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When a patient is assessed at triage and no beds are available, what happens next in your ED? Instead of sending patients to the waiting room, why not start care immediately? At St. Mary’s Hospital in Tucson, AZ, triage nurses use protocols to immediately initiate care for female abdominal pain, minor orthopedic injuries, and upper respiratory illnesses, says Cassie Pundt, RN, clinical manager for emergency services. (See triage protocols for adult respiratory distress and for abdominal pain.)
The protocols were developed by the triage coordinator and ED physicians and give a set of orders for nurses to implement for patients in each category, says Pundt. "The orders are implemented at triage, so if there is a need to draw blood or give a urine sample, these things can happen before the patient even gets in to see the physician," she explains.
If the patient still is waiting when the test results come back, nurses simply document them on the patient’s chart, adds Pundt. "As soon as the doctor does the medical screening exam [MSE], the results are already back," she says. "This saves us a lot of time."
One test saves 30 minutes
At Morrow County Hospital in Mount Gilead, OH, triage protocols are used for laboratory tests, X-rays, and pain management, says Kimberly Hickman, RN, BSN, director of the ED. "When we identified our throughput as being 140 to 160 minutes, we knew we needed to do something," she says. The protocols are kept in a notebook in the triage area for reference by triage nurses. The nurse initiates a protocol by writing it as a verbal order, and the physician signs off on it when he sees the patient for the MSE, says Hickman.
The rural ED has only seven beds, and patients often are waiting in the hallways, she explains. "Patients are happier because something is being done for them while they are waiting," Hickman says. For example, a rapid strep test is done for patients with sore throat, she says. "If no other work-up is warranted, the physician writes a prescription, if appropriate, and we can get the patient on their way," says Hickman. "In this scenario, doing the rapid strep can cut 30 minutes off a visit."
To significantly increase benefits of triage protocols, take the following steps:
• Train ED nurses in use of protocols. ED nurses attended a series of one-hour mandatory classes presented by the ED doctors on radiology exam ordering, says Mary G. Kelley, MS, ARNP, CEN, triage coordinator. The education for the other protocols was completed by "supertrainer" nurses, says Kelley. "These ED nurses were staff who volunteered to champion the protocol project and were trained by me," she says.
• Compare before and after times. To assess the impact of the protocols on patient flow, Kelley audits charts on an ongoing basis. "When I do chart review, I include time statistics for several patients whom we didn’t use the protocols for, although they met the criteria," she says. "I compare those times to patients who we used the protocol for." The average length of stay for this group of patients is four hours and 37 minutes, and that is reduced by one hour and nine minutes when protocols were used, says Kelley
• Ensure consistent use of protocols. At first, triage nurses were reluctant to use the protocol for patients with possible fractures because they were afraid they would order the wrong X-ray, says Kelley. "Also, if we were busy at triage and not adequately staffed, protocols sometimes took a back seat," she adds. To address the problem, the benefits of the protocols were emphasized to ED nurses, says Kelley. "I report our current length of stay back to the staff," she says.
ED nurses also saw the benefits firsthand when patients rapidly are discharged after having X-rays done, says Kelley. "Patients tell the nurses that it is so much better having the X-rays done ahead of time," she says. "When the nurses see how it satisfies the patient, they are more willing to use the protocols."
There also are dramatic improvements in patient care, says Kelley. For example, the abdominal pain protocol recently was used for a young woman with left lower quadrant pain, with a urinalysis and urine pregnancy test ordered at triage. Within 10 minutes, the technician reported the pregnancy test was positive and the urine test was negative, says Kelley. "She was positive for an ectopic pregnancy, which caught me by surprise because she did not look sick," says Kelley. "I was glad for the protocols."
For more information on use of triage protocols in the ED, contact:
• Kimberly Hickman, RN, BSN, Director of Performance Improvement/Risk Management/ED, Morrow County Hospital, 651 W. Marion Road, Mount Gilead, OH 43338. Telephone: (419) 947-9120, ext. 2750. Fax: (419) 947-8956. E-mail: KHickman@OhioHealth.com.
• Mary G. Kelley, MS, ARNP, CEN, Triage Coordinator, Carondelet St. Mary’s Hospital, 1601 W. St. Mary’s Road, Tucson, AZ 85745. Telephone: (520) 218-0289. Fax: (520) 872-4925. E-mail: email@example.com.
• Cassie Pundt, RN, Clinical Manager, Emergency Services, Carondelet St. Mary’s Hospital, 1601 W. St. Mary’s Road, Tucson, AZ 85745. Telephone: (520) 872-6082. E-mail: firstname.lastname@example.org.