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Nursing triage indispensable to ED care: “Zero waiting room time” has been proved a fad
, Nursingtriage indispensableto EDcare: “Zero waitiniroor6 time” hasbeenproved a fad Dear Editor: Prompted by a recent Journal article on triage by Gilboy et al (1999;25:468-73), I write to share with Journal readers some triage-related experiences. I have managed emergency departments in New York and Arkansas and currently work in a community hospital in Illinois. Medical directors at all 3 institutions have sought to eliminate the triage function because of the perception that this function causes an unnecessary delay in the treatment process. They envision a system in which the patient is met by a nurse in the reception area and is immediately brought back to the appropriate stretcher. If the patient is brought back to the appropriate stretcher, then the director has not eliminated triage, but rather has just redefined it. Triage was developed in the military as a means of effectively distributing resources inadequate to the task at hand. In emergency departments we used to do it by eyeball, then progressed to chief complaint; temperature, pulse, and respiration/blood pressure/ oximetry; medical history; allergies; and medications. We did it to enable the more efficient operation of an emergency department that is not a delicatessen and that often lacks the resources to provide immediate down-front seating for all guests. Now, in the interest of superficial patient satisfaction, marketing, favorable quality improvement statistics, and apparent appropriateness in the sequencing of treatment and billing, we are abandoning the concept of sorting in favor of “have it your way.” Accomplishing zero waiting room time (ZWRT) necessitates having ED physical and human resources capable of expanding to accommodate N + 1 patients, where N equals the busiest day you ever had. Facilities that lack these resources (flexible staff resources being particularly expensive) will eventually J Emerg Copyright
Nurs 2000;26:6-7. 0 2000 by the Emergency Nurses 0099-1767/2000 $12.00 +0 18/84/104311
6 Volume 26, Number 1
Association
have to resurrect triage, presumably without the resources to do so, because, in eliminating triage, the space and staff to perform it will have been eliminated. I believe that ZWRT is a fad, a product of poor advice from attorneys, marketers, and quality improvement consultants in the age of managed care and the Emergency Medical Treatment and Active Labor Act. Customer satisfaction is certainly related to ZWRT, but it is also related to good outcomes in the emergent and critical categories of ED care. Achieving ZWRT is difficult without sacrificing the resources necessary for cases of these categories within the physical and budgetary constraints of most emergency departments.-Mike Brennan, MS, RN, Staff Nurse, Emergency Department, Holy Family Medical Center, Des Plaikes, Ill
Lymevaccine:Somecaveats Dear Editor: The Food and Drug Administration has recently approved a Lyme disease vaccine. However, use of this vaccine has some caveats of which nurses should be aware before suggesting it to patients, especially in an emergency department. 1. Being vaccinated may allow Lyme disease to develop without the characteristic rash, and thus the first symptoms may be arthralgias and arthritis, or worse, cardiomyopathy or encephalitis. In this case, the diagnosis and treatment will almost certainly be delayed or entirely missed. 2. The vaccine’s efficacy of 78% pales next to the 95% to 98% effectiveness of early treatment with various antibiotics. A very reasonable and perhaps preferable course to take is to treat a patient for Lyme disease when one has a high index of suspicion. 3. The vaccine course is expensive-about $300, with discounts. 4. The vaccine has adverse effects, many of which are probably unknown at present. Thanks for your kind attention.-David Davis, MD, JD, Emergency Physician, North Arundel Hospital, Glen Burm’e, Md
IOLJRNAL
The most important scientific breakthrough of the last millennium Dear Editor: I read with interest the Journal article by Iris Frank in which she surveyed others for a listing of the most important contributions to medicine in the last millennium (1999;25[61:23A-25A). Most of the contributions listed were, arguably, some of the most important scientific breakthroughs to which humankind can lay claim. However, they were achieved by people who stood on the shoulders of giants, and not necessarily scientific giants Take Johannes Gensfleisch Gutenberg, for example. Sometime around 1452 he borrowed some money from Johan Fust and built the first printing press. (Movable type had been used for centuries in China, but never for printing books.) Every medical text, journal, and package insert we have gone blind trying to read at 3 AM was printed with some mechanical descendent of Gutenberg’s press. Whether you consider medicine a scientific form of art or an artful application of science, it builds upon itself. The information that allows medicine to do so is recorded, passed on, reinterpreted, re-recorded (2nd editions, 3rd editions, etc), translated, put on the Web, and broadcast globally. Gutenberg hoped to make enough money by printing Bibles to pay off debts he had incurred as a failed businessman, He did not do so. In 1455 he even lost his printing press to Fust. However, the wealth of information he has allowed us to amass and apply to medicine (and every other human endeavor) has left us all the richer. Right on Gutenberg’s heels is, of course, the person who invented the deep fat fryer. This device has given rise to the donut, the french fried potato, and those beignets at Cafe Du Monde.--Bill Fults, Medical Training Officer, US Army. 75th Ranger Regiment, Fort Benning, Ga
