ED nurses revamp triage because of overcrowding

System addresses need for early intervention

At Johns Hopkins Hospital in Baltimore, MD, ED nurses revamped their triage process due to crowded waiting rooms causing delays in clinical interventions, says Kathy DeRuggiero, RN, MSN, assistant director of nursing for the Department of Emergency Medicine.

"We have made changes to get to the bad news faster," she says. "We have an ED built for 150 patients on average; but some days, we see over 200. We had a capacity issue on the back end."

This meant that patients in need of early intervention were waiting too long for chest X-rays and electrocardiograms (ECGs), says DeRuggiero. A new "rapid triage" system was created to sort patients in a different way and "move the diagnostics up front to the waiting room" for these patients, she says.

Two nurses now handle triage, with the first nurse finding out the chief complaint of every patient in less than 60 seconds, DeRuggiero says. "If the patient is in jeopardy of losing life or limb, they go right back," she explains. "We can't wait for patients to get back to beds anymore. All the studies show that the earlier these interventions are done, the better the outcomes."

For example, in order to give a pneumonia patient antibiotics within the first four hours of arrival, a chest X-ray needs to be done in the waiting room, as opposed to waiting until the patient is brought back to a treatment room, she says.

With the previous triage system, the nurse obtained vital signs and history for each patient, and this took too much time, says DeRuggiero. "That alone takes 10 minutes per patient. If you are four patients deep and one is having an AMI [acute myocardial infarction], there is no way to get to them in a timely fashion," she says.

What could you have done better?

Every pneumonia and AMI case is reviewed by DeRuggiero and the ED clinical director to see what could have been done better at triage. Recently, they identified that patients who are possible candidates for percutaneous coronary intervention (PCI) would benefit from the cardiac catheterization team being called before the patient even arrives at the ED.

"The medics actually call in the ECG reads, and the team is activated based on the reading so we can get them moving," she says. "If you've only got 90 minutes to get them from the door to the balloon, you don't have 45 minutes to wait for the cath team to get there during off hours."

Much of the time, the team is canceled because the patient turns out not to be a candidate for PCI, DeRuggiero adds. "But we are willing to do that to find that needle in the haystack," she says. "There are a certain amount of patients that you will respond to who don't meet the criteria, in order to find that one who does."

Nurses are given feedback about the good outcomes of patients who otherwise would have been sitting in the waiting room and possibly would have died, says DeRuggiero. "Because of this early recognition process, we have saved lives of pneumonia, AMI, and stroke patients," she says.


For more information on the ED's rapid triage system, contact:

  • Kathy DeRuggiero, RN, MSN, Assistant Director of Nursing, Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore, MD. Phone: (410) 502-4480. Fax: (410) 614-6888. E-mail: kderuggi@jhmi.edu.