PA's in Triage

[sp911]

I have been working for a rather large EM group here in California and the Triage area is staffed by one midlevel, one nurse and sometimes one tech. In theory it allows the pt to be Medically Screened much quicker and makes for better stats to show the hospital.

Depending on the time ones shift starts, a PA can spend anywhere from zero hours to 4 (or more) hours in Triage. I must say that spending 4 hours in Triage (fairly busy ED 60+K visits a year, HEAVY in migrant non-English speaking) just about drains all my patience for the shift.

I am not sure who came up with this idea but it was not a PA who actually has to spend the time in Triage. As providers in triage we are supposed to: take a history, perform a brief physical exam (at least three things must be documented for it to fulfill the MSE requirements), order all of the labs and radiology tests (actually input them into the computer) we think the pt will need, all under say 6 minutes. Now, there is not actual time limit set by the company but at our ED everything gets backed up if you don’t do it in the above mentioned time. On top of that, depending on which docs are in the back depends on what tests each one wants ordered for each presenting chief complaint, and if they don’t like what you ordered they call and question you about it.

On top of that, we are supposed to maintain at least a 1.4-1.6 Pt/Hr for the month. So instead of seeing patients for a normal 10 hours each shift we only get 6-8 hours but 10 hours are actually calculated for the month’s time. The time spent in triage doesn’t count towards Pt/Hr for the month. So instead of seeing 14-16 patients in 10 hours we have to see them in 6-8. I was told that I should also be able to discharge at least one patient per hour from triage but, where is the time to do the above mentioned work plus the paperwork and discharge summary for a patient in say 6 minutes. I work mainly a swing shift and it is ALWAYS backed up with 5+ people waiting to be triaged at all times when I arrive.

Does anybody else here have a similar structure in their ED? Does this sound like a system you would want to work in? Is the restraints place upon us reasonable? It’s not like I have any say in the matter just curious what others in EM think.

[EMEDPA]

hvae done it before at a prior job 4 out of 12 hrs/shift and felt the same way about it.

hope to not do it again.

[drewryan9]

Ya, I have been informed that the ED I work in is going to try this formula for a bit. I must say I am not to excited about the proposal.

[EMEDPA]

Ya, I have been informed that the ED I work in is going to try this formula for a bit. I must say I am not to excited about the proposal.

 

I work at one facility that is going to start doing this soon and I will probably cut back my hrs there because of this....

[Febrifuge]

If there were any actual agreement on what a MSE entails, and if it really could be done with the patient sitting there in Triage (i.e., without true privacy), then this idea might make some sense. In the real world, it's a steaming cauldron of ridiculousness with bubbles of idiocy and a pinch of insult for flavor.

 

It's an idea that reveals a deep misunderstanding as to why the triage desk is in a different part of the ED from the exam rooms.

[True Anomaly]

During school, the first ER I rotated in used their midlevels in precisely this manner. It did not look appealing in the least, but the midlevels I met there seemed okay with it since they were several years into their career and wanted something rather easy. They did hire a new grad to start doing the same thing, and I can't imagine that at this point in my career.

[mmw0703]

I can honestly say that I have seen this system work well for the patients in 1 situation. A very large high volume ER with wait times upwards 4-8 hours on a daily basis. Labs and xray were done from triage after an intitial MSE. Alot of times those such labs/films would come back with a critical finding and it allowed that truly sick pt to be moved up in level of acuity and therefore evaluated in main ER in a quicker fashion. In this particular hospital no pain meds were administered while pts were waiting to be seen with the exception of tylenol and ibuprofen. Drug seekers rarely hung out long enough to make it to the main ER!!

 

I am currrently working in another ER where the wait time almost never becomes that extreme. The idea of an MSE in this situation doesnt seem to be beneficial. It ends up being extra time the pt must wait to be sent to the main ER when beds are already available. These pts would probably be evaluated in close to the same amount of time and appropriate labs then ordered by the practitioner who will be seing the pt throughout the visit.

 

The reason this ER is run in this manner is because lower acuity pts are then not sent to the main ER but instead evaluated and discharged by the same person responsible for doing MSE's on every pt that walks in the door. (think mini fast track) Obvious this makes for a hectic day and the entire 10 hr shift is staffed by 1 midlevel. Exhausting!!!

[Guest VTPADawg]

I would rather eat a bullet than sit out in triage. I understand the theory behind it, but it does not fully utilize the staff's capabilities to its best.

[paintx]

I agree VTPADawg. I believe the real purpose behind this model is to beef up door-to-provider times. It does have value in getting the MSE done faster and potentially picking up that sick patient and avoiding a bad outcome, but structured, well designed nursing protocol order systems and face to face communication with the triage nurse and a provider as needed works well too.