Innovative plan for drug-seeking patients Dear Editor: I thought that Journal readers might be interested in knowing about an innovative program that has worked well in our emergency department. We are a small (lo-bed) department that in the past had a huge population of drug-seeking individuals before we devised with a plan to deal with them. We developed a “Medical Management Plan” that is initiated by the person’s primary care physician (PCP) or by the Urgent Care Clinic or emergency department. The plan can be
OF EMERGENCY
NURSING
shared among all of us because we are in the same system; furthermore, the patient signs a form saying that the information will be shared with the PCP and other providers in our system. Once a drug-seeking patient is identified and a plan is prepared, all areas have a copy of the plan (one of our ED nurses takes on the task of distributing it). Every time the patient registers, a code alerts registration staff that the patient’s file includes a “Red Dot Alert.” The staff then places a red dot sticker on the chart and sends it to the back. The staff member who checks in the patient sees the red dot and pulls the plan. If the plan has not yet been shared with the patient, the ED physician reviews it with the patient at that time and the patient signs it. If it has already been shared, the patient is reminded about the plan that he or she signed. We have been using this system for 4 years now. It was a lot of work at first, but you would not believe the results! Provision of consistent care throughout the system and the practice of holding doctors accountable if they provide narcotics when they are not supposed to has made the system successful. Of course, we still have patients who come in off the freeway, for example, but our doctors and staff are better able to deal with them because we are used to such patients. A few patients have become upset, but we have security stand outside the door, and most of them sign the form. It is amazing! The “qualifications” for a medical management plan are as follows: Chronic pain disorder, drug-seeking behavior, repeated visits seeking narcotics, altered prescriptions, aggressive mannerisms toward clinical/registration staff, known history of drug abuse, a condition requiring coordination of care among clinical sites, and “other” at a physician’s discretion. The plan of care includes the following: Coordinate care with PCP; PCP only to prescribe all narcotics; no narcotics; cautious use of narcotics; and other. Any patient can be recommended for a Medical Management Plan by ED staff. The recommendation is sent to the ED nurse, who coordinates it, reviews the visits, and presents it to our ED physician director who authorizes the plan. This system has worked very well for us. The old repeaters are long gone (along with our black Rolodex! And the Joint Commission on the Accreditation of Healthcare Organizations liked the plans!) If you have any questions, feel free to E-mail me at dgiboneyQfirstcarehealth.org.-Danette Giboney; RN, BSN, CEN, Staff Nurse, Emergency Department, Albany General Hospital, Albany; Oregon
February2000 7
Nurs 2000;26:6-7. 0 2000 by the Emergency Nurses 0099-1767/2000 $12.00 +0 18/84/104311
6 Volume 26, Number 1
Association
have to resurrect triage, presumably without the resources to do so, because, in eliminating triage, the space and staff to perform it will have been eliminated. I believe that ZWRT is a fad, a product of poor advice from attorneys, marketers, and quality improvement consultants in the age of managed care and the Emergency Medical Treatment and Active Labor Act. Customer satisfaction is certainly related to ZWRT, but it is also related to good outcomes in the emergent and critical categories of ED care. Achieving ZWRT is difficult without sacrificing the resources necessary for cases of these categories within the physical and budgetary constraints of most emergency departments.-Mike Brennan, MS, RN, Staff Nurse, Emergency Department, Holy Family Medical Center, Des Plaikes, Ill
Lymevaccine:Somecaveats Dear Editor: The Food and Drug Administration has recently approved a Lyme disease vaccine. However, use of this vaccine has some caveats of which nurses should be aware before suggesting it to patients, especially in an emergency department. 1. Being vaccinated may allow Lyme disease to develop without the characteristic rash, and thus the first symptoms may be arthralgias and arthritis, or worse, cardiomyopathy or encephalitis. In this case, the diagnosis and treatment will almost certainly be delayed or entirely missed. 2. The vaccine’s efficacy of 78% pales next to the 95% to 98% effectiveness of early treatment with various antibiotics. A very reasonable and perhaps preferable course to take is to treat a patient for Lyme disease when one has a high index of suspicion. 3. The vaccine course is expensive-about $300, with discounts. 4. The vaccine has adverse effects, many of which are probably unknown at present. Thanks for your kind attention.-David Davis, MD, JD, Emergency Physician, North Arundel Hospital, Glen Burm’e, Md
