EDs using non-nurses in triage, waiting rooms

Practices 'take a lot of the risk out of triage'

A recent Illinois case of a patient dying in an ED waiting room after being seen briefly at triage underscores the increased pressures emergency nurses are facing, due to long wait times and overcrowded EDs.

"Most disturbing is the fact that this kind of scenario could happen in almost any ED," says Donna L. Mason, RN, MS, CEN, nurse manager of the ED at Vanderbilt University Medical Center in Nashville, TN.

Failure to address ED crowding and wait times is "a disaster waiting to occur" in many EDs, she says. "It affects patient safety. The frustration leads to nurse dissatisfaction and retention issues, leading to an even worsening of nursing shortages," Mason adds.

To ensure that no patients are overlooked during long waits, some EDs are using non-nurses at triage and in waiting rooms. Here are two of the ways this is being done:

  • Physicians or midlevel providers work with triage nurses.

At Vanderbilt's ED, a physician is at triage 16 hours a day to initiate orders, evaluate patients, or determine who can be treated in the waiting room safely. The program has been very successful, reports Mason. "Some patients never go to an exam room," she says. "Our left-without-being-seen rate has dropped from 11% to 2%."

To see how this program works, consider the example of a young person with abdominal pain who is hemodynamically stable with good vital signs. This patient would be assessed by the triage nurse, with necessary tests ordered by the physician. An LPN or paramedic would ensure contrast is given and any necessary medications are started. "Then tests are obtained and done, and the patient never goes to a bed," she explains. "When a bed becomes available, they are placed."

The ED has two triage stations and three "team triage" small examination rooms divided by walls with curtains in the front for privacy. "Blood draws are done in these rooms if needed but may also be done at triage," says Mason. "There are stretchers in the rooms, so electrocardiograms can be done there also."

Don't miss patients at risk

At University of Texas Health Science Center in Houston, nurse practitioners or physician assistants work with ED triage nurses 24 hours a day. "I sit up front with the triage nurses so I can actually start treating the patient, which takes a lot of the risk out of triage," says Elda Ramirez, MSN, RN, PhD, FNP-C, CEN, an ED nurse practitioner at the University of Texas Health Science Center (UTHSC) in Houston.

The goal is to be sure that patients at risk of getting progressively worse aren't missed, she says. "The patient may be awake and alert and breathing right now, but based on their history, this can change quickly," says Ramirez. "I may see a baby playing at triage, but if the history is vomiting and diarrhea for 24 hours, that kid can turn on me on a dime."

  • Patients in waiting rooms are closely observed.

At Vanderbilt's ED, paramedics alert nurses when a patient's condition changes or their pain become more severe. The paramedics are seated at a desk at the ED entrance, with clear visibility of the waiting room. Triage nurses tell patients that the paramedics are there in case they have any concerns. "Having those medical 'eyes' in crowded waiting rooms lets patients and families know there is a medical person to liaison with," says Mason.

For example, patients may present with kidney stones without pain but may develop significant pain during their wait. "The medical 'eyes' can spot an increase in pain, changes in a patient's color, or altered behavior, and address it immediately with the triage nurse, physician, or charge nurse," she explains. "They are also the 'go-to' person for questions that our patients may have."

At University of Texas' ED, volunteers and security guards are stationed in waiting rooms, wearing identification so patients are alerted to their presence. Volunteers attend orientation training, and they communicate with triage nurses using handheld radios. "They go directly to the nurse if a patient doesn't look right or for any kind of situation," says Ramirez.

Recently, a greeter ran to Ramirez and told her that a patient looked very ill. The man had come in earlier with family members saying that his arm had been shaking earlier in the day, but he reported no other symptoms. "I immediately went out front and saw that his eye was flickering, and it turned out he was having a petit mal seizure," she recalls. The man was taken right to a room, had an intravenous line put in, and medications administered. "If this patient had been kept waiting, he could have lost oxygen to his brain or his airway could have been compromised," says Ramirez.

The Illinois case underscores the liability risks emergency nurses face every day, she notes. "Right now, every nurse is feeling, 'This could have happened to me,'" Ramirez says. "As emergency nurses, we never know what's going to come in the door."

Sources

For more information on reducing risks at triage, contact:

  • Donna L. Mason, RN, MS, CEN, Nurse Manager, Emergency Services, Vanderbilt University Medical Center, 1314-VUH, 1211 Medical Center Drive, Nashville, TN 37232-7240. Telephone: (615) 343-7223. Fax: (615) 322-1494. E-mail: donna.mason@vanderbilt.edu.
  • Elda Ramirez, MSN, RN, PhD, FNP-C, CEN, Assistant Professor of Nursing, Clinical Department of Acute & Continuing Care, Emergency Care Division, The University of Texas Health Science Center at Houston School of Nursing, 6901 Bertner, Houston, TX 77030. Telephone: (713) 500-2162. Fax: (713) 500-2171. E-mail: elda.g.ramirez@uth.tmc.edu.