May 28, 2006, 9:49 pm

Triage: How Much Is Too Much?

firenurses

This ad is for fire sprinklers.

Notice the quick and efficient nurses executing the hospital fire evacuation plan.

I guess they are waiting for the patients to become victims so they can then put their “quick plans” into good use.

The one on the far left looks like she has comes from a “dreaded harsh toilet tissue” ad.

The next one looks like she is eating an ice cream cone.

Hard to do in a fire, don’t you think?

I mean, it melts and all.

Then we have two with so much air in their heads they have risen spontaneously like human helium balloons.

The enthusiastic professional on the right is just counting the minutes until her shift is over.

I thought automatic sprinkler systems were a more recent invention.

Sure would wreck havoc on a nurse’s cap.

******************************

In my department, the designated Charge Nurse is the triage nurse.

This can be tough on hellacious shifts because one cannot be in triage 100% of the time and really know what is going on in the department itself.

This is not as big a problem in my ED because, well, basically everyone is so experienced and self-sufficient there is no need of any major interventions. The Charge Nurse gets involved if there is a patient complaint, a problem with getting a patient upstairs or re-arranging patients if a specific ED room is needed.

I love triage, but don’t like being in charge.

In the huge tribe of health care I am an excellent Indian with no aspirations to the position of Chief.

******************************

There are three theories to how triage should be handled.

  • The Down and Dirty Doorway Destination Decision
    • Pass the triage room and go directly to Park Place, meaning you park your derriere immediately in a place on a gurney.
    • Chest pain, severe dyspnea, CVA symptoms or hemmoraging at the secretary’s desk gets you this designation. Throwing up on the secretary’s desk can, on some occasions, also facilitate your entry into a room.
    • You usually meet 90% of the ED staff within one minute of arrival as they all converge to get you “settled” (an IV, blood draw, EKG, portable chest and monitors all over your body, foley or CPR if you’re unlucky). Then they all disappear.
  • Surf ‘em and Turf ‘em
    • A one sentence chief complaint, multiple hash marks in a few boxes, allergies and half a set of vitals as you visually surf the patient.
    • Then you turf ‘em to the waiting room to wait for registration.
    • NEXT!
  • The Triage Trifecta
    • A complete history of the present illness with focused assessment.
    • Past medical history including surgeries, last period, pregnancy status (yes/no), Gravida/Parida, and immunization status including last DT when appropriate.
    • A full set of vital signs including pain scale, weights on pedi patients and head circumference on infants (don’t get me started on that one)

There is no problem with the first system – emergent patients are emergently treated and that is universal.

So how far should you go when triaging a patient? How much information is too much information? Can you ever have too much information about a patient?

For the record, I’m a “Teresa Trifecta”. Every inch of that triage sheet is filled, checked, slashed, listed and signed. I ask about previous surgeries. I send families home for the medications or the list they forgot if the chief complaint warrants it.

But….I’m confused.

I’ve been told by a colleague that, in her opinion, I’m too thorough. Spit ‘em out faster is her philosophy (a full triage with a patient that speaks English takes me 5 minutes, a child slightly longer).

I’ve had physicians tell me they love my triage notes, that they know what to expect when they go to see the patient.

How can you just “spit ‘em out faster” when some EDs require that tetanus boosters and fever control medications be given at triage? Along with the usual ice, elevation and the occasional pressure dressing or splint? Or the extra time it takes to get rectal temps on small children? Or the writing of 15-20 medications for the elderly?

It’s a catch-22. You are supposed to move faster because there are more people to see, but every year more information is required from each patient at the point of intake.

I say that the more information you collect up front the better. Some will say otherwise and as long as we do the mandated check marking, it gets by quality control.

But 5 years from now, I don’t want to be sitting in a courtroom with a practically blank triage note blown up for a jury with my name on it.

So “Teresa Trifecta” I shall remain.

When you’re dealing with someone’s health, there is no such thing as too much information.

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13 Comments

  • Flea
    Flea

    May 29, 2006 at 3:08 am

    I don’t envy you, Kim,

    It’s a lousy job, ED triage. I so wish we fleas on the outside could help you out be managing the friggin’ patients ourselves!

    best,

    Flea


  • Shannon
    Shannon

    May 29, 2006 at 10:10 am

    In our ED, when you present as a walk-in at external Triage, you are categorized by complaint. When entered into the ED tracking system, you get a triage sheet printed out that asks complaint-specific questions. Chest pains? A million questions specific to chest pain. Chest WALL pain? Entirely different set of questions. The smallest Triage sheet that prints happens to be Rx Refills. Cut and dry. If the patient is a female, there are additional questions that print out for pregnancy, LMP, etc. It’s a nice system. We went through a period where we had an additional med sheet for each patient.

    Some nurses are very thorough. Others will just rattle of questions like robots and send the patients out to the waiting room. I personally think thorough is better. You can paint a clearer picture for the staff inside if you complete a full triage. I think it saves time inside, too. Once you know all the complaints a patient is presenting with, you can avoid surprises later. “I’m having arm pain” will generate a triage sheet for an extremity complaint… but a thorough triage on let’s say, a 55 yr old overweight male with a family history of heart disease, might reveal that he has also had chest pains in the last 24 hours… and that constitutes a whole slew of blood work and a different priority level.

    In my opinion, you can’t really ask TOO much. But, you can ask too LITTLE.


