Provider in triage

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watermanMD

watermanMD

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**** that ****. What is your take on this?
1) I don’t think it needs to be a doc
2) Increased liability? Court: “Doc why didn’t you bring back that benign syncope young person who left and died?”
3) I imagine this to be mostly for the higher-up’s/bean counters, not us or patients (decreases LWBS = more $)
I didn’t go to medical school to do this BS. Feel more like a cog in the wheel than ever.
 
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Yeah, it was an idea...
It even seemed like a good idea at first.

Narrator: "IT WAS NOT A GOOD IDEA."
 
Many physicians dislike as they can be demanding shifts and antithetical to direct/ideal patient care in rooms, although some love. Can be highly lucrative. Systems like as can start patient care process sooner and reduce LWBS. NPPs perform worse with over-testing. Liability probably overstated.
 
I've seen it deployed and it was incredibly effective at throughout.

But it involves two things;

1) spending money. It's doc coverage.

2) as mentioned, liability.

If you can surmount those two things it appears to be completely worth it
 
I have worked in systems that have it.

Let’s be clear this is often the result of a broken system and a cheap solution for the hospitals.

What is the benefit over simply doing triage orders? I would venture to guess that triage orders plus the nurse talking to a doc on 5% of patients is equally efficient and cheaper. Most patients are not diagnostic mysteries.
 
These types of shifts are put in place to cook the numbers for admin. First contact, door to doc times, reduce LWBS, etc.. It's always in the guise of "best for the patient" but it's essentially best for the hospital admin bonuses which often rely on these metrics.

I don't think liability is really an issue because it's essentially one big screening exam for the pts you aren't picking up, you just have to document it as such.

We employed this method at one of my old gigs. It wasn't a forced shift and about half of us volunteered for them and half requested not to work them. They were extremely busy shifts and stressful in their own way but you didn't have alpha traumas or coding patients, etc.. They were very lucrative on our RVU productivity model and were some of the highest paying shifts which was the dirty secret among those of us choosing to work them. We had 3-4 rooms we could stick people for labs or I&D, etc.. Everyone else you just placed screening orders, fine tuned ESI and then they would dump into the main ED at the appropriate time.

I haven't worked anywhere else that was able to effectively strong-arm docs into doing these types of shifts because they are often very unpopular. That being said, they no doubt drastically improve ED flow as long as you have adequate nursing and ancillary staff to carry out your triage orders. I'm not productivity anymore but to be honest...I often will function similarly if we have no rooms. I dump in WR orders if there's a clear triage note and/or go out to the WR and treat/street people. I think I'm one of the only ones in the group that does this type of thing but it's also why my metrics are the best so there's a little selfishness in the process but hey...it definitely improves flow and decompresses a busy WR. Once I finish my notes and am wrapping up my shifts, I often will snipe 2-3 WR patients on my way out to cook my LOS and PPH, decompress, etc.
 
Depends on if you have a provider in triage or a team. If you stick a doc out there alone, you get amazing door to doc and turn all your LWBSs into elopements. The rest of the metrics look the same. If you put a doc in triage and give them 2-3 nurses to run orders then your length of stay and door to admit decision plummet. Biggest gains in systems were the ED is constantly full and door to room times are super long. Unfortunately, those are the same systems were it's extremely unlikely to get the resources needed to do full workups in triage.
 
I worked in a system that did this, and I always hated these shifts, but it wasn't a place with RVU-based pay. Speaking of cooking the books, one of the things they wanted us to do was eavesdrop while the triage nurse got the basic info from the patient, then do an "exam" (listen to heart/lungs, eyeball the area of chief complaint, etc., all with patient fully clothed, of course) and write a note consisting of a couple of lines. "Seen" by physician? Check. (Obviously they did see someone for real later on, but this made the door-to-doc time look pretty.) I also hated being in a place where the whole waiting room could see me, because according to the general population, if you're doing stuff on a computer, you're not working, since they only ever use a computer for social media...
 
Never worked anywhere where it was officially done. I'll see people in triage if we're slow and its the ESI 4-5, "here's your Z-Pak and work note", or the "You've been here 59 times in the past year and you're not getting narcs and/or benzos" MSE and GTFO.

We'd do it during residency due to the god-awful boarding situation and COVID, because it was the only way we could effectively see patients

Seems to be a way to buff the numbers and decrease LWBS
 
CajunMedic said:
Never worked anywhere where it was officially done. I'll see people in triage if we're slow and its the ESI 4-5, "here's your Z-Pak and work note", or the "You've been here 59 times in the past year and you're not getting narcs and/or benzos" MSE and GTFO.

