Standing orders in triage

[chimichanga]

Can any PAs, NPs and docs help me understand why an ER medicine group of physicians (in a 120 pts/day ER) won't allow even for the SIMPLEST of triage protocols to be initiated (not even a throat swab) when, oftentimes, the ER has an average triage/lobby wait time of 3-4 hours...

Their response is "we don't want nursing ordering labs"

Physicians write these protocols...

Train the triage nurses (5 tier ESI triage system seems best so far)

CBC, CMP, amy, lip, UA, for belly pain
CT head for worst HA of life
CXR for cough
RSS and CX for sore throat

what am I missing?

thanks

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[50960]

Sit in on medical staff meetings and you will see why. It usually is hospital politics and cost reduction, and not about better patient care.

 

[chimichanga]

I would agree with that statement...

However,

Standing triage orders seem to be the industry standard for ERs...

This is a one hospital city, and has always been...

The ER docs make their own policy, as that is how the board has operated, historically...

However, These simple tests are ordered anyway...that's inarguable...So the cost argument seems moot here...If the triage nurses get order happy, retrain them...

A 77y/o female who's been vomiting x 4 days will get a bmp...I can guarantee it...Why have her wait 3 hours, then get her to a bed, THEN get labs, that will inevitably take another hour...that's poor care...

but this is how they would have it stay...

 

[50960]

I totally agree, and feel it would make alot more sense clinically. However, hospital administration puts ALOT of pressure on medical staffs in areas of writing protocol because it saves them $.

 

[deleted6669]

Can any PAs, NPs and docs help me understand why an ER medicine group of physicians (in a 120 pts/day ER) won't allow even for the SIMPLEST of triage protocols to be initiated (not even a throat swab) when, oftentimes, the ER has an average triage/lobby wait time of 3-4 hours...

Their response is "we don't want nursing ordering labs"

Physicians write these protocols...

Train the triage nurses (5 tier ESI triage system seems best so far)

CBC, CMP, amy, lip, UA, for belly pain
CT head for worst HA of life
CXR for cough
RSS and CX for sore throat

what am I missing?

thanks

my er sees about 2x as many pts/day as the one you describe.
we have a nurse menu that allows for basic labs/tx as follows:
strep for sore throat
ua for females with uti sx(men need std eval before ua)
start iv,cbc/cmp/lipase, ua,ucg in fe, for abd pain
extremity films for trauma
tylenol/ibu for fever in kids without belly pain.
not every cough needs a cxr. many just have colds or bronchitis which are clinical dx.
not every h/a needs a ct. several "worst h/a's" on further hx are really not as bad as they sound out front. when they say worst h/a of life and then say pain almost as bad as an ankle sprain and they are seen for h/a's 3x/week in the er they don't need a ct. we have many pts who give that hx just to get traiged 1st as they hope to get their narc shot faster.
granted if they have no hx of h/a's and present with an abrupt onset new h/a they will get the ct.
the nurses at triage will often call us and give a quick summary and ask for orders(much like a paramedic) and often these orders will go beyond the regular nursing protocol.
I agree with you. a busy er needs some basic nursing menu options.

 

[chimichanga]

agreed, not every cough needs a CXR, just a basic example...

and yes, anything outside of the protocol, we'd call (CT, percocet) to get a verbal...

I must still ask, why would they not sign on for this?

it's a patient satisfier, it speeds up the flow, and truthfully, it helps the triage process..

If a WBC came back 28,000 for the belly pain, but the pt looks good, he buys a bed before the asthmatic whose sats are 94%, and ran out of his inhaler, who both came in at the same time (besides, in a real hospital, I would give the neb in triage, but not here)

I think it's a pt safety issue...And the $$ mean nothing to front line staff, trying to juggle 20 patients (one RN, and one tech), who are all an ESI III...

And I restate it, 98% of these tests WILL be ordered in the back...

I get what you are saying EM, but in an ER full of just out of residency docs, and with things not being what they were like 15 years ago, they generally order everything on everybody...you may be the exception...Even our fast track turns into a zebra hunt...

