It is an important but under-appreciated skill for ER nurses to be able to go through the JCAHO-required ER screening questions as fast as possible, similar to someone running a farm auction, because we all know that the answers are largely irrelevant to whatever we're about to do.
Oh, so you are an otherwise healthy housewife who cut your finger on a broken glass while washing the dishes and probably need a couple stitches, eh? Let me take your vital signs, determine your pain level, characteristic and location of said pain as if it's not obvious, your last menstrual period (or "the 6th vital sign" as I call it), and the approximate time of your last tetanus shot. Lemme ask you some other stuff:
1) Are you being hit, kicked, pushed or yelled at by anyone important to you? [Then I have to click through another list of things that are "warning signs" of domestic abuse like "neglect in seeking treatment."]
2) Are you allergic to avacados, bananas, or kiwifruit? [Not kidding, actual screening question for a latex allergy]
3) Have you had an unplanned weight loss of greater than 10 pounds in the last 3 months? [Are we going to address this during a visit for a lac? Nope, but still have to ask because we do.] Do you have any trouble chewing or swallowing? Can you afford food? Have you not eaten your usual amount for more than the last four days?
4) Do you have any trouble learning such as vision loss, hearing loss, or a learning disability?
5) Have you had a productive cough for greater than 3 months? Night sweats?
6) Do you have any metal or implanted devices in your body? [A fun one to ask acutely psychotic patients]
7) Have you ever been told you have an MRSA or VRE infection? [I like the answers to this one. "Oh, I'm allergic to sulfa." "I think I have a cold." "I'm diabetic so I get lots of infections." Um, okay.]
Then I have to click through if I think the patient is a known sex offender, known to be violent or is currently threatening and likely to be violent towards staff, or, if in my opinion, the patient is showing signs of suicidality.
Then it's medical/surgical history, med rec (entering names, dosages and frequency of medications taken without using any "banned" phrases like, heaven forbid, 'QD', including herbal supplements and vitamins, I might add) , and FINALLY, a triage note summarizing everything in 2-3 sentences.
Patient arrives by car. Chief complaint is a laceration in right middle finger. Bleeding controlled, no numbness. Tetanus up-to-date.Wow. It's like I could have written the same note without asking any of the screening questions. Go figure.
Picture a more reality-based episode of 'ER' where the happy, prototypically-perfect child with a benign-sounding sore throat suddenly codes in the lobby (every happy child with a benign complaint codes in 'ER' as we all know), except no one rushes in with great fanfare to help the child because they're screening everyone for kiwifruit allergies and the other patients think the poor lad is just sleeping and the parents are off smoking meth in the car in the parking lot. Incidentally, part II of II is entitled "The Lawsuit" and the kiwifruit-screening triage nurse is paraded in front of cameras flanked by her union rep saying "I was just following orders" and allegorical comparisons to Nuremberg are made. Or some shit.
All I'm trying to say:
Imagine if that kiwifruit time could be devoted to, oh, I dunno, retriaging people? Seeing if anyone is deteriorating? Seeing if that little old lady is sleeping in the lobby or crumping? I think turning emergency triage nurses into de facto public health and community wellness nurses is the wrong thing to do. If you're going to make us sing kumbaya with all the patients or else discipline me, my boss or my hospital, don't complain when the triage nurse doesn't catch something bad going on in the lobby.
10 comments:
If you worked in my ER, I would say your could officially answer all these silly questions yourself and move on to more important things. I love it when the RN asks a drunk "have you been a victim of domestic violence" and they are like "ablblblblblblub yeah, hic".
JCAHO, a boondoggle...
I think a more productive way of dealing with all that crap is to LOCK THE JHACO people in an ER, and force them to undergo EVERY SINGLE ONE of their stupid procedures, INCLUDING waiting for pain meds because the Pyxis is malfunctioning, while they're screaming for help. I'm sure they'd be singing a different tune.
They could fill out a questionnaire answering all that crap while they are waiting to be seen.
Or not. As you said, the answers don't really matter anyway.
JCAHO sucks.
Huh. I've never been asked any of those questions. I was once assigned a triage priority number without actually being triaged, though.
I think this will only get much worse. Remember the SBI - Screening and Brief Intervention
for alcohol use, that is supposed to be coming.
We should change the name from Emergency Department to Unfunded Mandate Department.
It is frustrating that you have to ask all the questions...BUT...when DV is a leading cause for murder wouldn't it be nice to be able to help someone who needs that one questions to open up and tell you that no she did not hit her head against the door frame but instead had a glass ashtray thrown at her lead leading to 26 stitches? I know it sucks but it is also frustrating to see a lack of empathy as well for those that do need it just because you don't like the question.
Yeah, but we have to ask MALES too and the domestic abuse advocates won't even see males. At least limit it to females. I don't mind helping people out; I do mind being told that I have to ask elderly males having chest pain though. Screening "everyone" is airport stupid.
PS Dannielle, I've been a victim of domestic abuse too on several occasions with Crayzee Ex, so don't give me the "no empathy" speech. Restraining orders, court, break-ins, choking, phone calls threatening to "blow my head off" if I leave...I've done a lot for the women in my department.
You don't know me. Sometimes the triage questions are helpful, sometimes it's a big fucking waste of time. I have the judgment to determine when something is helpful and when it's not. Most of these questions are major time killers though. We don't DO anything if someone says they've lost > 10 lbs in the last 3 months, so why ask in the emergency department? They get a nutrition consult if they're admitted, but why not ask when they're admitted then? It's simple no-duhr stuff.
Dannielle,
These are mandatory questions for everybody. They are supposed to be asked in triage, so they are supposed to come before patient care.
Are any of these questions more important than patient care?
Life threatening conditions will be prioritized and these questions will be asked after the patient is already receiving care. Nurses and doctors understand how to prioritize and ask questions appropriately.
Of course, the rationale for this rule is that nurses and doctors do not know how to prioritize and ask questions appropriately, at least according to JCAHO. Do the JCAHO Clipboard Police know what they are doing? They are making money off of the hospitals.
Think of the benefit of asking paranoid schizophrenics these questions. Think of the benefit of asking these questions in front of an abuser, who brought the patient to the ED and is in triage with the patient.
We should think about how these delays in patient care affect the patients. JCAHO does not appear to think about the patients who need emergency treatment, only about those who need a social worker. This is not the Emergency Social Work Department.
A good assessment of an injury includes determining the cause. It involves asking questions about inconsistent answers. The same is true for patients who have signs that may indicate neglect.
It isn't that the questions are inappropriate. What is inappropriate is putting them before patient care. The nurse and doctor should have more discretion in when to ask pertinent questions.
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