getting rid of the triage nurse

[MSmentor018]

with having physician in triage (PIT) docs/pa, there's really no need for the triage RN to "sort" pts. the concept was back in the day (military) when we needed to figure out who needed resources now vs later. the only thing we're triaging these days is the clock. has anyone with a PIT doc gotten rid of the triage RN/system?

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[BAM!]

you need someone up there taking vital signs, checking them into your computer system, and rooming patients. I suppose this could be an MA of some sorts, but this usually is an RN.

 

[GonnaBeADoc2222]

Also, hasn't the concept of a PIT been shown to not improve any metric aside from "click time" (i.e. door to provider time; which is artificially shortened here) and ends up frustrating the provider on the back end (from ordering things like dimers and troponins)?

 

[RustedFox]

Even better yet; I know of a case where the PIT doc (not a MLP) triages an ancient guy with tracheal stenosis and a widget problem (whatever it was, his widget was broken) 20 mins prior to the end of his shift. Guy is stable as a rock. PIT doc goes home after his shift. Patient crashes and burns 4+ hours later.

Yep. PIT doc sued for failure to predict the future.

 

[Druggernaut]

When there's a lot of open beds, we've gone to direct rooming of patients. Still a triage nurse to do all the mandatory nursing click boxes at check in when it's busy and we have an NP in triage.

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[gro2001]

Triage is about matching needs (patients) with resources (docs, RNs, rooms, etc) through procedures and experience. You want to have the job of keeping track of which RN has what patient load, when they are going on break, what rooms have been turned over, etc etc etc in addition to the medical decision making? I'll pass.

 

[GonnaBeADoc2222]

When there's a lot of open beds, we've gone to direct rooming of patients. Still a triage nurse to do all the mandatory nursing click boxes at check in when it's busy and we have an NP in triage.

We have also gone to this model recently in an effort to decompress our waiting room and reduce throughput times. While a lot of residents B&M about this, I think it's good to get the patients back as soon as possible and at least lay eyes on them as the attendings are just as responsible for the MI in the waiting room as they are for the one in the resuscitation bay.

 

[deleted547339]

We have also gone to this model recently in an effort to decompress our waiting room and reduce throughput times. While a lot of residents B&M about this, I think it's good to get the patients back as soon as possible and at least lay eyes on them as the attendings are just as responsible for the MI in the waiting room as they are for the one in the resuscitation bay.

Residents hate it because it is damaging to resident education.

 

[Janders]

Direct rooming is the best way to run an ED if it is all possible.

I do NOT think it has to be damaging to resident education. A good resident sees a new patient being brought back, and hops up and goes to that room and does the initial eval alongside the RN/tech as they triage. If the attending comes, they can stand in the back and add anything they want at the end. Very efficient and in no way harmful to the resident.

Now if the attending staff is constantly getting in to the patients prior to the residents... heh.

 

[deleted547339]

Direct rooming is the best way to run an ED if it is all possible.

I do NOT think it has to be damaging to resident education. A good resident sees a new patient being brought back, and hops up and goes to that room and does the initial eval alongside the RN/tech as they triage. If the attending comes, they can stand in the back and add anything they want at the end. Very efficient and in no way harmful to the resident.

Now if the attending staff is constantly getting in to the patients prior to the residents... heh.

That's not what I'm talking about.

When there are long wait times and a physician in triage orders labs +/- X-rays and they are back before they are put in a room, that kills the residents ability to think through the presenting complaint.

 

[engineeredout]

Direct rooming is the best way to run an ED if it is all possible.

I do NOT think it has to be damaging to resident education. A good resident sees a new patient being brought back, and hops up and goes to that room and does the initial eval alongside the RN/tech as they triage. If the attending comes, they can stand in the back and add anything they want at the end. Very efficient and in no way harmful to the resident.

Now if the attending staff is constantly getting in to the patients prior to the residents... heh.

Problem is that if I don't dive into the room immediately after the patient is placed there, the nursing evaluation begins. And no it isn't just "Hey why are you here" and VS, it's Ebola screening, suicide screening, abuse screening, vaccination status, when is the last time you took your bentyl, what does your mother in law do for a living, brand of food your dog eats etc... Try to interrupt that and you end up with a pair of trauma shears in your chest. 30 minutes later I might actually get the opportunity to evaluate the patient

 

[Janders]

That's not what I'm talking about.

When there are long wait times and a physician in triage orders labs +/- X-rays and they are back before they are put in a room, that kills the residents ability to think through the presenting complaint.

Ah. Where I've worked (and am working) if there is a long wait time in triage the triage RN puts in Xrays and labs (via physician-driven ordersets).
Still requires same thought on the back side, just already have your chest xray and BMP back

That said, if there is a doc out front ordering all the CT scans before a resident gets there, I get your issue. I would say a resident should be out there sometimes TOO, otherwise they are missing out.

