Rebecca McNair
RN, CEN, President

As Triage First continues to offer our Comprehensive Triage Education (including live instruction, interactive online modules and post-tests, and continuing education competency series), I want to take this opportunity to express our commitment to constantly updating our content to keep pace with the art and science of emergency department triage.

Speaking of the art of triage, as those who are acquainted with our work will attest, one aspect of triage that transcends the clinical aspect of our work is that of customer service. There is much written on the subject of customer service in the health care community and yet patient satisfaction scores continue to be affected by wait times in the ED. Point-of-entry bottlenecks certainly serve to set a discouraging tone not only to patients and significant others but to ED staff as well.

EDs must focus on some clear, proven and effective measures beyond triage education. They are:

1. Rapid triage on all patients
2. Quick registration (name, DOB, SSN) as a parallel process
3. Correctly obtaining and documenting a symptom-driven chief complaint
4. A patient tracking system that includes all necessary components: Room/Patient Name/Acuity/Nurse/MD/Lab/X-ray/Disposition
5. Immediate bedding when all three of the following criteria are met:
1. Able to assign appropriate acuity and disposition
2. Bed available
3. Care provider available
6. Continue with comprehensive triage only:
1. If there are not beds available, or
2. You cannot assign appropriate acuity and disposition, or
3. There are no caregivers available
7. AOB instituted – patients can be placed in any open bed (requires flexible-use rooms)
8. Bedside registration on at least 50% of patients – goal of 80%
9. Reassess patients according to facility guidelines
10. Decrease ED holding by improving backend or output processes (including discharges, transfers, and admissions)
11. Triage arena to fulfill all “principles of triage ”
12. Last, but not least, though certainly the most controversial: Practice mercy.

What Triage First teaches about practicing mercy has been misunderstood by some who perceive that we want ED nurses to be martyrs rather than clinical experts. I would respond to that interpretation of our teaching by saying that we are absolutely NOT advocating that nurses or physicians should endure any abuse (whether verbal or physical). Instead, we are simply reminding caretakers that they should access the depth of psychological and social knowledge that has always been the bedrock of nursing care, realizing that the physical component of the patient is only one part. Establishing rapport is an essential piece of our professional practice. Any layperson can respond “in kind”…it takes a pro to recognize anger and impatience as symptoms and to not take such attacks personally, but to respond wisely—with clinical expertise and with compassion.

Losing Your Objectivity

I’d like to close with this friendly reminder to ALWAYS and in every patient presentation CONSIDER worst-case scenario!

The patients seen most frequently in the ED are at greatest risk when we as caretakers lose our objectivity. It is vital that we remember: ALL patients returning to the ED within 72 hours of their last visit and all frequent flyers are at risk for serious illness or injury and must be given a thorough and unbiased assessment. Consider the following scenario that occurred in a busy ED.

A patient comes to the ED multiple times for lower back pain. In fact, he has been in so many times that it is not uncommon to see him angrily tearing up the scripts we give him for Motrin. The nursing staff calls a few neighboring EDs and discovers that not only has this patient been to our ED, he has been to several of the other EDs in neighboring counties. Now, let’s see if we all see this case similarly. What conclusion would you draw regarding this patient?

We would all probably guess that this patient is exhibiting drug-seeking behavior. Finally, however, despite her clinical opinion that this is most likely a drug seeker, one triage nurse performs a thorough and unbiased exam, and finds that he is experiencing numbness and tingling in his genitalia. Knowing that this is indicative of “cord-syndrome,” the nurse documents appropriately, assigns a higher level of acuity, and communicates her disposition directly to the primary treatment nurse. The ED physician orders a spiral CT, and it is discovered that what the patient is actually experiencing is pain from a large tumor pressing on his spine.

The patient dies several weeks later.

Yes, most of the time—maybe even 98% or more—we will be correct in guessing that such patients are in fact drug seekers. It takes a true professional nurse to find that remaining 1–2% that are not.