 

[deleted6669]

"I get what you are saying EM, but in an ER full of just out of residency docs, and with things not being what they were like 15 years ago, they generally order everything on everybody...you may be the exception...Even our fast track turns into a zebra hunt..."

sounds like a different type of em group. our avg doc or PA is probably 45-50 years old. we have a few newer docs but not many and no new grad pa's.
we have R.T. nazis at my place so no one except an R.T. can give a neb tx, it's ridiculous. the providers actually have a stash of mdi's and spacers to start pt therapy while waiting for RT to return their pages and show up....
don't know why you don't have an rn menu. do you have lots of new/inexperienced nurses? have there been "bad outcomes" when a nurse gave a treatment or ordered the wrong test? I don't get it either.

 

[chimichanga]

They tell me it's never been allowed...

This has been the only hospital in town (40,000 population) ever...The ER used to be manned by the rotating FP docs in town...Then this physician group came in the early 80s...

There is one nursing college in town, and for RNs, the only other jobs are at the nursing homes...

A lot of these nurses don't know any better than to question this lunacy...

The average doc age is probably 38 years old...the new guys would be fine w/ a triage menu...Not the core group (partners)...

And the chief of the hospital board also runs and owns the ONLY hospitalist group (75% of admissions go to them)

do the math (not trying to doc bash, this just kills me though, as I know how hospitals in bigger cities are run; and even the small, community hospitals and URGENT CARES in Phoenix had triage protocols for extended wait times)

This is the ol' boy network...They will not budge on this (no) triage protocol...

They don't even use Cerebyx, because "it's cost prohibitive"

they're still managing status w/ IV dilantin (ever see this stuff infiltrated?) and q 30 minute Ativan...It's archaic...And ignorance and apathy are the norm from the other clinical staff...

 

[fab4fan]

"I get what you are saying EM, but in an ER full of just out of residency docs, and with things not being what they were like 15 years ago, they generally order everything on everybody...you may be the exception...Even our fast track turns into a zebra hunt..."

sounds like a different type of em group. our avg doc or PA is probably 45-50 years old. we have a few newer docs but not many and no new grad pa's.
we have R.T. nazis at my place so no one except an R.T. can give a neb tx, it's ridiculous. the providers actually have a stash of mdi's and spacers to start pt therapy while waiting for RT to return their pages and show up....
don't know why you don't have an rn menu. do you have lots of new/inexperienced nurses? have there been "bad outcomes" when a nurse gave a treatment or ordered the wrong test? I don't get it either.

That bugs me to no end. We used to be able to give nebs to pts. Now we have to wait for RT. Of course, we're expected to "play fetch" for RT and get them the meds, saline, etc.

The ED I worked in went through a major change. It used to be a core group of docs, and they expected (and trusted) us to get appropriate tests/tx started. Now we have about 15 docs, almost all part-timers, and trying to remember who wants you to do what is maddening.

 

[polygonal]

I have mixed feelings about the whole triage order thing. When I worked as an RN I was all for it. I am less so now. The problem is that the execution seems to result in a lot of unnecessary testing and sometimes worse (in my experience). As bad as some want us to believe, medicine does not follow an algorithm.

I've worked at small places and big places and I think the best system I've seen is when the RNs developed a relationship with the physicians and had a sort of unspoken agreement that they would order whatever tests they thought were appropriate during the nursing assessment. A good nurse can use judgment and order tests pretty effectively. Having said that, as much of a supporter of good nursing that I am, I don't think it's ever really appropriate for a nurse to order a CT scan on their own. A CT is expensive and exposes the pt to lots of radiation; not a triage decision.

There are many angles to this subject. Having seen both sides of this argument, I would be in favor of some very limited triage orders (UA for female with UTI symptoms).

As for your examples:
CT head for worst HA of life - Explained above, totally inappropriate
CXR for cough - $$ and exposure to rads for something that is not standard care
RSS and CX for sore throat - Hmm... Let me give you an example here. Kid comes in with a "sore throat." Turns out he has epiglottitis and you probe his throat. Bad news. Unlikely? Just saw a case today.