 

[deleted547339]

Problem is that if I don't dive into the room immediately after the patient is placed there, the nursing evaluation begins. And no it isn't just "Hey why are you here" and VS, it's Ebola screening, suicide screening, abuse screening, vaccination status, when is the last time you took your bentyl, what does your mother in law do for a living, brand of food your dog eats etc... Try to interrupt that and you end up with a pair of trauma shears in your chest. 30 minutes later I might actually get the opportunity to evaluate the patient

"Sir, I understand you're having chest pain, but what I asked you is if you feel safe at home.......sir?......SIR!!"

 

[alpinism]

Problem is that if I don't dive into the room immediately after the patient is placed there, the nursing evaluation begins. And no it isn't just "Hey why are you here" and VS, it's Ebola screening, suicide screening, abuse screening, vaccination status, when is the last time you took your bentyl, what does your mother in law do for a living, brand of food your dog eats etc... Try to interrupt that and you end up with a pair of trauma shears in your chest. 30 minutes later I might actually get the opportunity to evaluate the patient

This.

Not only that but you have to drop everything you're doing (putting in orders, dictating a chart, etc) to run into the room with the nurse. Plus you don't have any time to look up the patient beforehand (previous admissions, clinic notes, etc) so you end up wasting time asking questions that could have easily been answered with a quick EMR review.

Its horribly inefficient and disruptive to workflow.

 

[TrumpetDoc]

This.

Not only that but you have to drop everything you're doing (putting in orders, dictating a chart, etc) to run into the room with the nurse. Plus you don't have any time to look up the patient beforehand (previous admissions, clinic notes, etc) so you end up wasting time asking questions that could have easily been answered with a quick EMR review.

Its horribly inefficient and disruptive to workflow.

I've worked in a couple places with rapid/direct rooming and triage in the room and I find this to be true for me.

 

[Arcan57]

This.

Not only that but you have to drop everything you're doing (putting in orders, dictating a chart, etc) to run into the room with the nurse. Plus you don't have any time to look up the patient beforehand (previous admissions, clinic notes, etc) so you end up wasting time asking questions that could have easily been answered with a quick EMR review.

Its horribly inefficient and disruptive to workflow.

Just going to toss out that if you find direct bedding horrible for workflow then you're doing it wrong. Only legit grievances are 1) you get there on a not sick patient and there aren't vitals or 2) patient hasn't been put in computer so you can't immediately enter orders. Making sure everyone gets vitals and is put into the computer at triage fixes both of those things.

My workflow goes something like this:
1) Pt brought back to room
2) I check EMR to see if there are any pertinent red flags/old EKGs/PMHx/etc.
3) While I'm doing that nurse is hooking patient up to the monitor and opens up his/her triage screen.
4) I walk in.
5) Nurse introduces me to the patient
6) I introduce myself to the patient.
7) I turn to the nurse and ask what they've learned so far.
8) Do my H&P while the nurse cribs off of my questions.
9) Leave, nurse finishes asking all the non-pertinent triage stuff.

 

[Janders]

Just going to toss out that if you find direct bedding horrible for workflow then you're doing it wrong. Only legit grievances are 1) you get there on a not sick patient and there aren't vitals or 2) patient hasn't been put in computer so you can't immediately enter orders. Making sure everyone gets vitals and is put into the computer at triage fixes both of those things.

My workflow goes something like this:
1) Pt brought back to room
2) I check EMR to see if there are any pertinent red flags/old EKGs/PMHx/etc.
3) While I'm doing that nurse is hooking patient up to the monitor and opens up his/her triage screen.
4) I walk in.
5) Nurse introduces me to the patient
6) I introduce myself to the patient.
7) I turn to the nurse and ask what they've learned so far.
8) Do my H&P while the nurse cribs off of my questions.
9) Leave, nurse finishes asking all the non-pertinent triage stuff.

Ditto here. I like direct placement without triage. I LOVE what it does for flow and throughput. I like going in with the RNs. I don't find that it disrupts me any more than I'm already disrupted.

If it is NOT busy, I'll sit and let the RN do their thing with the ridiculous questions and chart and smile at the patient, then add my questions.
If it is busy, I do like Arcan and get my questions in first (which the RN needs know as well), then walk off while they get the rest of theirs done.
If I come in late to the party, 90% of the time the RN will stop their parade of question and defer to me (they are too nice).

 

[TrumpetDoc]

The two EDs I have been to did not have a good process going.
They would room patients and vitals would not be on the chart until well after. I would have to check some myself if I thought they were sick. Interestingly both of these hospitals were run by the same company and RNs at both would not do it bc "that's the tech's job".

I was also freelancing at those places so I think that will make a difference.