Triage derived from French verb trier To separate sort select Lori Van Zoeren BS RN Ferris State University Objectives Identify skills and qualifications necessary for LD Triage Success ID: 426220
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Slide1
L&D Triage Orientation
Triage derived from French verb trier: To separate, sort, select
Lori Van
Zoeren
BS, RN
Ferris State UniversitySlide2
Objectives
Identify skills and qualifications necessary for LD Triage SuccessDescribe EMTALA and how it applies to the LD triage rolePractice scoring patients for Medical Exam Screen and identify patients who require immediate provider evaluationDiscuss supplies needed to assist providers in triage evaluation
Assess and accurately interpret real life scenarios through case studies
Evaluate the effectiveness of the orientation program Slide3
ED triage skills for
successENA, 2009
Diverse knowledge base
Strong interpersonal skills
Independent
Effectively communicate
Strong critical thinking
Ability to perform a brief, focused interview and physical assessmentAbility to make quick accurate decisions
Multi-
tasker
under stress
Ability to provide on-going education
Ability to work collaboratively
Delegation ability
Adaptability to fluctuations in workflow
Understanding of the cultural diversity of not just patient but familySlide4
L&D Triage Nurse Qualifications
Successful L&D unit orientation At least two years of labor and delivery experience
At least one year of labor and delivery experience at BronsonSlide5
Emergency Triage VS OB TriageSlide6
Prioritizing Case Study
Patient presents with complaint of passing a plum sized clot at 37 weeks. Baby is active and there are no other risk factors communicated initially.Patient presents with complaint of a MVA two days ago and just wanted to make sure baby was alright. She is 28 weeks gestation and no other risk factors noted initially. Patient presents to triage at 18 weeks with complaint of lower back pain and cramping for 4 hours which has gotten progressively worse over the last hour. Patient states she is scared as she has lost a baby at 20 weeks due to incompetent cervix.Slide7
What is EMTALA ?
Austin, 2011
Emergency Medical Treatment and Active Labor Act
Medical Exam Screen
250 foot rule
Capability & CapacitySlide8
EMTALA Violation Example
Austin, 2011Patient was evaluated and deemed in active labor at a hospital that did not deliver babies. Patient was allowed to be transported in friend’s car to the delivering hospital. The patient was delivered a few minutes after arrival and both mom and baby were fine.
The hospital paid $40,000 dollars in civil monetary penalties for allegations that they failed to provide appropriate medical exam screening and stabilizing treatment as well as not providing appropriate transfer vehicle.Slide9
Initial Documentation
EMR requirements include the triage portion of the triage/admission tab in the EPIC chartMedical exam screen within 20 minutesComplex physical assessmentPTA medications (prior to admission)
Labor flow sheet with fetal monitor tracing interpretation and any interventions if indicated
Consent for treatment signed upon arrival
Allergies documentedSlide10
Medical Exam Screen Policy
Screening within 20 minutes of arrival and again prior to dischargePatients scoring 10 or greater must be seen by a provider in a timely fashionEmergency Medical ConditionAcute pain vs. regular contractions
10
minute fetal heart rate monitorSlide11
Medical Exam Screen Scoring
Patient presents to LD triage. SVE reveals: 2cm, 70% effaced, and -2 station. Membranes intact. Contractions are every 4 min, lasting 30-40 seconds, palpate mild, regular, no urge to push. Vital signs are: Temp 98.8, BP is 138/88, Resp 20. There is no edema of extremities but facial edema is present. Is having normal bloody show and FHT stable and reactive. Baby is vertex. Slide12
Medical Exam Screen Scoring
Patient presents to triage who is 38 weeks gestation with bright red bleeding like her normal periods. SVE deferred due to bleeding initially. She is having an occasional contraction, no urge to push, VS are stable, no edema. FHR is normal and reactive. Baby was vertex by Leopold's.Slide13
Medical Exam Screen Scoring
Patient presents to triage with complaint of abdominal pain that rates a 10 on the pain scale. She is writhing around in the bed to the point it is difficult to palpate for contractions. SVE reveals cervix that is 0 cm, 40% effaced, and 0 station. She states no leaking of fluid or bleeding, she is holding her breath like she is bearing down. BP stable, pulse is 110, Temp 100. No edema. FHR 110 with moderate variability and accelerations. Baby is vertex.Slide14
Re-evaluation guidelines
Pre-eclampsia-B/P every 15 if elevated, FHR every hourLabor evaluation- FHR every hour, VS every 4 hoursPreterm labor- FHR every hour, VS every 4 hours
Any abnormalities would indicate increased surveillanceSlide15
Med exam screen: Not always
Austin, 2011
Non-emergency situations such as:
Patients admitted directly into the hospital, bypassing triage.
