Timothy:
Thanks for the clarification on who can perform MSE, I wasn't aware some
states didn't allow RN's to do so.
Absolutely an ESI is not and won't stand as an MSE, it wasn't intended to.
That's why, in our system anyway, we have a designated MSE RN. As we do have a
peds and ortho clinic which is off-campus, referring, even immediately, a
patient to the clinic falls within the EMTALA guidelines hence a full MSE is
performed. We have a standardized procedure that defines who may perform MSE,
what types of pt can be sent out, etc. Being a self-contained HMO also helps.
As far as the medics go, coming from a 20 year stint as a medic prior to
nursing school, I agree with you, ED triage is not like field triage. We are,
however talking about Gail's particular scenario of a greeter-type person.
Ideally having an RN meet them at the door would be wonderful, would serve not
only the function of "screener" but is also a tool of the hospital's public
affairs department. Could a medic be taught that specific function, yes in the
same way we teach our EMT's in our department splinting with plaster. I would
like to point out not all RNs make good triage folks either. It's both a
knowledge and experience based skill. Also, not everyone is comfortable
performing the task either.
As we do know, who ever performs your ESI and MSE should be one of the most
experienced folks in the department.
Having worked a rural EDs even smaller than Gail's, the reality is one often
has to make compromises just to survive in the current healthcare environment.
In most cases we ED nurses don't have the final say as to how things will be
done but we can have a great influence upon it. Personally, I think the ED RN is
the perfect greeter and screener and could offer a compelling argument as to why
to management.
I am fortunate to work for an employer who has seen the light and doesn't
place me in Gail's position of having to do so.
Dave


----- Original Message -----
From: Timothy Marks
To: emergency-nurse@yahoogroups.com
Sent: Sunday, October 05, 2008 7:56 PM
Subject: RE: [emergency-nurse.org] Triage question



Be care ful to review your nurse practice act for your state and your
institution's policy.
In many states (I thought all) nurses are not allowed to perform a MSE. ESI is
a ENA recommendation and should be adopted if possible over three level triage
systems but is in no way a MSE.
All triage should be performed by a qualified RN, paramedics, although good at
field triage, are not trianed like nurses and may miss some patient cues that
could lead to a medical/legal disaster. Triage is one of the most important
parts of the ED. However, in smaller institutions when there is always a bed
open and patients walk in and go directly to a bed for triage a triage nurse may
not be neccesary...but if the rooms are full and patients need to be sorted
based on acuity or resource consumption a qualified RN should be in this
position.

http://www.medlaw.com/handout.htm#mse

Timothy D. Marks, RN, MSN, CEN
Clinical Advanced Practice Nurse- EDtimdoggrn@... timdoggrn@...

To: emergency-nurse@...: d.fromer@...: Sun, 5 Oct
2008 18:05:28 -0700Subject: Re: [emergency-nurse.org] Triage question

Gail:California has a regulation that states in essence that a triage nurse
can have no other duties. They can assist in some other functions but must be
immediately available to triage. That said, I work for the Kaiser Hospital chain
in northern California. What we have adopted for use as a triage tool is the
Emergency Severity Index (ESI) and utilize it quite religiously with great
result. As we have clinics both on and off-campus, we triage -actually MSE -
many patients in the 4 and 5 categories to our clinics directly or, when they
are closed, to the waiting room until we can get them.With the exception of the
night shift which utilizes the charge nurse to MSE/triage, we have a dedicated
triage nurse whoose sole function is to medically screen everyone who comes in
the door. We also have an additional nurse, for when the volume picks up
(usually a charge nurse as they don't take a patient assignment) who will do the
ESI which, if you aren't acquainted with the system, gauges the patient's
complaint to the number of resources may be needed to deal with it, the lower
the number the greater the number of resoucres and sicker the patient. If we
have the room in the department, anyone with an ESI of 1, 2 or 3 are brought
back into the department and a complete bedside triage/MSE is performed by that
patient's nurse. Anyone with a 4 or 5 ESI is informed to have a seat and the MSE
nurse will get to them, perform the complete eval and then send them on to our
clinics.We are usually able to screen away conservatively 70% of those that
present to the window when the clinics are open (1AM). Our goal is an ESI within
5 minutes and complete MSE within 30 or less. We have the highest satisfaction
scores in our region. Given your situation, it would strike me that hiring an
EMT or paramedic to be your concierge would be more cost effective. They are
more than capable of performing a basic ESI triage (if trained) and would allow
you the ability of pulling the RN devoted to that task into a full time triage
nurse. ESI does not meet the requirements set forth in EMTALA for a medical
screening exam which requires the MSE be performed by either a MD or qualified
RN but it does allow you to move people quickly, utilize your resources more
appropriately and frankly, save some money.Hope that answers your
question.Dave----- Original Message ----- From: northeastlnc To:
emergency-nurse@yahoogroups.com Sent: Thursday, October 02, 2008 5:03 PMSubject:
[emergency-nurse.org] Triage questionQuestion for all you talented ER nurses.I
work in a small rural ER (70 bed hospital). We have a "concierge" at the
entrance to the hospital (RN position). She is mostly for the ER, but also helps
direct pts to other areas of the hospital. At this point, when a pt comes in for
the ER, she asks them their chief complaint after walking them into the waiting
room, and trying to provide a little privacy. This is written on a paper and
brought into the ER. THen the triage nurse goes and brings the pt in, or the
paper is hung if the triage nurse is busy. Other nurses take this patient in to
a room if they have an availabe. If it is a pt that needs to come right in, ie
chest pain, stroke symptoms etc, the concierge brings them into a room or stands
at the nursing station until someone takes the pt in.....Management wants to
change this so that the concierge is not so involved in the ER, and more as a
greeter. I am on the comittee as an ER nurse. We do not have enough staff to
have a triage nurse sit in triage, and I have pointed out that we rely heavily
on the concierge to be our eyes and ears. Can you email me privately how the
process works in your ER (especially smaller ER's). We are a coastal ER, and the
summer are SWAMPED, but in the winter things slow down a bit. Thank you so
much.Gail Hendricksonnortheastlnc@... am fighting to keep this RN more for
the ER, or we need to increase our staff to have a nurse always in triage.
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