IOLJRNAL
The most important scientific breakthrough of the last millennium Dear Editor: I read with interest the Journal article by Iris Frank in which she surveyed others for a listing of the most important contributions to medicine in the last millennium (1999;25[61:23A-25A). Most of the contributions listed were, arguably, some of the most important scientific breakthroughs to which humankind can lay claim. However, they were achieved by people who stood on the shoulders of giants, and not necessarily scientific giants Take Johannes Gensfleisch Gutenberg, for example. Sometime around 1452 he borrowed some money from Johan Fust and built the first printing press. (Movable type had been used for centuries in China, but never for printing books.) Every medical text, journal, and package insert we have gone blind trying to read at 3 AM was printed with some mechanical descendent of Gutenberg’s press. Whether you consider medicine a scientific form of art or an artful application of science, it builds upon itself. The information that allows medicine to do so is recorded, passed on, reinterpreted, re-recorded (2nd editions, 3rd editions, etc), translated, put on the Web, and broadcast globally. Gutenberg hoped to make enough money by printing Bibles to pay off debts he had incurred as a failed businessman, He did not do so. In 1455 he even lost his printing press to Fust. However, the wealth of information he has allowed us to amass and apply to medicine (and every other human endeavor) has left us all the richer. Right on Gutenberg’s heels is, of course, the person who invented the deep fat fryer. This device has given rise to the donut, the french fried potato, and those beignets at Cafe Du Monde.--Bill Fults, Medical Training Officer, US Army. 75th Ranger Regiment, Fort Benning, Ga
Innovative plan for drug-seeking patients Dear Editor: I thought that Journal readers might be interested in knowing about an innovative program that has worked well in our emergency department. We are a small (lo-bed) department that in the past had a huge population of drug-seeking individuals before we devised with a plan to deal with them. We developed a “Medical Management Plan” that is initiated by the person’s primary care physician (PCP) or by the Urgent Care Clinic or emergency department. The plan can be
OF EMERGENCY
NURSING
shared among all of us because we are in the same system; furthermore, the patient signs a form saying that the information will be shared with the PCP and other providers in our system. Once a drug-seeking patient is identified and a plan is prepared, all areas have a copy of the plan (one of our ED nurses takes on the task of distributing it). Every time the patient registers, a code alerts registration staff that the patient’s file includes a “Red Dot Alert.” The staff then places a red dot sticker on the chart and sends it to the back. The staff member who checks in the patient sees the red dot and pulls the plan. If the plan has not yet been shared with the patient, the ED physician reviews it with the patient at that time and the patient signs it. If it has already been shared, the patient is reminded about the plan that he or she signed. We have been using this system for 4 years now. It was a lot of work at first, but you would not believe the results! Provision of consistent care throughout the system and the practice of holding doctors accountable if they provide narcotics when they are not supposed to has made the system successful. Of course, we still have patients who come in off the freeway, for example, but our doctors and staff are better able to deal with them because we are used to such patients. A few patients have become upset, but we have security stand outside the door, and most of them sign the form. It is amazing! The “qualifications” for a medical management plan are as follows: Chronic pain disorder, drug-seeking behavior, repeated visits seeking narcotics, altered prescriptions, aggressive mannerisms toward clinical/registration staff, known history of drug abuse, a condition requiring coordination of care among clinical sites, and “other” at a physician’s discretion. The plan of care includes the following: Coordinate care with PCP; PCP only to prescribe all narcotics; no narcotics; cautious use of narcotics; and other. Any patient can be recommended for a Medical Management Plan by ED staff. The recommendation is sent to the ED nurse, who coordinates it, reviews the visits, and presents it to our ED physician director who authorizes the plan. This system has worked very well for us. The old repeaters are long gone (along with our black Rolodex! And the Joint Commission on the Accreditation of Healthcare Organizations liked the plans!) If you have any questions, feel free to E-mail me at dgiboneyQfirstcarehealth.org.-Danette Giboney; RN, BSN, CEN, Staff Nurse, Emergency Department, Albany General Hospital, Albany; Oregon
February2000 7