Betamethasone
Injections or NSTsSlide16
Success in L & D Triage
Resources readily availableKnow your parametersDo you always have the backing to place orders? OB section/More to followOrder to do an SVE
Do not be fooled
Communication & Situation Background Assessment Recommendation (SBAR)Slide17
Chain of Command
Charge NurseUnit CoordinatorManagerDirectorCNOPAUL BERKOWITZ, MD
(OB/GYN)
CAMELIA MERATI, MD
(Hospitalist)
STEVEN POLLENS, MD
(Family Practice)
JOHN SIKORA, DO (Anesthesia)Slide18
Stryker Gynnie
CartsSlide19
Know the supplies needed to assist providers in specimen collectionSlide20
Amnisure
Review policy if not familiarExplain procedure (insert 2-3 inches into vagina and leave for 60 seconds)Insert swab into solvent and rotate swab for 60 secondsProperly label specimen and collect in Epic for the lab requisition
Tube to lab as a stat and call 6440 to notify an
Amnisure
is coming for evaluationSlide21
Amnisure Collection
Inaccurate results can occur in the presence of:
Meconium
, antifungal creams, lubricating jelly, baby oil, Replens, expired solution, gross presence of blood, digital exams prior to swabbing, sample is collected greater than 12 hours after ruptured membranesSlide22
Fetal FibronectinSlide23
No Prenatal CareSlide24
“Abdominal” Pain
Devarajan & Chandraharan, 2011Preterm LaborTerm labor
Epigastric
Round ligament
Kidney
Ovarian Torsion
Appendix
AbruptionSlide25
Underlying Pathology
Devarajan & Chandraharan, 2011
Area of Pain
Organs to consider
Possible causes
Left
Hypochondrial
Spleen, pancreas, colon
Splenic
infarc
, colitis
Epigastric
Stomach, pancreas, aorta, heart
Gastritis,
pancr
, aortic dissection/
mayocarditis
/MI
Right
Hypochondrial
Liver, Kidney, hepatic flex
colon, gall bladder
Liver issues, Fatty Liver
of
preg
, HELLP, Pre-
eclamp
Right Lumbar
Kidney, ascending colon
Pyleo
, renal calc, IBS
Umbilical
Trans colon, appendix, uterus
Appy
, gastro, pancreatitis, abruption, uterine rupture
Left Lumbar
Kidney,
descending colon
Pyelo
, renal calc, IBS
Left Iliac
Sigmoid, Lt tube/ovary
IBS, Ectopic, tube
abscess or rupture, ovarian torsion
Right Iliac
Appendix,
rt
tube/ovary
Appy
,
diverticulistis
, above
Supra-pubic
Bladder,
Uterus
Cystitis,abrup
, Scar
ruptSlide26
Which of the following is not associated with
abruptio placenta?CocaineHeroinHTN
Smoking
Advanced Maternal Age
Women under 20 years of age
Abdominal trauma
Alcohol Use
Male fetusChorioamnionitisSlide27
Triage Imminent Delivery
The infant warmer is in triage in the corner by the blanket warmer. Supplies are covered but is stocked with needed emergency supplies to deliver a baby in the triage area. Slide28
Discharge Process
EPICSlide29
Social Work Resources
CoverageCab passesPhone cardsChild LifeDomestic violenceSlide30
Drug Seeking Behavior
Never chart that a patient is drug seekingDescribe patient’s perception of her painDocument assessment of patient’s observable symptomsBE OBJECTIVE!