[kieuhanh]

I have been working here for over a year and loving the interactions with the triage nurses; learning alot from them--passed my boards in 2011. There is really no respect to the position but I feel I am making a difference.

[RetNavyPAC]

I think concepts like this, while good in theory, are all about numbers for administrators to crow about - but more importantly it is an incredible waste of talent. There is more bang for the buck and for the time having an EM PA do what an EM PA does best back in the ED.

[jwells78]

I work at a facility that began using this concept about a year after I started. Since that time, there was a 1 year period during which the mid-level providers worked either Fast track or triage (during ER reconstruction). We have since been transitioned into the new main ER and see high acuity patients with 100% physician overwatch (we pick up everything but level 1 trauma now; physician is "Roving brain"). From my experience, spending too much time at RME/triage/ whatever you want to call it is a quick way for a PA/NP to lose precious skills. When they moved first moved us back to the main side, I felt almost like a new graduate; I had to relearn and stumble my way through acute workups again, and worse- I felt like a hinderence to the Attendings. We have a new grad that "loves it" at RME; again, that's because it's easy to send home cough/cold/staples in the head and not learn a damn thing for the first, most important years of your career. Someone stated above that they are learning a lot from the nurses; yes- do that, but what you really need to do is learn from who you were MEANT to learn from- the ER Attendings. Unfortunately, PA/NP at triage is absolutely the best solution for decreasing door to provider times. Bean counters love this and the ER MDs sure as hell don't want to do it (ours did it for and lasted about 6 months; I guess they hated it too). I hate to think that this is going to become a staple of our ER existence, but it looks that way- at least in bigger hospitals. I looked at a job in Colorado a few years ago, and they wanted me to come help them stand up THEIR PA at triage program. Ahem, "no thanks." It's not fun, it's not helping our image (globally), and it's about as fun as a colonoscopy.

[EMEDPA]

the only way to do rme without going nuts is just do it for a few hrs of each shift. I used to work at a place with multiple overlapping 12 hr shifts and we did it the first 4 hrs of our shift then moved to the acute area in back for the last 8 hrs.

very efficient but not a lot of fun. everyone in back(including your own pa partners) will think you over/under ordered for many pts because we all do things a little differently. I was yelled at twice in the same shift for both ordering and not ordering d-dimers on different pts.

we can do triage better than the nurses because we know more and they get defensive about it. at the job mentioned above we stopped rme after 6 months even in the face of better turnaround times, etc when the nursing union filed a complaint against the hospital. ( we did away with a few rn shifts because we didn't need them anymore...)

[treejay]

During school, the first ER I rotated in used their midlevels in precisely this manner. It did not look appealing in the least, but the midlevels I met there seemed okay with it since they were several years into their career and wanted something rather easy. They did hire a new grad to start doing the same thing, and I can't imagine that at this point in my career.

 

I recognize this is an old thread but I'm considering an ER job like this as a new grad.  Can you elaborate on why you can't imagine a new grad in this type of position?  Thanks

[KMD16]

For a new grad yes. In addition, I would get a FM or IM outpt clinic gig as well. All in an attempt to walk you way up in the ED. Things would makes a lot heck of sense if you do.

[EMEDPA]

I recognize this is an old thread but I'm considering an ER job like this as a new grad.  Can you elaborate on why you can't imagine a new grad in this type of position?  Thanks

a new grad (unless they were a former medic or er rn) probably lacks the judgement to do this type of work right out of school. if you don't know all the differentials yourself without asking another PA or your SP how can you make triage decisions independently for the whole dept?

[GetMeOuttaThisMess]

^^^

[treejay]

Well I just spoke with the lead PA in the ED and he says half of each shift of this job would be in triage and half in the main ED.  It's tempting because EM is what I've been focused on doing for years leading up to PA school.  This is the only EM job I've been offered at this time.

 

Right now on the table, I have the aforementioned EM job offered and an outpatient IM offer with a solid group.  Tearing myself apart trying to choose which job to take.  Locations are quite different too.  I prefer the location of the IM job, and would have to make a substantial relocation for the EM job.  But I'm trying to break into EM as a PA and I'm seeing this as a good way to do it.  I know nobody can help me make up my mind but I'm open to suggestions.

