Provider in Triage

[sk732]

Something I've been noticing EM folks talking about lately is putting a PA/NP/MD in with the triage nurse...for those of you who work in that sort of atmosphere, how is it working for you and the dept as a whole?  I seem to recall when I was in 2nd year on my peds rotations that a lot of the foreign fellows noted that many things could have been turfed very quickly (to the family doc, to the pharmacy or just out the door) by having someone as a second gatekeeper.

 

I'm considering proposing this to my director, as my facility is starting to get slammed because of other peripheral facilities choosing to be open only when convenient - our's is the hub for the region, but not exactly built to deal with the numbers we're getting.  I'm thinking of ways to manage flow better at the waiting room side of the doors.  If people also have some access to research, I'd be happy to have that too - both good, bad and meh.

 

Thanks in advance.

 

Sean K

 

 

[rev ronin]

It will really depend on how similar your Canadian equivalents of EMTALA and Tort Liability are.  Provider triage in the U.S. seems to be more designed to single out the really sick, rather than cut short pointless/needless ER visits.  The latter is what APPs are hired in "fast track" to deal with.

[sk732]

One province I was in did empower senior triage nurses to turf people to their family docs for non-emergent issues if reviewed with the ED Doc in the Dept.  We do have a minor treatment area, however it isn't utilized properly due to it also being used as the minor surg area for the family docs, out patient follow ups for specialists, etc, which ties up rooms/beds.  Our alleged grown ups won't confront people about it - especially since the equipment used doesn't come out of the fee for service docs pockets, so they're afraid of backlash ::).

 

We do have two walk ins here in town - though the one the Province set up to be run by NP's is a joke..."Quick Care Clinic" is a real misnomer, as they only see same day appointments - so not a true WIC/UCC - and half the time they turf people to us anyway.  The one run by a FFS doc is often overwhelmed, so back to us again.

 

Thanks again for your input.

 

SK

[treejay]

It will really depend on how similar your Canadian equivalents of EMTALA and Tort Liability are.  Provider triage in the U.S. seems to be more designed to single out the really sick, rather than cut short pointless/needless ER visits.  The latter is what APPs are hired in "fast track" to deal with.

 

Even more so, I think it's designed to initiate the workup of labs/imaging before the patient even get a bed/seat in the ED to move them along more rapidly through the whole process

[dmdpac]

Even more so, I think it's designed to initiate the workup of labs/imaging before the patient even get a bed/seat in the ED to move them along more rapidly through the whole process

 

Our system can allow the triage provider to initiate a workup.  The real goal for us, however, and as it was emphasized when started to put a provider in triage, is to stop the clock on the door to provider time.  Sure, labs and/or imaging are nice and can help get things moving (depending on other factors) before the patient gets to a room.  Even then they asked we be conservative in tests ordered through triage so providers in the back don't wind up chasing values on a test they may not have ordered to begin with.  But we don't have to initiate anything.  Just stop the clock.

 

Check the box.  Hit the metric.  Move on to the next one.

[sk732]

Our system can allow the triage provider to initiate a workup.  The real goal for us, however, and as it was emphasized when started to put a provider in triage, is to stop the clock on the door to provider time.  Sure, labs and/or imaging are nice and can help get things moving (depending on other factors) before the patient gets to a room.  Even then they asked we be conservative in tests ordered through triage so providers in the back don't wind up chasing values on a test they may not have ordered to begin with.  But we don't have to initiate anything.  Just stop the clock.

 

Check the box.  Hit the metric.  Move on to the next one.

 

So your system is more in place for LCF (Look Cool Factor) and management satisfaction scores vice improving the system.  The clock on the door to provider time would be a bit useful, since we are monitored on it, but you can't do jack with no rooms for many problems.  I have done waiting room medicine in the past, but there is that confidentiality thing they get upset about in a crowded waiting room.  There are standing orders for certain conditions to have tests ordered by triage nurses, but I find they're overkill sometimes - people not really looking at the patient and just ordering shotgun tests without thought.  I've had some things show up with only a basic chem 7 but needed LFT's done and such or too much done, then we're hunting zebras when something weird turns up.  Most RN's don't know how to order XRays, so many aren't comfortable with it. 

