I bring you a patient I pretty much have my story ready. I even have a set way I like to tell the story, but I’m flexible, I’ll go with the flow of your charting system. I like this order in particular, Name, Age, Chief Complaint, Associated Symptoms, History of Present Illness/Injury, PMH, including medications and allergies, primary assessment, secondary findings, treatment, and finally result. I’ll give you a date of birth and hospital medical record number as well. This should take me about two minutes to tell, maybe less. It’s a thumb nail sketch as a partner of mine used to say. I’ll flesh this out in the written report, where I’ll add date of birth, social security number, and insurance information if I have it.

Now, if I can give the story in about two minutes, it shouldn’t take you tremendously longer to put it on paper on in the computer. This is especially true if the patient is frequent flier “valued repeat customer”.

Here is what I don’t care about and frankly neither should you UNLESS it impacts the patient care in the next 30 or so minutes. Pack year history, alcohol or drug use, if the patient feels safe in their domestic relationships, if they have firearms in the house and if they do, are they locked up, favorite vegetable, or shoe size. I know that JCAHO, your head nurse, and the resident who is doing some highly important study that’s been done about 50 times before need that information, but it doesn’t have to be done at triage. It can be done at any time during the ED visit or if they are admitted to the hospital.

If I were a nurse and I had union representation, I’d be raising holy hell about this. That sort of foolishness takes you away from what you should be doing. Social work is not your job, that’s why the hospitals have social workers, volunteers, and useless administrators. If it’s so damned important, let them come in at 0300 and ask the questions. Yeah, I didn’t think so.

Which is a nice segue to my next point, the not my job part. Taking vital signs at the triage station isn’t. My job that is. If I don’t have a bunch of other things to do, like clean the truck, write a report, use the bathroom, grab a bite to eat, TRY TO GET HOME AT THE END OF A SHIFT, I’ll be more than happy to help you help me. The difference is that it’s a courtesy, not a requirement.

If you tell me it’s my job, I’m going to point out a couple of things to you.

First, if I’m in your facility, or under most circumstances within 250 yards of your facility, your hospital is responsible for the patient. See 42 CFR 413.65:*

Second, I’m willing to bet that somewhere in your hospital rules or JCAHO guidelines there is a requirement that all hospital personnel be trained to use any equipment that they are required to use in the course of their daily duties. Where every hospital in the area seems to use totally different equipment, I can’t be expected to use any of it. If you really press the issue, I’m going to ask you in excruciating detail to show me how to do every step in the process. It won’t be pretty. Oh, and I’m not “hospital personnel” either. Which is the big deal some nurses make when they don’t want to accept the bloods I’ve drawn in the field. Can’t have it both way, folks.

Once the triage process is done, please give me a bed assignment right away. I don’t want to hear that you don’t have any beds and we’ll have to wait. Our job is to treat the patient in the field and get them to your hospital. Your job is to find a place to put them and start treating them.

So, let’s work together to speed up triage. You pester your bosses to remove superfluous questions from the triage forms and I’ll be more than happy to help you out with vital signs. I’ll give you a good report and you find a place to put the patient that isn’t on my stretcher.

Deal?

*Note: This is not legal advice. I’m not a lawyer, I just use a tiny font when I want to make something tiny.

14 COMMENTS

  1. I think the nurses will recognize that this is not directed so much at them as at those who would be incapable of managing time well, even if they were EMTs or doctors, and at the administration that makes such well thought out rules that inspire us to regularly give them the “You’re Number One” salute.

  2. Are you in my head? I have that discussion at our local ED at least once a week. OH can I mention one other small pet peeve. If you answer the radio when the medics call in please actually tell the charge nurse we are coming so we don’t have to get the ” why didn’t you call us?” question when we roll in the door. The eye roll, sigh and stomping off doesn’t make for a fun night either. It’s really not my fault that whoever answered didn’t tell you. I wasn’t trying to surprise you.