 

[fab4fan]

I have mixed feelings about the whole triage order thing. When I worked as an RN I was all for it. I am less so now. The problem is that the execution seems to result in a lot of unnecessary testing and sometimes worse (in my experience). As bad as some want us to believe, medicine does not follow an algorithm.

I've worked at small places and big places and I think the best system I've seen is when the RNs developed a relationship with the physicians and had a sort of unspoken agreement that they would order whatever tests they thought were appropriate during the nursing assessment. A good nurse can use judgment and order tests pretty effectively. Having said that, as much of a supporter of good nursing that I am, I don't think it's ever really appropriate for a nurse to order a CT scan on their own. A CT is expensive and exposes the pt to lots of radiation; not a triage decision.

There are many angles to this subject. Having seen both sides of this argument, I would be in favor of some very limited triage orders (UA for female with UTI symptoms).

As for your examples:
CT head for worst HA of life - Explained above, totally inappropriate
CXR for cough - $$ and exposure to rads for something that is not standard care
RSS and CX for sore throat - Hmm... Let me give you an example here. Kid comes in with a "sore throat." Turns out he has epiglottitis and you probe his throat. Bad news. Unlikely? Just saw a case today.

That's the system I was accustomed to. We knew our docs, they knew us. None of us would have ever ordered a CT, BTW. Ortho injuries, yes, we would order XR, but then again, we knew what our docs wanted. Most of them didn't even want to see the pt. until there were films. Never ordered a CXR for just a cough, but you'd better believe I have for CP or asthmatics/CHF/COPD pts. Throat cultures...for older kids or adults, sometimes...little kid, nope. Almost always medicated febrile kids with Tyelnol or ibuprofen right away.

Things have gotten a lot more complicated now that the docs have changed. There are two (I believe) that are still there, so when I work with them I know I don't have to ask about getting the basics. With the others, I'm still trying to figure out their preferences.

 

[chimichanga]

interesting points...

maybe phoenix ERs (I've worked several) have it all wrong...

I'd say (in my last 5 years in the ER):

"worst HA of my life" gets a CT 95% of the time (at an UC where I worked, if we heard this in triage, we were taught to get the provider to come talk to the patient, who was 100% of the time sent to the ER for a CT)
cough gets a CXR 75% of the time...add a fever, 99%

guys, maybe I am just spoiled...

My last ER job was at the world renowned St Joes, in Phx...

They loved triage protocols...(agree w/ the CT, as we needed a physician order...no prob w/ that...That being said, they ALWAYS gave the order)

Over the last 11 years, (in Phx), I have worked in 7 of their ERs...The amount of tests that are ordered on the avg ER patient has greatly increased...Certainly I have no "scientific" data, just personal experience...

Agree w/ the unnecessary radiation, BUT, at Joes, we get pts from all over the state, most have already had CTs, labs, xrays, etc, WITHIN the last 4-6 hours...WE REPEATED EVERYTHING...This was a losing battle for me, and I left, primarily because of the overordering...The ER docs were at the mercy of neurology and neurosurg as far as the CTs went... A kiddo would be sent for pneumonia, from an UC, w/ a CD of his CXR...it was ALWAYS redone...

I digress...

I certainly am not advocating for order whatever you want (which was the way at Joes)...

I just think that people sitting in a waiting room for 4 hours, w/ belly pain, and not even a UA is allowed to be done, is wrong...They are way too restrictive on this...

 

[chimichanga]

As bad as some want us to believe, medicine does not follow an algorithm.

I don't want to believe this, but ER medicine seems to be getting more algorithmic as my years of experience increase...

please, there are more docs that do the same exact tests for a given complaint, than those that seem to "put more thought into it" if you will...

certainly, I am not a doc, or midlevel, and there is much I do not know...

BUT, I know what I see...And having worked many nights, where the doc wants to sleep, and ONLY awakened when we have results from what we decided to order, based on rote memorization for what that particular doc ALWAYS orders...And the effective triage nurse knows when to awaken him right away, before ordering...

