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