We'd do it during residency due to the god-awful boarding situation and COVID, because it was the only way we could effectively see patients

Seems to be a way to buff the numbers and decrease LWBS
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We do it because we have critically ill people that sit in triage for hours and hours and hours.

Hospital / system doesn't care. They don't track metrics. Our private medical group made the decision. We don't want sick people getting worse in our high acuity ED because hospital can't manage patient flow.
 
You have to have a team, it doesn't do any good for a doc to put in orders that don't get done for 4 hours because you don't have a tech/phleb/RN etc. If you have a good functioning team, it works well.
 
This was so 10 years ago. You know the Arrival to provider time. That metric that was supposed to be the end all.

Our private group said, pay us. Having an extra doc in the front does not improve our group's income. That didn't go anywhere and they ended up having an APC.

If the hospital want to have substantial improvement of flow, they need to have a dedicated staff and open Quick care areas. Put an APP there and they can do all the xrays/swabs/discharge they want. I worked in the QC areas sometimes and I could see 40-50 pts in 8 hrs.

But they will not find the space or the staff which essentially means they really do not care about flow.
 
At one system I was in they made docs do this shift because the midlevels essentially had no clue what they were doing. I refused to do those shifts because they were very stressful and morphed into a role where you were expected to manage the waiting room including all the nursing "this patient wants to leave" blah blah blah.

Current system works much better. We have a midlevel in triage and they mostly get it right. By the time the patient comes back to us labs are usually done. When there is no one to triage the midlevel will come into the department and see patients.
 
WhatJobDoIPick said:
At one system I was in they made docs do this shift because the midlevels essentially had no clue what they were doing. I refused to do those shifts because they were very stressful and morphed into a role where you were expected to manage the waiting room including all the nursing "this patient wants to leave" blah blah blah.

Current system works much better. We have a midlevel in triage and they mostly get it right. By the time the patient comes back to us labs are usually done. When there is no one to triage the midlevel will come into the department and see patients.
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Again this isnt much better than triage order sets. Your feelings on this IMO depend a lot on who is paying for the PIT and whether or not you have to work there
 
A better idea when beds are a limited resource is using queing theory. Docs see people in some staging area. Everyone gets seen and workups/treatments get started up front based on whoever is actually taking care of them (as opposed to some random PIT midlevel). Only patients that truly need a bed/monitor go back to a bed. Patients that don't, don't.

The traditional PIT with some PA in triage trying to guess the orders of the docs in the back just doesn't work.

I mean ideally none of this would be necessary and admits wouldn't be holding up EDs around the country.
 
If you want a provider in Triage and make it actually work, then said provider should be allowed to do what is clinically appropriate without fear retribution/lawsuits.

If I was a provider in triage, I should be able to tell 80% of those showing up that they can go to UC or see their PCP tomorrow. If admin really wants to improve ER care and flow, then triage should do what the name says.

But Admin just care about money and making the numbers look good without spending any additional money on space/staff b/c the ER is a money drain. If the ER was a profit leader, they would be building huge ERs and staffing it for max flow.
 
WhatJobDoIPick said:
Agree, but this isn't the world we live in.

If we lived in that world we would also probably MSE 80% of patients at the door and kick them out.

I like making money though.
Click to expand...

When the staffing crunch happened after covid that burned me out super bad our department was bursting at the seams.

There was talk about doing MSEs to help decompress and I was legit excited to finally do it, lawsuit bait be damned. It would have been my only time I could have ever said, you're fine, go away

Came thiiiiiis close to happening but sadly they chose to backlog it further, which ironically also spiked lawsuits from avoidable lobby deaths
 
WhatJobDoIPick said:
Agree, but this isn't the world we live in.

If we lived in that world we would also probably MSE 80% of patients at the door and kick them out.

I like making money though.
Click to expand...
Meeting stupid hospital metrics isnt the same as making money for docs.

Ill take the MSE patients.. real easy.. ill do 40 ankle sprains a shift.. low risk, simple, level 4 chart. I could do 80 of these a shift easy..
 
xaelia said:
Ahh, the ol' greet and toss. No problemo!
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Yup. My best door to D/C recently has been 6 minutes. I had been on shift only a couple of hours and had a parade of school-aged children with the crud come in. "Lemme guess, coughing up yellow stuff, sinuses hurt, body aches, fever, and same thing as everyone else in your class?". Here's your Z-Pak, Prednisone, Inhaler, school note, and 20 cc of GTFO.