[GetMeOuttaThisMess]

Here's a question that I think is being overlooked with many of these ED threads. What do you want to accomplish/see in the ED? In other words, why EM? The reason why I ask is that I think many who want EM want the gun/knife club and I would argue that unless you're like EMEDPA where in one of his locations he's the only game in town, you're probably not going to see much of this, unless you're in a suburban/smaller local ED that's equivalent to a level II where you and the ED physician are all that's available. If a large metro area, especially with a teaching affiliation, I suspect you'll get pushed to the back burner. If this is the case then urgent care may be just as fulfilling if you're seeing the same type of clientele. Hospitalist positions may be more to the liking of some of these individuals. Scheduling would be similar for the UC as it would with EM.

[True Anomaly]

Well I just spoke with the lead PA in the ED and he says half of each shift of this job would be in triage and half in the main ED.  It's tempting because EM is what I've been focused on doing for years leading up to PA school.  This is the only EM job I've been offered at this time.

 

Right now on the table, I have the aforementioned EM job offered and an outpatient IM offer with a solid group.  Tearing myself apart trying to choose which job to take.  Locations are quite different too.  I prefer the location of the IM job, and would have to make a substantial relocation for the EM job.  But I'm trying to break into EM as a PA and I'm seeing this as a good way to do it.  I know nobody can help me make up my mind but I'm open to suggestions.

The post you quoted from me was when I was just starting out as a PA during my residency. Now that I've got a few more years experience in the ER, I feel even stronger about my point for pretty much the reasons that EMEDPA laid out. Without a good differential dx (which is hard for ANYONE, even new grads with prior pre-PA healthcare experience) and a good feel for "sick vs not sick", it can really put the providers in back and the department in a precarious position.

 

I know you're really eager to jump into the EM game, and GetMeOuttaThisMess brings up good points as to what you're ultimately looking for in an ER job, so that's definitely food for thought. If your heart is set on it though, none of what we say will matter :) But I would find out exactly what it is that they want out of you in triage- are you simply replacing the nurse and assigning a triage score of 1 (peri-code situation) to 5 (non-urgent)? Or are you actually ordering tests and medications to help expedite the process of someone being seen in an ER? Situation 2, to me, is the only reason why a doc or PA/NP should be placed in triage- not allowing you to order tests/meds and just doing triage is a waste of resources. But....that's provided you have the experience to know what to order. Ordering unnecessary CTs, Xrays, lab tests (D-dimers and troponins on everyone who has a twinge of dyspnea and chest pain, for example) can not only cost money that wasn't needed in the first place for these tests, but you also can also influence the overall disposition of the patient and lead to MORE unnecessary testing and hospital admissions that might have been saved otherwise.

 

For example, let's say you have a 23-year old with no risk factors who comes to the ED because they have "chest pain" for the past 2 days. During their triage, you also add on a high-sensitive troponin assay. They go to the back to be seen by someone else. It may end up being positive because it's so sensitive but not exactly specific that they end up having to stay overnight and be seen by cardiology. Or maybe the troponin is negative, but the phenomenom of "test inertia" leads the doc/provider to put the patient in the hospital overnight for serial enzymes and stress test in the AM. Now they're taking up a hospital bed for an unnecessary stress test because someone else got a sign out of a young pt with chest pain who had a troponin evaluation so now we're obligated to pursue it because there was one provider who felt the troponin was necessary. And let's say the stress comes back "slightly positive". Well, that pt isn't going home now, even though a stress test isn't exactly very specific or sensitive either- and there are several different stress tests to choose from, all of which have their own sensitivity/specificity profile! Now, they get the "gold standard"- the cardiac cath. Lots of radiation, lots of nephrotoxic dye- and their coronaries are completely clean because, guess what, they're 23 and had no risk factors! If they had been risk-stratified properly in the beginning, the "testing inertia" might have been halted before it began. Not to mention all the complications that can come from all this testing and hospital admission- exposure to hospital pathogens, side effects/complications from the cardiac cath (kidney failure, central vessel bacteremia) and the like.

 

Seeing patients in the ED requires a healthy appreciation for the concept of "pre-test probability"- ie, how likely is this patient in front of me, given their history and physical, to have the disease states that I'm worried about? And what will it take, testing-wise, for me to arrive at either one of two dispositions- discharge or admission?

 

I know this was really long, and I'm honestly not trying to scare you away from taking the job- if the docs are willing to work with you and it's a good system that can gradually ease you into the world of EM without feeling like you're gonna be left hanging out on a limb, then it might be worth a shot. Just some food for thought as to what working the ER might entail.