There's something to be said for "spidey sense" (see epiglottitis reference above )

 

[fab4fan]

This is true. Wake up a doc for a CP and don't have labs drawn, EKG done, CXR ordered , line started, and just see what happens.

 

[chimichanga]

This is true. Wake up a doc for a CP and don't have labs drawn, EKG done, CXR ordered , line started, and just see what happens.

BTW, the doc group that doesn't want standing orders in triage, also wants to sleep at night, AND have the patient worked up before we wake them...

Hmmmm...I wonder how their cake tastes, while they're eating it too..

Blatant hypocrisy...

 

[polygonal]

I guess we are just arguing about some semantics. I really prefer the system that fab4fan wrote about. It’s great when the nurses and docs know each other and work together. A well run chest pain is like rehearsed play.

I'm all about the system above. I just think there is some sort of disconnect when the orders originate from a "protocol" at triage. Maybe the triage nurse feels more obligated to order stuff just because its there than using their judgment after the nursing assessment. I can only speak to my experience but I always saw a bunch of what-the-??? tests done that increased our operating expenses.

BTW, I've also tried the system where the RN and doc both saw the pt as soon as they came back instead of the triage, nurse assessment, doc assessment that usually happens. Another great idea that I personally never saw work in reality.

 

[chimichanga]

I guess we are just arguing about some semantics. I really prefer the system that fab4fan wrote about. It's great when the nurses and docs know each other and work together. A well run chest pain is like rehearsed play.

.

no argument here...it's what I want as well...I'm not advocating for robotic triage based on a CC...

My point is that 2/3 of this nursing staff has worked alongside this same group of docs for 10-20+ years, and still no triage protocols...

didn't mean to get too tangential...

I'm just the new guy trying to get a CBC, UA, and BMP on the febrile, vomiting patient...

 

[fab4fan]

We briefly had an ED director who tried all these standing order algorithms for practically every complaint under the sun. It was a nightmare, because you just can't take a complaint and work it up like it's a recipe in a cookbook.

Ex: The other day I had a pt. present in triage who c/o migraine; she was actually a bounce-back. During triage she gave me one of those "Oh, by the way...I'm having chest pain" complaints. Her description was a little too perfect, and honestly, her story didn't square with her presentation. I had the feeling I was being scammed.

So, theorectically, I should have gotten the full cardiac work up because she c/o chest pain. What I actually did was just get an EKG (which of course was stone cold normal) to cover myself and waited for the doc to see her before proceeding with drawing labs. Then, a miracle happened...once she knew she was getting her narc. of choice, poof! No more chest pain. So no labs, no CXR needed.

Had I followed a set chest pain standing order sheet, that pt would have gotten labs, CXR, etc. Right or wrong, I used my judgement. Had I had the slightest whiff of suspicion her chest pain was legit, I would have gotten the workup.

 

[fab4fan]

no argument here...it's what I want as well...I'm not advocating for robotic triage based on a CC...

My point is that 2/3 of this nursing staff has worked alongside this same group of docs for 10-20+ years, and still no triage protocols...

didn't mean to get too tangential...

I'm just the new guy trying to get a CBC, UA, and BMP on the febrile, vomiting patient...

Now see, where I work, it would be expected that you would get that stuff right away. Personally, I would slap a hep-lock in that pt. If I was working with one of the docs I knew, I'd start the saline bolus, because that's what they'd want. In your case, you could always draw the labs and get the UA, and just hold them until the doc sees the pt and orders them. If he wants labs, great...you've got them. If he doesn't, no harm, no foul...you didn't send them.

You mean after all this time you still haven't learned to read minds, chimi?

 

[EMT2RN2MD]

You mean after all this time you still haven't learned to read minds, chimi?