Or what I had at 530 this morning: Chronic sciatica. "Whelp, I saw you last month for the same thing. Told you then, no narcotics, I wrote it in your chart. Here's your IM Solu-Medrol, Robaxin, Lidocaine Patch, meloxicam for after, keep your PCP appointment and find a pain management doc. Buh-bye"
 
Do any of you use a dot phrase for medicolegal/ CYA stuff you could share?

(“Given the current constraints in the emergency department, I have conducted a focused triage assessment to identify obvious immediate life-threatening conditions. This initial evaluation does not replace a comprehensive medical examination. Yadaw yada i adviced patient to await assigned room, yada yada”)??
 
watermanMD said:
Do any of you use a dot phrase for medicolegal/ CYA stuff you could share?

(“Given the current constraints in the emergency department, I have conducted a focused triage assessment to identify obvious immediate life-threatening conditions. This initial evaluation does not replace a comprehensive medical examination. Yadaw yada i adviced patient to await assigned room, yada yada”)??
Click to expand...
I don’t have a canned one, and I think in some circumstances they can cause more harm than good.

I do frequently note when I see a patient in the WR within the chart (due to hospital crowding and current code disaster status, I did perform an initial history and brief exam in the waiting room to expedite care), especially when the patient clearly requires admission / the waiting room labs come back horrible etc. frankly most patients love it if I go see them in the WR… probably mitigates risk in and of itself.

Also if patients have WR care and labs and then elope / lwbs I do tend to put a one liner in the chart, and I frequent call their contact number if there is anything concerning.
 
Janders said:
I don’t have a canned one, and I think in some circumstances they can cause more harm than good.

I do frequently note when I see a patient in the WR within the chart (due to hospital crowding and current code disaster status, I did perform an initial history and brief exam in the waiting room to expedite care), especially when the patient clearly requires admission / the waiting room labs come back horrible etc. frankly most patients love it if I go see them in the WR… probably mitigates risk in and of itself.

Also if patients have WR care and labs and then elope / lwbs I do tend to put a one liner in the chart, and I frequent call their contact number if there is anything concerning.
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Curious when it might cause more harm than good?
 
Janders said:
I’ve had some malpractice experts warn against canned text that basically states you’re provided lower than standard care (regardless of reason)
Janders said:
I don’t have a canned one, and I think in some circumstances they can cause more harm than good.

I do frequently note when I see a patient in the WR within the chart (due to hospital crowding and current code disaster status, I did perform an initial history and brief exam in the waiting room to expedite care), especially when the patient clearly requires admission / the waiting room labs come back horrible etc. frankly most patients love it if I go see them in the WR… probably mitigates risk in and of itself.

Also if patients have WR care and labs and then elope / lwbs I do tend to put a one liner in the chart, and I frequent call their contact number if there is anything concerning.
Click to expand...
I see 100+ per shift in PIT—I can’t follow up on all of this ****. Big obvious things, sure, but I don’t go checking on everyone to see if lab work showed subtle anion gap acidosis, etc.
Click to expand...
 
watermanMD said:
Do any of you use a dot phrase for medicolegal/ CYA stuff you could share?

(“Given the current constraints in the emergency department, I have conducted a focused triage assessment to identify obvious immediate life-threatening conditions. This initial evaluation does not replace a comprehensive medical examination. Yadaw yada i adviced patient to await assigned room, yada yada”)??
Click to expand...
devils advocate: when they code on the WR they're going to say: you saw the patient, why/how didn't you recognize how sick they were and find them a spot to receive care?

Recent lawsuit addresses this issue: Beloved mother of 2 suffers excruciating death in emergency room lobby, lawsuit says
 
TooMuchResearch said:
Because union nurses don't take hallway beds?
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And they call out "sick" on the busiest days with no repercussions.

In todays climate, there's pretty much nothing you can do to protect yourself from a lawsuit, if you have bad luck with a patient in the WR. It won't be your fault but you'll still be named.

Students: don't go into EM.
 
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Emapp20177 said:
And they call out "sick" on the busiest days with no repercussions.

In todays climate, there's pretty much nothing you do can protect you from a lawsuit if you have bad luck with a patient in the WR. It won't be your fault but you'll still be named.

Students: don't go into EM.
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Don't forget holidays and nice weather days.
 
watermanMD said:
Do any of you use a dot phrase for medicolegal/ CYA stuff you could share?

(“Given the current constraints in the emergency department, I have conducted a focused triage assessment to identify obvious immediate life-threatening conditions. This initial evaluation does not replace a comprehensive medical examination. Yadaw yada i adviced patient to await assigned room, yada yada”)??
Click to expand...

I don't think a prosecuting mal practice attorney would give 2 chitts about that phrase above.
 
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