ED nurses say care is quicker and safer

Orders at triage standardize care

Standing orders used by emergency nurses not only speeds patient care; it also "adds a measure of safety in that they are standardized," says Gayle Walker-Cillo, RN, MSN/Ed, CEN, an ED clinician at Morristown (NJ) Memorial Hospital.

Morristown Memorial's emergency nurses use standing orders that are complaint-specific, developed by ED physicians. "We took the top patient complaints presenting to our ED and identified the first level of interventions," says Walker-Cillo.

These are: patients over 21 years old with asthma, patients over 21 years old with abdominal pain, chest pain patients over 40 years old, patients with fever over 65 years old, patients with syncope over 40 years old, flank pain, stroke, pediatric diabetic ketoacidosis, children with cyclic vomiting, and children with fever.

For example, if a patient reports to the triage nurse that they are having chest pain, these steps occur:

  • A 12-lead electrocardiogram (EKG) is done at triage to rapidly identify patients who are having an ST-segment elevation myocardial infarction.
  • The EKG is reviewed by the attending physician.
  • While the physician is reviewing the EKG, the nurse independently places an intravenous line and initiates lab work, continuous cardiac monitoring, and oxygen.

"These initial interventions prepare the patient for rapid medication administration and facilitation to the cath lab," says Walker-Cillo. "The process allows the patients to receive complex and comprehensive care, vs. a linear and more time-consuming process. This is imperative when time is muscle."

At Wake Forest University Baptist Medical Center in Winston-Salem, NC, ED nurses use standing orders for extremity X-rays with isolated injuries, and urinalysis and urine pregnancy tests for females with abdominal pain.

"The volume of ED patients continues to rise. Expeditiously moving them through our department is essential," says Michelle Collins, BSN, RN, unit manager of the ED.

Performing diagnostic tests at triage decreases length of stay when no bed is available for a patient with a foot injury or abdominal pain, she says. "Many times once a treatment space is opened for one of these patients, the physician already has the X-ray or initial lab report. This expedites the patient's diagnosis, treatment and disposition," says Collins.

At University of California — Irvine, ED nurses are trained to initiate clinical pathways beginning at triage for chief complaints of chest pain, stroke, abdominal pain, shortness of breath, and vaginal bleeding. "They can also initiate blood work and radiological exams which are protocol-driven," says Sarah Landrum, RN, a clinical nurse II. "These actions not only expedite the care of the patient; they also reduce the length of time in the emergency department."