 

Thanks...I suppose we could just shut our ER down one day and make the people that are supposed to work do their jobs for once :-)

 

SK

[dmdpac]

So your system is more in place for LCF (Look Cool Factor) and management satisfaction scores vice improving the system.  The clock on the door to provider time would be a bit useful, since we are monitored on it, but you can't do jack with no rooms for many problems.  I have done waiting room medicine in the past, but there is that confidentiality thing they get upset about in a crowded waiting room.  There are standing orders for certain conditions to have tests ordered by triage nurses, but I find they're overkill sometimes - people not really looking at the patient and just ordering shotgun tests without thought.  I've had some things show up with only a basic chem 7 but needed LFT's done and such or too much done, then we're hunting zebras when something weird turns up.  Most RN's don't know how to order XRays, so many aren't comfortable with it. 

 

Thanks...I suppose we could just shut our ER down one day and make the people that are supposed to work do their jobs for once :-)

 

SK

 

 

I know it sounds crazy but yes.  The LCF and our poor door to provider times were the initial motivation for putting a provider in triage.  Most of us when working in triage will make an effort to initiate an appropriate work up including labs and imaging.  We'll call the walk-in stroke or trauma alert.  And we do on occasion see the easy to dispo case that doesn't need to go back to a room (even though we're discouraged from doing this). 

 

Don't get me wrong.  Most of us are dedicated to doing the right thing for the patients we see even in as hectic a setting as our triage can be.  But we were put there to stop that clock because we were off on that particular metric.

[sk732]

This again points out the problems with non-clinical (or couldn't cope in clinical) people making decisions based on arbitrarily obtained, mentally challenged metrics for medicine.  Optically, things are getting done...in reality, it's still status quo. Patients feel like something is being done, but in reality, they're still being stalled somewhere if there is nowhere to put or see them.  Usually they figure it out after a couple hours of waiting when all is said and done...

 

Lots of negatives and no real positives...thus far.  One hospital I worked in was hand in hand with the clinic for the medical group in town, so we could easily look at the patient, call the office and have an appointment for them within 36 hours, since it was us calling about our patients (I'd just call my own office for people I knew or were orphaned and would see them within a day or two).  Here, we don't have that luxury...the EM docs I work with don't do family anymore except for one, so becomes an issue of tufing to FMD.

 

My biggest beef is I hate optics - I like real problems being really solved instead of just glossed over.  I hate handing my crap to someone else - I was the same in the Army in that I tried to solve things instead of giving them to someone else.  My higher management pretends to listen to some stuff, but in the end, they seem to have decision making disorders about the hard stuff that needs to happen.

 

SK

[Guest ERCat]

My ER did the provider in triage thing. It really was there to "look cool" so we could improve our door to provider times and put up fancy billboards saying "45 minutes or less!" I felt like a fraud when I was the PIT - the triage nurse would lead the encounter and I would just slink back in the sidelines and order tests, then send each poor patient back to the lobby for hours but HEY! They were seeing a provider in their first 45 minutes! While it did help get orders done quickly for some reason it didn't seem to help the overall discharge times. Our ER stopped doing it for that reason AND they didn't find it cost effective to pay a provider to do just that. However I am so glad because I hated doing triage. It was frightening knowing that if somebody dies in the lobby you were the last provider to see them...

[EMEDPA]

ERCat- we did it for a while and stopped because the RNs complained. our model was PA/Tech and no triage nurse.

glad it stopped anyway, I totally hated it.

[billo]

I worked as a provider in triage for 8 months.  I hated it and ended up quitting.  I would triage alone and at times had an ER tech take vitals for me.  It was miserable and it was to improve "numbers".  The door to doc time was not more than 15 minutes when a PA was triaging.  I wasn't gaining any knowledge or experience.  The nurses would always lash out at the PAs because they felt there job was taken away.  They would always find reasons why a patient was triaged properly (not checking a blood pressure on a 6 month old, not placing a pt on a back board etc) The docs would at times get upset because they would feel that a patient was mis triaged.  It was a miserable job and unfortunately it's a widely practiced model nowadays.  I don't think it improved how quickly patients were being discharged or the number of patients the docs were evaluating. 

[sk732]

So, if I were to try and set something up, I'd have to be able to prove that (a) I could knock down wait times, which on paper it decreases, but in reality doesn't affect; (b) it can be done without harming patients; © can get people where they need to be sooner, be it a room, minor tmt area or turfed out the door to a pharmacy or their bed.

 

Got my work cut out for me...thanks for your help folks.

 

Sean K