The Art of ER Triage

Guest Post By: Richard D Ramsey

Triage is quickly becoming a lost art.

For those of you who don’t know, triage is the art of adding degrees of urgency to medical matters. For highly trained medical personnel, it’s a rapid process.

I can look at a room full of about 50 people and tell you if any of them are critically ill in about ten seconds. It’s the way ER nurses are taught to think and process information. Secondarily, we’re trained to take vital signs and ask the right questions to determine if a medical matter deserves immediate attention or not.

But, this skill is being eroded under the paradigm of patient satisfaction, that grim specter that’s killing healthcare from the inside out. Let me take you back to an emergency room twenty years ago. You go to the ER for whatever is ailing you, and the first person you encounter is the triage nurse. This person makes note of your chief complaint, takes your vital signs, and gives you a quick once over. Your treatment plan starts right then and there.

Emergency Rooms aren’t just spaces with cubicles. They’re set up in verities of ways to accommodate different needs. In fact, most ERs have minor care areas where you can be seen for bumps or bruises without having to compete with the critically ill. Also, they have different rooms with capabilities. Some rooms are larger than others, giving more room to work on more critical people. Some rooms have oxygen, some rooms have toilets, and some rooms are even better suited for pelvic exams. In a majority of hospitals, rooms are assigned to nurses in bundles. When a nurse comes on duty, they’re assigned a bundle of rooms, and they rotate patients in and out of those rooms throughout the day.

The triage nurse and the charge nurse (which is my role in the ER) must have a good working relationship and line of communication. Together, we determine where patients can be placed to maximize outcomes and efficiency. Knowing my team of nurses is important in determining this. I need to know everyone’s experience, particular skill set, strengths, and weaknesses. These factors are an important part of where I’m going to place you in the ER. Sounds logical, right? You would think so.

Let’s skip forward to today. Third-party payer systems (Medicaid, Medicare, insurance, HMOs, etc.) have warped competition between healthcare companies. When you choose which gasoline to put in your car, you usually chose the cheaper option. That’s why fuel stations post their prices on their signs. With emergency care, you don’t care how much it costs. Your third-party payer covers it, and you’re just responsible for the copay. Even if you’re not covered, you can still be seen and opt to get a bill in the mail. There is NO INCENTIVE for hospitals to lower their cost of goods and services. I’ll say that again. There is NO INCENTIVE for hospitals to lower their cost of goods and services.

So where does that leave us? Hospital A still wants your business over hospital B. So, how do they compel you to use their service over the competition? Simple, they’re going to gratify you.
There’s so much we could discuss about how the paradigm of patient satisfaction has changed healthcare, but we’re here to talk about triage. Remember the triage nurse we were talking about earlier? A recent development in the race to the bottom of patient satisfaction is called immediate bedding. Immediate bedding is exactly what it sounds like. You walk into an ER and they immediately place you in a bed. This has come about as a result of satisfaction metrics, like “door to doc” time. That’s the time it takes you to see a doctor after you walk in the door. Metrics just like that are the new driving force behind how healthcare is run. This has even become such a big deal that Medicaid and Medicare reimbursement is being attached to it under the pretense of “quality indicators” as implemented by laws like Obamacare.

Just look at the billboards in your hometown. Signs that tell you how long the wait at Emergency Room X is have sprung up left and right! This sounds like a great plan, and in some respects, it is. It’s practical to get patients in front of doctors faster. That is why they come to the ER, and we shouldn’t arbitrarily hinder that process. But, the devil is in the details. When we “immediate bed” patients, we’re not taking those critical five minutes to find the best place for them so we can maximize outcomes for everyone. A child with an earache is placed immediately in a critical area because that’s where the open beds are poor stewardship of resources, and it’s highly inefficient.

In the dawn of the 21st century, when people are living longer, and those with chronic illnesses are surviving them, our ER clientele as a whole is getting larger and sicker. Skipping steps in their health care plan to improve satisfaction metrics is both inappropriate and dangerous. Be relieved if you have to wait a few minutes in the ER. It’s the people that go ahead of you that are in the worst shape. They had a competent triage and charge nurse that made that decision based on objective data.

About Richard Ramsey:  I’ve been in nursing since 1995 and full-time ER since 2000. I live in Deep East Texas with my wife and my teenage son. As well as nursing, I play music, write (having many fiction books published) and appear on TV shows from time to time; most notably “Untold Stories of the ER,” where I wrote and acted in episodes for seasons 9 and 10.