  • Krista
    Krista

    May 29, 2006 at 4:21 pm

    I subscribe to the Triage Trifecta myself. Partly because I too fear the blown-up blank triage note in a courtroom, and also because I respect my colleagues too much to send a “surprise” to the back. And also because I am an anal-retentive perfectionist.

    But mostly–because five minutes is not too long when you have to determine if a person needs treatment immediately, can wait 15 minutes, or can wait 2 hours. It’s a big decision that we are forced to make on the fly.

    Side note–it kinda bugs me when other nurses tell me to chart less/chart differently. Seeing as how it’s my license, I’ll chart how I see fit–which is usually nice and thorough to cover my ass!


  • Mel
    Mel

    May 29, 2006 at 6:25 pm

    I’m a triage trifecta advocate because my husband wouldn’t be alive today if the triage nurse hadn’t been one when he had an e. coli infection. He waited less than 10 minutes to get to a room. I was still giving the admitting folks our insurance information when they took him back. If she’d turfed him to a waiting room because most of his symptoms were the same as a g.i. virus that was going around and our whole family had had that week, he’d have been sent home after an IV for fluids and told to go to his GP on Monday. I don’t think he’d have lived that long – as it was he was months before he fully recovered after a nearly week long stay.


  • difficult patient
    difficult patient

    May 30, 2006 at 7:17 am

    Kim–I don’t envy you, but I’m glad you are thorough!


  • Erica
    Erica

    May 30, 2006 at 7:24 am

    I’ll throw my cap into the Triage Trifecta ring… my reasoning is that if I can ask just a few more questions and thereby have a pretty good idea of what’s going on with the patient, I can medicate and order labs/rads appropriately – thus expediting their care and shortening their visit (theoretically, anyhow). Our ED has plenty of protocols/standing orders and physicians who trust us nurses explicitly to get the ball rolling in the right direction – so it often works out that the workup is complete before the doc comes into the picture. And I pride myself on being that kind of nurse. Sure, we have RNs who do the surf & turf… and they usually end up turfing stuff like that subarachnoid or ectopic because they were in too much of a hurry.
    (And oh my god, kudos to you for being both Triage Goddess and Charge – I cannot imagine. We see around 300 patients a day in our department, and at times our *three* triage nurses can’t keep up; as a Charge Nurse I can’t imagine personally doing triage on top of running the department!)


  • Margaret
    Margaret

    May 30, 2006 at 8:37 am

    I think you’re doing the right thing. Note that the physicians love your notes (because it makes their work easier?), and it’s a nurse who tells you to hurry up and spit them out. If everybody would do a thourough job, triage would routinely take longer and the message send to the hospital is that triage takes 5-15 minutes and they better adjust their staffing levels. End of Story.

    People who accomodate the faster triage are partially responsible for the hospitals getting away with lower staffing rates. Nurse, care for thyself.


  • Rita Schwab
    Rita Schwab

    May 30, 2006 at 9:27 am

    About that head circumference thing, I think I’ll suggest to my friends at JCAHO that head circumference should be measured on all patients – not just kids.

    Think of the benefit – when someone accuses us of being “fat headed” we could give them exact numbers.

    Besides, you don’t have anything else to do… :)


  • Medic5
    Medic5

    May 30, 2006 at 9:45 am

    Keep up that Triage Trifecta – better that than the triage nurse who told the patient complaining of “back pain” to go wait in the waiting room…without noticing as he turned the very large knife sticking out of his back. After my partner and I stopped him and did an anterior standing backboard take-down, the triage nurse marched up to the patient and said “Next time, TELL me you have a knife in your back…” (I kid you not).


  • Nancy B.
    Nancy B.

    May 30, 2006 at 11:53 am

    My late husband was on so many meds in his last few years that I put them on a computer spread sheet with dosages, time of day taken and name of prescribing doctor. This was printed out and taken on office visits and to emergency rooms (many times). This plus a printed list of the operations he had, with dates, was handed in along with the informational form we were requested to fill out. It saved a lot of writing and remembering at stressful times.


  • Annemiek
    Annemiek

    May 30, 2006 at 1:22 pm

    As a med surg nurse I like it when I get a full report on patients before they come to the floor. How many times I get “only a history of (1 blank), and when you do your focus assesment you find out an extensive medical history. Keep being thoughough!


  • Gimpy Mumpy
    Gimpy Mumpy

    May 30, 2006 at 3:32 pm

    I am glad that there are still some thorough nurses out there!
    Speaking as a chronic disabled patient though I do feel that at least SOME responsibility lies with the patient (and patient’s family) and so keep organized medical records in binders (just in case) and always go to the hospital/clinic with a typed CURRENT list of medications (with doses, etc). I feel like this is being a responsible patient, however after some of the reactions my hospital and clinic staff I have to ask, “Is this what nursing staff want? Need?”
    I have been treated as though I were a hypochondriac by some and flat out crazy by others. Perhaps I’m a little too organized? ;)


  • Healthcare Today
    Healthcare Today

    September 2, 2009 at 6:47 pm

    Triage: How Much Is Too Much? // Emergiblog…

    Yes I agree after 21 plus years in many EDs doing Triage and in various leadership roles CNS, NM and Director .. if you want to do the best for each patient .. efficient but complete assessment and documentation is necessary and the standard. If you a…


About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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