We actually had a short mind reading course built into our nursing program. We'd get doctors from the local hospital to come in and think of numbers b/t 0 & 100. Sometimes they would actually think about letters. But, those items were either kicked out or became bonus points. Wish we had spent more time on the Jedi mind trick. "~These (Ultram) are the drugs your looking for.~" & "~Take these d/c instructions. You do not need a work excuse.~"

 

[Febrifuge]

<< you could always draw the labs and get the UA, and just hold them until the doc sees the pt and orders them. If he wants labs, great...you've got them. If he doesn't, no harm, no foul...you didn't send them. >>

Heck, at my ER, I do this, and I'm a tech. Just last night, I got a Breathalyzer reading on a frequent flyer, and spoke with the pit boss. I said, "I know you didn't order a breath ETOH, but if you did, would you want to know what it is?"

And she thought for a moment and said, "yeah. I guess, if we knew he was going to be okay to go home before 7am, that would help things."

And I said, "what if we knew that he probably couldn't leave before 8:30?"

And she said, "aww, crap. Okay, tell me. What is it?"

Same principle. Can be a very effective method, used moderately.

 

[fab4fan]

<< you could always draw the labs and get the UA, and just hold them until the doc sees the pt and orders them. If he wants labs, great...you've got them. If he doesn't, no harm, no foul...you didn't send them. >>

Heck, at my ER, I do this, and I'm a tech. Just last night, I got a Breathalyzer reading on a frequent flyer, and spoke with the pit boss. I said, "I know you didn't order a breath ETOH, but if you did, would you want to know what it is?"

And she thought for a moment and said, "yeah. I guess, if we knew he was going to be okay to go home before 7am, that would help things."

And I said, "what if we knew that he probably couldn't leave before 8:30?"

And she said, "aww, crap. Okay, tell me. What is it?"

Please...there's no such thing as "just a tech." I am glad when we have a tech working.

Same principle. Can be a very effective method, used moderately.

Please...there is no such thing as "just a tech." You guys keep the ED moving. Most of the techs I've worked with have been great, and I'm always glad for their help.

 

[f_w]

CBC, CMP, amy, lip, UA, for belly pain

I'll give you that one.

CT head for worst HA of life

Standing orders for CTs lead to the insanity practiced at some urban hospitals where patients get >10CTs/month for a recurring complaint. Most of them are drug seekers, the majority are probably migraine patients who lack maintenance meds.

CXR for cough

Without physical findings, without shortness of breath, without fever ??

Bad enough that people come to the ER with a URI, we don't have to waste another $170 for a unneccessary CXR.
I'll give you protocol based CXR for chest-pain and leveled trauma, mostly bc speed is of importance. But for cough without other sx of pneumonia it is a gross overutilization.

RSS and CX for sore throat

Again, while unfortunately this happens in many EDs, not everyone with a sore throat needs a $200 test to give an excuse for antibiotic therapy.

what am I missing?

That there is:
- no free lunch in medicine (every test comes with a cost, either financially or through the need to work up incidental findings)
- your ER needs to reduce its waiting times, either by developing an urgentcare (for the 'cough' and 'sore throat' crowd), or by improving staffing/facilities. Increasing the ordering of tests, just seems to improve throughput, in reality it clogs up the system even more.

Standing orders in triage should be used very sparingly, and the only questions before one is introduced should be:
- will this improve care for the individual patient involved ?
- will this increase patient safety for the entire institution ?

Often, they are introduced because providers are lazy and/or the logistics of the ER are broken, both not exactly valid reasons to increase the expenditure of healthcare $$s.

 

[chimichanga]

Standing orders for CTs lead to the insanity practiced at some urban hospitals where patients get >10CTs/month for a recurring complaint. Most of them are drug seekers, the majority are probably migraine patients who lack maintenance meds.

This is life at st joes...

pts sent to er for MRI of brain, daily...some wait 2-3 days in the ED's overflow/obs unit for it...another 24 hours for a READ...craziest thing I have ever seen...

i oversimplified my initial examples...
good, experienced triage nurses can effectively decide when to get things started, provided with written guidelines and protocols, AND open communication (quick synopsis) w/ the ER provider...

