Nursing Triage: How to Ensure Appropriate Care Delivery With limited Resources Mark Ellsworth, RN,...

Nursing Triage: How to Ensure Appropriate Care

Delivery With limited Resources

Nursing Triage: How to Ensure Appropriate Care

Delivery With limited Resources

Mark Ellsworth, RN, BSN, CCHP

Dr. Todd Wilcox, MD, MBA, CCHP-A

Mark Ellsworth, RN, BSN, CCHP

Dr. Todd Wilcox, MD, MBA, CCHP-A

“Learning Experiences”“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.

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 ProblemThe Problem Clinical mistakes being made under old

system Scheduling issues Doctors frustrated Nurses frustrated Officers frustrated Patients frustrated Litigation exposure

Clinical mistakes being made under old system

Scheduling issues Doctors frustrated Nurses frustrated Officers frustrated Patients frustrated Litigation exposure

The SolutionThe 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

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 TriageDefinition 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

“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 TriagePurpose 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

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

Spot Checking-Mass Casualty Model

Gravely injured Moderately injured Minor Injury

Gravely injured Moderately injured Minor Injury

Traffic Director- Physician Office Model

Traffic Director- Physician Office Model

A non clinical employee schedules the patient, can be moved up in priority based on “impressions”

A non clinical employee schedules the patient, can be moved up in priority based on “impressions”

Comprehensive Triage-Emergency Severity Index

Model

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

Based on 5 levels of Acuity An experienced nurse completes a

comprehensive assessment Adopted by most hospital ER’s

Clinical CaseClinical 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.

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 TriageKeys 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

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

No

Requires immediate life-saving intervention

or high risk situations

The patient is stable but could deteriorate if treatment is delayed

Triage Algorithm

No

Consider

No

1Yes

2

Yes

evaluate need for differential testing

none one many

4 3danger zone

vitals?

HR >100RR >20

SaO2<92%

3

Building a 5 Tier SystemBuilding 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.

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 SystemBuilding 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

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 SystemBuilding 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.

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 SystemBuilding a 5 Tier System

Level 4= Stable patient who will need multiple resources prior to appointment. These can be administrative or diagnostic in nature.

Level 4= Stable patient who will need multiple resources prior to appointment. These can be administrative or diagnostic in nature.

Building a 5 Tier SystemBuilding 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.

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

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

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”“Protocols”

Nurses can implement nursing interventions

Cannot Diagnose or implement medication without order of clinician

Contact clinician for questions or orders

Nurses can implement nursing interventions

Cannot Diagnose or implement medication without order of clinician

Contact clinician for questions or orders

The Keys to PerformanceThe Keys to Performance

Front load completion of resources. Resources=labs, x-rays, ECG,

serial vital signs, signed consents for medical records

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

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 TriageDental Triage

Level 1 Some abscesses can fall into this

category so it is advisable to call

Level 1 Some abscesses can fall into this

category so it is advisable to call

Dental TriageDental Triage

Level 2 Trauma with symptoms Tooth decay with severe

symptoms Wisdom teeth with severe pain and

swelling Visible facial swelling

Level 2 Trauma with symptoms Tooth decay with severe

symptoms Wisdom teeth with severe pain and

swelling Visible facial swelling

Dental TriageDental 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

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 TriageDental Triage

Level 4 Bleeding gingiva Tooth decay without symptoms Loose tooth without symptoms

Level 4 Bleeding gingiva Tooth decay without symptoms Loose tooth without symptoms

Mental HealthMental Health

Level 1 Suicidal ideation Threat of harm to others damage

to facility

Level 1 Suicidal ideation Threat of harm to others damage

to facility

Mental HealthMental Health

Level 2 Psychosis unable to perform ADL’s

Level 2 Psychosis unable to perform ADL’s

Mental HealthMental Health

Level 3 New mental health chief complaint Patients in treatment with changes

in symptoms

Level 3 New mental health chief complaint Patients in treatment with changes

in symptoms

Mental HealthMental Health

Level 4 Administrative issues Medication management

Level 4 Administrative issues Medication management

Avoiding PitfallsAvoiding 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

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 PitfallsAvoiding Pitfalls It is imperative that 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

It is imperative that 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 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

Resources Emergency severity

index;www.ahrq.gov/research Emergency Nursing 5-Tier Triage

Protocols, J.K.Biggs, V.G.A. Grossman