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Nursing Triage: How to Ensure Appropriate Care Delivery With limited Resources Mark Ellsworth, RN, BSN, CCHP Dr. Todd Wilcox, MD, MBA, CCHP-A
“Learning Experiences” Prisoner submits a Sick call request for low back pain. Seen by provider, diagnosed with chronic low back pain, given Tylenol. 2 weeks later, Patient complains of increased back pain, submits new kite every day for a week. Never seen in person, the paper triage disposition is “you have already been seen for this” Patient becomes a man-down, sent to ER where he is diagnosed with an acute abdominal aneurysm and died.
The Problem • Clinical mistakes being made under old system • Scheduling issues • Doctors frustrated • Nurses frustrated • Officers frustrated • Patients frustrated • Litigation exposure
The Solution • Redesign triage • Train up nurses to standardize skill set and knowledge base • Create an on-site nursing program • Physicians teach the curriculum • Skills pass off • CQI to revise curriculum and address problems
Definition of Triage • “To sort” • “Sorting of patients and setting priorities for their treatment in urgent care settings, emergency rooms, clinics, hospitals, and health maintenance organizations.” • Tabors Cyclopedic Medical Dictionary, 2001
Purpose of Triage • Determines severity of prisoner’s current chief complaint • Helps allocate limited resources in most effective manner • Assists in preventing the system from becoming overwhelmed
Spot Checking-Mass Casualty Model • Gravely injured • Moderately injured • Minor Injury
Traffic Director- Physician Office Model • A non clinical employee schedules the patient, can be moved up in priority based on “impressions”
Comprehensive Triage-Emergency Severity Index Model • Based on 5 levels of Acuity • An experienced nurse completes a comprehensive assessment • Adopted by most hospital ER’s
Clinical Case Prisoner submits sick call request for leg and back pain. Paper triage done, patient never evaluated, triage given a “routine” appointment which meant 3 week wait. Prisoner begged housing nurse and officers to have him seen, they responded with “submit a sick call”. Prisoner collapsed 2 days later, found to have totally necrotic leg from necrotizing fasciitis. Sent to ER, prisoner underwent a hemipelvectomy, ended up in hospital for a long time, huge bills, ultimately died, family sued for deliberate indifference , won several million dollars.
Keys to Performing Triage • Experienced Nurses • Encourage intuitive skills • Empower Nurses to use the skills they have been taught • Support Nursing with appropriate ancillary staff, you will loose the efficiencies of your nurses if you turn them into HUC’s
Building a 5 Tier System • Level 1=Resucitation or life or limb conditions, that demand care immediately. • Examples: Apnea or severe respiratory distress. Pale, diaphoretic and lightheaded or weak, hypotension.
Building a 5 Tier System • Level 2=High risk situations that will deteriorate if left untreated. • Examples: At risk vital signs, severe pain, lacerations, recent injury and pain increases with movement
Building a 5 Tier System • Level 3= Stable patient, chief complaint does not fall into nursing’s ability to care for with a nursing intervention, and is not in queue for a clinician follow up.
Building a 5 Tier System • Level 4= Stable patient who will need multiple resources prior to appointment. These can be administrative or diagnostic in nature.
Building a 5 Tier System • Level 5= Nursing interventions. Chief complaint can be treated by implementing a nursing care plan or a verbal order by a clinician.
Content of a good assessment • Talk with each and every inmate who has a completed sick call request (kites). • Face-to-face contact--Illogical and improper to base your healthcare delivery system on the written skills of a 4th grader (AT BEST) describing their problem • Obtain complete vital signs--all 5!!! • Focus assessment on chief complaint • Assign a priority for provider scheduling • Triage cannot be re-prioritized unless prisoner is seen face-to-face
“Protocols” • Nurses can implement nursing interventions • Cannot Diagnose or implement medication without order of clinician • Contact clinician for questions or orders
The Keys to Performance • Front load completion of resources. • Resources=labs, x-rays, ECG, serial vital signs, signed consents for medical records
Clinicians and nurses don’t always agree on the triage priority. • Evolving process • Dynamic • Continual refinement, quality feedback and education is essential for ALL professionals involved
Dental Triage • Level 1 • Some abscesses can fall into this category so it is advisable to call
Dental Triage • Level 2 • Trauma with symptoms • Tooth decay with severe symptoms • Wisdom teeth with severe pain and swelling • Visible facial swelling
Dental Triage • Level 3 • Trauma without symptoms • Bleeding gingiva with pus or necrosis • Tooth decay with symptoms • Loose tooth with pus or gingival swelling • Wisdom teeth • Ulcerative lesion • Sessile lesions
Dental Triage • Level 4 • Bleeding gingiva • Tooth decay without symptoms • Loose tooth without symptoms
Mental Health • Level 1 • Suicidal ideation • Threat of harm to others damage to facility
Mental Health • Level 2 • Psychosis unable to perform ADL’s
Mental Health • Level 3 • New mental health chief complaint • Patients in treatment with changes in symptoms
Mental Health • Level 4 • Administrative issues • Medication management
Avoiding Pitfalls • Must see the patient in person • Read the sick call request • Verify the history • Obtain complete set of vital signs, focused assessment • Assign triage grade • Research the chart for additional information • Document your care
Avoiding Pitfalls • It is imperativethat you see & talk with the inmate • It is imperative that a complete set of vital signs be documented • There is no right or wrong answer • Prioritize scheduling to the best of your ability • Practice brings confidence, confidence brings refined skills
Slides available at www.wellcon.net • Resources • Emergency severity index;www.ahrq.gov/research • Emergency Nursing 5-Tier Triage Protocols, J.K.Biggs, V.G.A. Grossman