 

[fab4fan]

This is life at st joes...

pts sent to er for MRI of brain, daily...some wait 2-3 days in the ED's overflow/obs unit for it...another 24 hours for a READ...craziest thing I have ever seen...

i oversimplified my initial examples...
good, experienced triage nurses can effectively decide when to get things started, provided with written guidelines and protocols, AND open communication (quick synopsis) w/ the ER provider...

Don't even get me started about holding pts. in the ED til a bed opens up.

Who is sending pts. to the ED specifically for radiology procedures? If that's all that's needed, that's a misuse of the ED. If a provider is sending you a pt. to be worked up for abd. pain, for example, and asks that you get an MRI, that's one thing. Then again, if a provider is sending a pt. to the ED to be worked up, the provider should be letting the ED physician decide what's needed, but I digress...

 

[chimichanga]

oohh, nooo

the MRI holds are not admits...yes, that's right, they remain ER status, many w/ discharge instructions (a 33 hour wait for mri, initial doc writes tentative instructions, anticipating a neg result), hands pt off to next guy, then the next, pt is another wing away (overflow)...pt finally gets MRI, waits another 12 hours for mri read...

this is daily at joe's

oh, and at times, there is a positive result (thoracic lesion, pus in C2 region, etc) then these pts become "instant" ICU pts...

oh, and one guy ended up a quad after 17 hours of waiting for MRI - he's the one w/ the pus; walked in to fast track, never walked out - since DC orders and instructions were on the chart, pt was ignored, fed, allowed to sit in high fowlers before his MRI (docs blessing), and pocket burst, causing paralysis...

bad times

even after this sentinel event, pts continue to be ER holds, waiting hours for mri...

i left this madness

 

[f_w]

good, experienced triage nurses can effectively decide when to get things started, provided with written guidelines and protocols, AND open communication (quick synopsis) w/ the ER provider...

And I have the highest respect for the 'good, experienced' type who can indeed facilitate the management of patients who won't be seen by a physician immediately.
Unfortunately, standing orders tend to drift into he 'checkbox medicine' which leads to crass overutilization of diagnostic testing in ERs.

 

[f_w]

pts sent to er for MRI of brain, daily...some wait 2-3 days in the ED's overflow/obs unit for it...another 24 hours for a READ...craziest thing I have ever seen...

A problem certainly aggravated by overutilization of radiology services rather than fixed by standing orders.

(A patient should NEVER be sent to the ER for a specific imaging procedure. a patient should CERTAINLY be sent to the ER for a potentially life-threatening medical condition that requires an imaging workup not immediately available on an outpatient basis. If the patient is sent for workup of such a condition, there is no reason why he should be waiting around in a ER holding bay but rather be admitted and adequately treated until the procedure becomes available. I realize that there are numerous issues of insurance coverage, HMO review policies and unwillingness of admitting services to take such patients, that doesn't fix the underlying medical issue.)

 

[chimichanga]

A problem certainly aggravated by overutilization of radiology services rather than fixed by standing orders.

the mri example is separate from my point for standing orders...I wanted to vent about the rediculosity of the process...(see below)

(A patient should NEVER be sent to the ER for a specific imaging procedure. a patient should CERTAINLY be sent to the ER for a potentially life-threatening medical condition that requires an imaging workup not immediately available on an outpatient basis. If the patient is sent for workup of such a condition, there is no reason why he should be waiting around in a ER holding bay but rather be admitted and adequately treated until the procedure becomes available. I realize that there are numerous issues of insurance coverage, HMO review policies and unwillingness of admitting services to take such patients, that doesn't fix the underlying medical issue.)

Agreed...however, Joe's is (for all intents and purposes) run by the neurology and NS depts...their clinics that surround the hospital send these pts in daily for MRIs...

Of course he should be admitted...a no brainer for me, but it falls on deaf ears of the department chairs...hell, our pts waited up to 16 hours for a neurology consult before dc at times...

It's not discouraged by our ER docs...they just give report to the next guy...try getting pain med orders 26 hours and 3 docs later...

