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Triage Specialist Course
Comprehensive Training for the Triage Educator

December 3-7, 2007
Asheville, NC
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Literature & Research

National Mandates: Improving Patient Safety

Does That Include Triage, Too?
Sometimes all it takes is hearing the words Joint Commission on Accreditation . . . and suddenly our ability to think clearly and logically is prevented by a loud buzzing sound in our heads as if a swarm of bees had taken up residence there. But, however unpleasant the prospect of reading and understanding them may seem, emergency nurses do have a responsibility to know and understand Joint Commission requirements as they pertain to the practice of emergency nursing. This article will examine the Joint Commission 2007 National Patient Safety Goals (NPSGs) and their application to the triage process.

The National Patient Safety Goals were launched in 2003 by the Joint Commission and the Sentinel Event Advisory Group in an effort to identify and provide possible solutions for areas identified as “problematic” to patient safety, and the goals have been updated on a yearly basis since that time. All Joint Commission accredited hospitals are evaluated for their compliance with these goals, which are evidence-based with expert consensus, and whenever possible the focus has been on system-wide solutions. Not all goals are intended for all areas of healthcare. Following are the NPSGs that are applicable to the hospital environment.

2007 National Patient Safety Goals

1. Improve the accuracy of patient identification.

Triage Application: Does your hospital use protocols or provide any type of treatment at triage? If so, this NPSG is applicable. It requires two patient identifiers when giving any medications or blood products, obtaining any type of specimen, and when providing treatments or performing procedures. Further, the Joint Commission states that patient location is not acceptable as an identifier and that all specimens obtained from a patient must be labeled in the patient’s presence.

2. Improve the effectiveness of communication among care givers.

Triage Application: This NPSG has multiple requirements and includes oral/telephone orders, the use of abbreviations, reporting of critical test results, and “hand-off” communication. The “hand-off” communication is required at shift changes or personnel changes and must include “interactive communications allowing for questioning between the giver and receiver of patient information” as well as “up-to-date information regarding the patient’s care, treatment and services, condition and any recent or anticipated changes.”

At many EDs, a shift change report at triage is often a casual mentioning of those patients we are worried about that are awaiting bed placement in the treatment area. To be in compliance, the above information must be provided for all the patients we assume responsibility for. What is the policy at your facility regarding report at shift change for triage?

3. Improve the safety of using medications.

Triage Application: This goal is aimed primarily at standard concentrations of medications, “look-alike/sound-alike” medications, and the appropriate labeling of medications. If your facility has protocols that include the administration of medications at triage, then this goal applies.

7. Reduce the risk of healthcare-associated infections.

Triage Application: Included in this goal is the requirement for facilities to be in compliance with the CDC’s (Centers for Disease Control and Prevention) guidelines for hand hygiene. This goal further states that “any death or major permanent loss of function associated with a healthcare-associated infection” must be managed as a sentinel event. If at first glance this does not seem to have much to do with triage, consider the potential outcome when a patient comes to the emergency department with a communicable disease that is not recognized by the triage nurse, and is placed in a busy, crowded waiting room.

8. Accurately and completely reconcile medications across the continuum of care.

Triage Application: Most (if not all) EDs require the triage nurse to start the process of med reconciliation by obtaining a list of current medications from patients presenting to triage. According to the Joint Commission (see FAQ – med reconciliation), as of January 2007 a consensus was reached between the American Association of Emergency Medicine, the American College of Emergency Physicians, and the Emergency Nurses Association with the following steps for reconciliation in the emergency department:

1. Screening Reconciliation: A current medication list is to be obtained from ALL patients at EACH visit and is usually obtained by the triage nurse.
2. Focused Reconciliation: As directed by the emergency physician, this consists of the exact medications, dosages, and route.
3. Full Reconciliation: Required for admitted patients, this is the responsibility of the inpatient unit and the pharmacist.

According to the Joint Commission, if these steps are followed, the facility is in compliance with the goal 8A/B.

9. Reduce the risk of patient harm resulting from falls.

Triage Application: This goal includes the expectation that facilities will provide “interventions to reduce the patient’s fall risk factors.”

Do you have enough wheelchairs that are easily available for patients at triage who are at risk for falling?

13. Encourage patients’ active involvement in their own care as a patient safety strategy.

Triage Application: Does everyone who performs triage at your facility advise every patient who is not placed in a treatment bed to notify the triage nurse if their condition worsens? This Joint Commission goal requires that “patients and families are educated on methods available to report concerns related to care, treatment, services and patient safety issues.”

15. The organization identifies safety risks inherent in its patient population.

Triage Application: This is one of the changes for 2007 in the NPSGs and specifically addresses patients at risk for suicide who are being treated in either a psychiatric hospital or a general hospital for emotional or behavioral disorders. According to the Joint Commission, suicide is the most frequently reported sentinel event since 1996. Included in the requirements for this goal is the expectation that a suicide risk assessment will be performed and that immediate safety concerns will be addressed. What is the policy at your hospital regarding patients at triage with emotional or behavioral disorders?

The Joint Commission 2007 National Patient Safety Goals clearly apply to the triage process. Triage First strongly encourages you to go to the following websites to gain in-depth understanding and knowledge of these goals.

Joint Commission NPSGs Fact Sheet
Joint Commission 2007 NPSGs Hospital Program
Joint Commission 2007 NPSGs Goal 8 Reconcile Medications

Methamphetamine: Destroying Everything in Its Path

Methamphetamine, a potent synthetic drug that stimulates the central and sympathetic nervous systems, has become a scourge on our society. A recent article in the Journal of Emergency Nursing, Evaluation of Children Removed from a Clandestine Methamphetamine Laboratory, defines how devastating a problem this substance is. The negative and often dangerous consequences of meth use and production is not limited only to the user but also to first responders, children, and others living in places where the drug is manufactured, as well as the public at large.

Because the production and use of methamphetamine is so prevalent, triage nurses should be well informed of symptoms associated not only with the intentional use of the drug, but also the symptoms of secondary exposure or accidental ingestion of meth and the products/chemicals used to produce it.

Children at Risk

Maintaining a high index of suspicion at triage for possible ingestion or accidental exposure to meth and/or its components is necessary since it is highly unlikely that caregivers are going to freely admit to allowing their children to live in such an environment. Further complicating recognition of these children is the potential for symptoms to be attributed to other etiologies such as scorpion envenomation. Children are at risk not only for the physical sequelae of exposure to meth, but also for neglect, abuse, and exposure to violence. 

The National Alliance for Drug Endangered Children is an excellent resource for health care providers, which we would encourage you to explore. The National Protocol for Medical Evaluation of Children Found in Methamphetamine Labs was developed by this organization.

At triage, we sometimes become complacent about presentations that are commonplace, and today, in some areas of the country, it sometimes seems as though half the population is using meth. This article, Evaluation of Children Removed from a Clandestine Methamphetamine Laboratory, is an excellent resource and provides the reader with in-depth information from pathophysiology and symptoms to decontamination and psychosocial considerations. We would strongly encourage you to read this article in its entirety and to maintain a high index of suspicion at triage.

Reference

Grant, P. Evaluation of Children Removed from a Clandestine Methamphetamine Laboratory, Journal of Emergency Nursing, 2007; 33:31-41.

Copyright 2007 Triage First, Inc.