MAPS reportSlide31
Case Study 1
41 year old G2 P1 30 week pregnant patient presents via ambulance to L&D triage. She was shopping and collapsed. She has no known medical conditions. She had an oral airway but spit out in route to hospital. Her VS are HR of 130, BP 190/110, Temp 97.3, Oxygen sat 93%, Glascow Coma scale 10/15.Slide32
Case Study 2
25 y/o G2 P1 presents to triage with painless vaginal bleeding at 24 weeks. She had a previous cesarean section delivery. VS BP 130/78, Pulse 92, Resp 20, Temp 98.4.Slide33
Case Study 3
Patient is 40 weeks gestation and presents to L&D triage in active labor. Fetal heart tones are 145. After asking if any bleeding or leakage of fluid you perform a SVE. Cervix is dilated 5 cm, 100% effaced, and -3 station. Patient rolled to left side and spontaneous ruptured membranes occurred. Fetal heart tones were then noted and verified at 70 bpm
as patient’s pulse is 96. Slide34
Case Study 4
Pt is a 20 year-old G3-P1 pregnant patient who complains of vaginal discharge which is especially prominent after intercourse. She states that it has a fishy odor. There is no bleeding and no regular contractions. VS are stable. She does complain of left lower quadrant pain that is constant. Slide35
Case Study 5
Call from the ER received with report to expect an ambulance bringing in a G3, P2 patient who is 32 weeks pregnant involved in a multivehicle pile up. Patient is alert and oriented, her VS are stable, fetal heart tones are 150 with positive fetal movement. Slide36
Case Study 6
A 31 year-old G4 P3 patient with twin gestation at 36 weeks presents to triage. When placed on cart she spontaneously ruptures membranes and there is a moderate amount of bleeding noted. Twin A now has fetal tachycardia and a sinusoidal heart rate pattern.Slide37
Vasa
PreviaSlide38
Case Study 7
Patient presents to L&D Triage with complaints of dizziness, headache, difficulty concentrating, pounding heart, tingling of the mouth, and feeling irritable. She is sweaty and pale.Slide39
In SummarySlide40Slide41
References
Austin, S. (2011, June). What does EMTALA mean for you? Nursing, 41(6),
55-59.
http
://dx.doi.org/10.1097/01.NURSE.0000398175.36147.bc
Bronson Methodist
Hospital website
.(2014). https://inside.bronsonhg.org/Devarajan, S., & Chandraharan
, E. (2011). Abdominal pain in pregnancy: A rational approach to management.
Obstetrics,
Gynaecology
, and Reproductive Medicine
,
21
(7), 198-206. http://dx.doi.org/10.1016/j.ogrm.2011.04.001
Emergency Nurses Association. (2011). Triage qualifications. Retrieved from http://www.ena.org/SiteCollectionDocuments/Position%20Statements/TriageQualifications.pdfSlide42
Project Goals and Objectives
Goal: To develop an orientation program for labor and delivery triage nurses at Bronson Methodist Hospital in Kalamazoo, MIObjectives: 1.1 Identify recommended LD triage nurse competencies required to care for the obstetrical patient population. 1.2 Provide an educational program for nurses who work in LD triage on skills needed for competency that are unique to triaging obstetrical patients. 1.3 Evaluate the effectiveness of the orientation program for staff. 1.4 Preceptor evaluation of the attainment of the proposed goals of the scholarly project. 1.4 Self-evaluation of the attainment of the proposed goals of the scholarly project. 1.5 Revise orientation program based on evaluation results.Slide43
Personal & Professional Accountability
Adherence to NLN Nurse Educator CompetenciesPerformed a comprehensive literature search Assimilated knowledge from lit reviewApplied new knowledge to the triage orientation program
Followed project plan utilizing time management skillsSlide44
Project Outcomes
Increased knowledge of EMTALA and the legal ramificationsIncreased knowledge of the differences between ER triage and LD triageBMH standards discussions for triage competency
Collaboration discussions
with
area hospitals
Hands on activities provided new knowledge of assisting providers with obtaining culturesSlide45
Project Evaluation
Do you have a better understanding of EMTALA?Was the PPT beneficial to learning about LD triage role?Did the PPT provide new knowledge?Do you feel the importance of the Medical Exam Screen was thoroughly explained?
Do you believe you can correctly prioritize patients listed in case studies?
Do you believe the objectives of the LD orientation and competency validation program were met?