It's a sad state, but, hey, it's St Joe's...(I don't mean to disparage, but it's dangerous - see my previous post about the quad)

 

[chimichanga]

And I have the highest respect for the 'good, experienced' type who can indeed facilitate the management of patients who won't be seen by a physician immediately.
Unfortunately, standing orders tend to drift into he 'checkbox medicine' which leads to crass overutilization of diagnostic testing in ERs.

yes, but with 2 triage nurses, 30 (er pts) in the waiting room, and trauma pts' families also in our wr, coming up to ask triage when can they see their loved one, triage has no time to consult w/ a doc every 7 minutes...

It was definitely checkbox, but was not discouraged by the docs...Most practiced checkbox medicine as well...

example: 50 day old, mom reports fever at home of 100.8...none in triage...pt playful, to exam room...automatic orders: IV .9 NS 20cc/kilo bolus...CXR, CBC, BMP, cath UA w/ cx, LP...2 of us go in, cath, start line, draw labs, start bolus...get doc...immediately he does lp, while at the same time, the other nurse mixes claforan and ampicillin as specimens are sent to lab...LP is done, lab has blood and ua, CSF is sent, ABX started BEFORE any results from anything, inpt bed is ordered...

I like the admission, but how about wait for a source before the big guns...I know clinically, much research says to hit w/ all this w/in 30 minutes, but many ERs start w/ CBC, a UA and a chest film...if you find the source, admit w/o LP...

 

[f_w]

Of course he should be admitted...a no brainer for me, but it falls on deaf ears of the department chairs...hell, our pts waited up to 16 hours for a neurology consult before dc at times...

A quality of care issue that needs to be addressed in the hospitals med-exec committee.

It's not discouraged by our ER docs...they just give report to the next guy...try getting pain med orders 26 hours and 3 docs later...

I guess it is called 'passing the buck'.

It's a sad state, but, hey, it's St Joe's...(I don't mean to disparage, but it's dangerous - see my previous post about the quad)

It is one 'St Joes'. I happen to work at one of the many 'St Joes' out there and while we have our own set of issues with he ER, keeping patients stored until they either die or get an MRI done is not one of them.

 

[chimichanga]

Not dragging any other Joe's into the mix ...I referenced it was in Phoenix here and in other threads...

 

[chimichanga]

......double...

 

[chimichanga]

A quality of care issue that needs to be addressed in the hospitals med-exec committee.

I went to the director of the ER, COO, CNO, and ethics...

It's been this way for years they tell me...

It's Barrows dude...they do what they want, how they want...The ER plays along...It's not like nobody knows...Our ER med director is also the hospital's med director...

 

[f_w]

I went to the director of the ER, COO, CNO, and ethics...

Admirable that you went up the ranks.

It's Barrows dude...they do what they want, how they want...The ER plays along...It's not like nobody knows...Our ER med director is also the hospital's med director...

If they want to make insanity the rule, there is probably no way to stop them.

 

[chimichanga]

thanks, though my only motivation was the 41 year old quad, whom I had taken care of for 2 hours...he returned from MRI asleep, apparently he felt a pop in his neck when he scooted from the MRI table to the gurney...he mentioned it to the tech in MRI (that info wasn't passed on to anyone)...Pt fell asleep (he had been sedated d/t anxiety - another reason for the long waits - 75% of the mri pts are sedated) He fell asleep on the way back to overflow - loooong way...I got vitals (remember he had dc orders on the chart, though I probably should have done a more complete head to toe); I called his name, he awoke, answered some Qs and fell back to sleep...he said nothing about a "pop." 90 minutes later, in rushes NS to confirm what they suspected (after the read)...no feeling below the neckline...

I was sick over it...Worst part was, the original ER doc who ordered the MRI, shrugged it off when I told him the next day...

