Embed Size (px)
Citation preview
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