  3. Rogue,I thought we had a problem down south about our triage situation. Pretty much, the nurses rant about a patient we bring, then rant because they have to triage them, then rant because they only had 35 mins for lunch. Meanwhile back at the ranch…EMT’s and Paramedics become frustrated because dispatch is raising holy hell for them to clear, leave, or get the hell out of the ER. Great Post Fellowmedic!Alex ~D~http://theapocalypsepapers.blogspot.com

  4. Alex D,Thanks for the compliment, but I did not write the original post.This is TOTWTYTR’s blog and all of the praise should go to TOTWTYTR.

  5. So…additionally, although we don’t have to deal with “triage” where we take our patients here in little rural hospital USA, I recently had a conversation and wrote a little article with an ER nurse from big city hospital ED out East. According to him, EMS doesn’t need to really give much of a radio report except the…we’re coming, he’s critical/not critical….heart, head, bone, bogus..so they can determine room assignment.Since where I live only has two rooms..why do you need to give that information if the patient has to go through triage in big city hospital anyway?Thanks

  6. The radio report only needs to cover the minimum – number of patients, stable/unstable, what you think the diagnosis is, any special needs (intubated, CPAP, restraints, isolation, . . .).All of the rest is not going to change a thing in the preparation of the hospital. Even the information I listed is largely ignored.Penner MS, Cone DC, MacMillan D.A time-motion study of ambulance-to-emergency department radio communications.Prehosp Emerg Care. 2003 Apr-Jun;7(2):204-8.PMID: 12710779 [PubMed – indexed for MEDLINE]P2 = stable patients.Conclusions. In the system studied, P2 reports rarely provide information that is acted on prior to the patient’s arrival. The time spent giving a radio report is frequently duplicated in the ED. Radio reports for low-priority patients may not be an efficient or productive use of providers’ or nurses’ time.

  7. I’m not saying he was wrong. I’m saying that in my world…that study isn’t valid. In my world, the radio report is important because there is no triage upon arrival. The doc, (additional) nurses, Xray, lab, etc all need to be called in adn the information IS important. When I worked in big city FD…I’d agree with you..nothing much was wanted or desired by the hospitals…except they wanted to know you were coming with a patient..period.Even in big city hospital here in my state, the patient that came in by ambulance had a room assignment pretty much upon arrival and DID NOT go through triage…again.I don’t understand a patient being run through triage coming in my ambulance…and if that is the policy, why bother with ANY radio report?

  8. The study was done by Dr. Cone at Yale, so a busy ED. OTOH, EDs are supposed to be somewhat prepared to deal with surprises. This was looking at stable patients, so how much preparation can the ED do, even if they want to throw a surprise party (not that I would mind)?It seems that sending EMS through triage is an idea that is catching on. One hospital has placed a phone at the entrance to the ED, when you pick it up it dials the charge nurse, who is supposed to answer. Often it rings through to registration, on the other side of the ED, not a help. If I have an unstable patient, I only need to raise my voice a bit and mention that the patient is unstable, but for the stable patients, it can be a bit of a wait.

  9. All of this probably varies by city, region, service area, or whatever. From what I’ve seen any notification over a minute is wasted, the nurse just stops listening. What they want to know is how sick the patient is and thus what resources they need to muster. That’s about it for us, your system might be different. Then again, this isn’t about radio reports, it’s about giving a report in person.

  10. “…. if they have firearms in the house and if they do, are they locked up ….”The answer to THAT question is “none of your damn business!”

  11. NO..it isn’t about radio reports..it’s about Triage..which a good, efficient BRIEF radio report is a part of…in my world and opinion.

  12. Unfortunately, many of the hospitals around me expect a full radio report. Only a doctor is permitted to answer the medic line. So, if we need to talk to a doctor, the first thing we need to say when calling is “is there a doctor available.” Then the nurse will spend a few minutes locating one.When we give report on the radio, it is almost never a person who you see, when you arrive, so you have to go through the same information all over again. I find that “You never called,” is a common accusation, so I generally ask for the name of the person I talk to before I give any report. The triage should not be long, it should not be a repeat of the radio notification, and it should be limited to what is relevant to the immediate disposition of the patient.

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