I finally realized that nothing could have likely been done to prevent this...Do we put an aspen collar on everyone w/ neck pain (no trauma) and tingling to the arm?

no

I hate apathy


sorry for getting this thread off topic...it seems we all agree on:

1) basic triage protocols
2) adequately trained RNs in triage, making good clinical decisions on starting care, if needed
3) open dialogue w/ the docs

 

[50960]

Told you chimi, it is all about $. Nurses (RN's that is) are the primary contact in American healthcare for most patients. Research has shown that "doing" something helps alot of patients more than waiting for a proper Dx, although we all know this pertains to the malingerers, psychosomatics, elderly, neurotics, and those who's fear is contributing greatly to their physical complaints, as opposed to those with a real acute or emergency situation. SO, a few labs that come back normal will help alot of people, but cost the facility alot of $..... that is the bottom-line.

 

[chimichanga]

well said psi...

 

[fab4fan]

Sounds like you were trying to rearrange the deck chairs on the Titanic, chimi. Good for you for getting out of there.

 

[chimichanga]

It's a great neuro hospital...If I am brain-injured, I'm first in line...

But this fact doesn't always bode well for the ER...

I had a great time...I love residents...They're the friendly ones...And quite trainable...Yes that's right, don't accept an already TPA'd pt to my ER...He goes to the unit...

Actual quote from a neuro pgy II: "Not all TPA'd pts go right to the unit; Some are even discharged home"

OOOH Yea!!!



It's the attendings... that, well...you know...

 

[fab4fan]

I have a theory on one of the reasons why standing orders were developed (certainly not the only one).

It used to be, back in the Dark Ages when I first became a nurse, that you had to have several years of experience before you could work in the ED. New grads in the ED? No way. It also used to be that you had to have at least a year of experience in the ED before you could do triage.

These days, with the shortage of nurses, new grads abound. They have no practical experience to draw on when they get to the ED. They don't have even the basic skills down. Now they're in an environment where you have to think on your feet and be able to act fast. Standing orders or clinical pathways, whatever you want to call them, allow an inexperienced person to function somewhat in the ED environment, thus giving the appearance of relieving staffing defecits.

It would be safe to say I am not a proponent of new nurses working in the ED.

 

[deleted6669]

I have a theory on one of the reasons why standing orders were developed (certainly not the only one).

It used to be, back in the Dark Ages when I first became a nurse, that you had to have several years of experience before you could work in the ED. New grads in the ED? No way. It also used to be that you had to have at least a year of experience in the ED before you could do triage.

These days, with the shortage of nurses, new grads abound. They have no practical experience to draw on when they get to the ED. They don't have even the basic skills down. Now they're in an environment where you have to think on your feet and be able to act fast. Standing orders or clinical pathways, whatever you want to call them, allow an inexperienced person to function somewhat in the ED environment, thus giving the appearance of relieving staffing defecits.

It would be safe to say I am not a proponent of new nurses working in the ED.

agree-we have lots of new grad nurses. my favorite story is about a unit secretarty who went to nursing school. one day she is entering lab requests into the computer, etc and the next day I see her in triage. that's right, on her 1st day as a nurse....you can imagine how well that went....

 

[f_w]

agree-we have lots of new grad nurses. my favorite story is about a unit secretarty who went to nursing school. one day she is entering lab requests into the computer, etc and the next day I see her in triage. that's right, on her 1st day as a nurse....you can imagine how well that went....

Although I must say that at times the clinical judgement of our registration staff (who saw the patients between triage and getting into the ED) was better than the triage nurses. These gals often had decades worth of experience on that job and more than once caught patients who either deteriorated in the waiting area or slipped through the cracks of triage.

A recent example of what can happen if triage slips up:

http://www.cbsnews.com/stories/2006/09/15/ap/national/mainD8K5DM2G0.shtml

(haven't followed the outcome, but basically an african american lady with chest pain was left in ED waiting until she passed away. apparently not without a little personality conflict between the patients daughter and the ED triage staff.)

 

[fab4fan]

agree-we have lots of new grad nurses. my favorite story is about a unit secretarty who went to nursing school. one day she is entering lab requests into the computer, etc and the next day I see her in triage. that's right, on her 1st day as a nurse....you can imagine how well that went....

Good grief.