Ask the Experts

Question:
Staffing issues are an ongoing problem at my emergency department - it seems that we work short staffed almost every day. How can I convince leadership that we should always staff triage with the most clinically experienced and "best" nurses in the department - especially when we are busy?

Answer:
This is unequivocally one of the most important questions that can be asked vis-a-vis emergency department triage. To effectively discuss this question, however, we must first begin with a specific and important premise: triage is not a place, it is a process. This is a critical concept in addressing the underlying question because there is often a misunderstanding that triage is where we go - it is not, it is a process. This being clearly understood, we are now able to fully discuss your question. The Emergency Nurses Association (ENA) outlines the specific recommendations for nurses who perform triage. These recommendations include:

• Minimum of 6 months emergency department experience
• Successful completion of triage education course
• Current certification in BLS and ALS
• Successful completion of TNCC
• Successful completion of ENPC
• Certified Emergency Nurse (preferred)
• Strong interpersonal skills
• Ability to conduct brief, focused interviews
• Strong physical assessment skills
• Ability to make rapid, accurate decisions
• Ability to work collaboratively
• Flexibility in the face of changing workloads
• Effective communication skills with patients and families
• Cultural and religious competency
• Knowledge of institution-specific policies¹

This is further clarified by the statement "The triage process is conducted by an experienced ED RN whose competency has been validated"². Stated differently, just putting "warm bodies" in the front end arena to perform the triage process is first and foremost, a patient safety issue. Even if one considered only the recommendations as defined by ENA, it is abundantly clear that "warm bodies" does not meet the accepted standard for assigning nurses to perform the triage role in the front end arena. Further validation of the importance in assigning the most clinically experienced as well as clinically excellent emergency nurses as designated triage nurses comes from legal perspective as well. Recent literature highlights this very issue "too often the department's least experienced nurses are sent out to triage, or the ED 'borrows' nurses from an inpatient unit or staffing service to work in triage, when in fact the complexities of the issues related to triage and the ramifications to patient safety from the prolonged waiting time to be seen by a physician demand exactly the opposite - the best and the brightest nurses need to be in triage."³ Further recommendations from a legal perspective include but are not limited to:
Identify who is qualified to conduct triage: "Only nurses with substantial ED experience, recognized clinical skill, and excellent interpersonal and communication skills should be allowed to conduct triage for the ED"³.
Utilize the designated qualified triage individuals at all times, not just during the busiest hours of the day
Specifically train individuals who will work in the triage area
Have advanced training on EMTALA issues
Training specific to dealing with patients who wants to leave before the medical screen exam.³
Although there remain hospitals that do assign the triage role based on factors that are invalid such as an agency nurse who is not fully able to assume assignments in the treatment area, nurses who have interpersonal challenges with other staff members in the treatment area, or the nurse who has some type of physical deficit, these are clearly unacceptable reasons. The nurse with the best clinical skills, physical assessment skills and interpersonal skills and who has successfully completed the recommended requirements is the nurse who should be assigned to the triage role.

¹Emergency Nurses Association. (2007). Emergency Nursing: Core Curriculum (6th ed.). St. Louis: Saunders.

²Emergency Nurses Association. (2010). Sheehy's Emergency Nursing: Principles and Practice (6th ed.). St. Louis: Mosby.

³Bitterman, R. A. (2009). Emergency department triage - the new hotbed of litigation? ED Legal Letter, 20(5), 49-53

Ask the Experts a question by clicking here.

Copyright 2010 Triage First, Inc.