[EMEDPA]

Here's a question that I think is being overlooked with many of these ED threads. What do you want to accomplish/see in the ED? In other words, why EM? The reason why I ask is that I think many who want EM want the gun/knife club and I would argue that unless you're like EMEDPA where in one of his locations he's the only game in town, you're probably not going to see much of this, unless you're in a suburban/smaller local ED that's equivalent to a level II where you and the ED physician are all that's available.

my 2 high autonomy positions are both rural, so while there is trauma(mostly of the mva variety or farm accidents, etc) there is not a lot of knife/gun club type stuff. At my full time inner city position any significant trauma(and they do get a decent amount) is taken over by the in-house trauma team almost as soon as the pt arrives. at both rural facilities a typical sick pt is an elderly medical pt with sepsis, chf, etc which I find a lot more interesting than trauma. for all intents and purposes, serious trauma is surgical disease, so once you have done your 15 min stabilization the next step(if they need it) takes place in the o.r.

my last shift at my solo rural gig I had a medical code, an elderly code stroke inside the TPA window(who opted not to get TPA), an elderly chest pain worrisome for PE, and a kid with an anaphylactic reaction to nuts. during those few hrs the pts with minor stuff had to wait. that's just how it is.

[ajnelson]

I know you're really eager to jump into the EM game, and GetMeOuttaThisMess brings up good points as to what you're ultimately looking for in an ER job, so that's definitely food for thought. If your heart is set on it though, none of what we say will matter :) But I would find out exactly what it is that they want out of you in triage- are you simply replacing the nurse and assigning a triage score of 1 (peri-code situation) to 5 (non-urgent)? Or are you actually ordering tests and medications to help expedite the process of someone being seen in an ER? Situation 2, to me, is the only reason why a doc or PA/NP should be placed in triage- not allowing you to order tests/meds and just doing triage is a waste of resources. But....that's provided you have the experience to know what to order. Ordering unnecessary CTs, Xrays, lab tests (D-dimers and troponins on everyone who has a twinge of dyspnea and chest pain, for example) can not only cost money that wasn't needed in the first place for these tests, but you also can also influence the overall disposition of the patient and lead to MORE unnecessary testing and hospital admissions that might have been saved otherwise.

 

For example, let's say you have a 23-year old with no risk factors who comes to the ED because they have "chest pain" for the past 2 days. During their triage, you also add on a high-sensitive troponin assay. They go to the back to be seen by someone else. It may end up being positive because it's so sensitive but not exactly specific that they end up having to stay overnight and be seen by cardiology. Or maybe the troponin is negative, but the phenomenom of "test inertia" leads the doc/provider to put the patient in the hospital overnight for serial enzymes and stress test in the AM. Now they're taking up a hospital bed for an unnecessary stress test because someone else got a sign out of a young pt with chest pain who had a troponin evaluation so now we're obligated to pursue it because there was one provider who felt the troponin was necessary. And let's say the stress comes back "slightly positive". Well, that pt isn't going home now, even though a stress test isn't exactly very specific or sensitive either- and there are several different stress tests to choose from, all of which have their own sensitivity/specificity profile! Now, they get the "gold standard"- the cardiac cath. Lots of radiation, lots of nephrotoxic dye- and their coronaries are completely clean because, guess what, they're 23 and had no risk factors! If they had been risk-stratified properly in the beginning, the "testing inertia" might have been halted before it began. Not to mention all the complications that can come from all this testing and hospital admission- exposure to hospital pathogens, side effects/complications from the cardiac cath (kidney failure, central vein bacteremia) and the like.

 

Seeing patients in the ED requires a healthy appreciation for the concept of "pre-test probability"- ie, how likely is this patient in front of me, given their history and physical, to have the disease states that I'm worried about? And what will it take, testing-wise, for me to arrive at either one of two dispositions- discharge or admission?

 

 

And this right here is the problem with in having providers in triage (whether it be a doc, PA or NP).  In the facilities I've seen this type of set up in, many providers (docs included) will just order the whole kit and caboodle on these people.  Every belly pain gets labs, CT and/or US, without really talking to and examining the patient. Then when someone actually goes back and gets an accurate and FULL history and physical exam, we find that almost none, if not all of this was not necessary....

In my area, they have used the provider in triage to help get "door to doc" times down.  I feel these artificial metrics are truly a disservice to our patients as we are looking to push these arbitrary numbers instead of truly caring for the patients in the best way possible and not provide them any further harm.  Medicine is about doing a good history and physical to determine our diagnosis.  The ancillary testing should be used to guide diagnosis. 

[EMEDPA]

agree with ajnelson above.

all the artificial metrics used to judge "quality" actually do a disservice to the pt.

I would rather hear that my colleagues think I am a quality medical provider than ask 10 random pts out of the 100 I have seen this week if they think that my withholding of abx when they had a uri was good care or not or whether refusing to refill their oxycodone for chronic back pain was a good idea or not....the issue is that for the most part the avg pt does not know what good medical care is. they equate it with getting what they want which might not always be in their best interest.