1. 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

2. “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.

3. The 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

4. 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 / 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

5. 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 / “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

6. 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 / Determines severity of prisoner’s current chief complaint / Helps allocate limited resources in most effective manner / Assists in preventing the system from becoming overwhelmed

7. Spot Checking-Mass Casualty Model / Gravely injured / Moderately injured / Minor Injury / Gravely injured / Moderately injured / Minor Injury

8. Traffic Director- Physician Office Model / A non clinical employee schedules the patient, can be moved up in priority based on “impressions”

9. 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

10. 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.

11. 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 / 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

13. 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. / 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.

14. 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 / 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

15. 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.

16. 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.

17. 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.

18. 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

19. “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

20. The 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

21. / 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

22. Dental 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

23. Dental 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

24. 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 / 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

25. Dental 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

26. Mental 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

27. Mental Health / Level 2 / Psychosis unable to perform ADL’s / Level 2 / Psychosis unable to perform ADL’s

28. Mental 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

29. Mental Health / Level 4 / Administrative issues / Medication management / Level 4 / Administrative issues / Medication management

30. 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 / 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

31. Avoiding 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

32. 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