Case Study : The New Triage System

system after the RN has been evaluated and approved as having met the education and

When focusing on the Centers for Medicare and Medicaid Systems strategies for improvement with unnecessary emergency room visits, a major key area is accessibility to health care at the appropriate health care setting. For many years, there has been the perception that the emergency department is the only place for someone who is uninsured or underinsured can go to receive the needed and appropriate health care, and in some situations that may be the case. (Rhodes et al, 2013, p.394) Due to the decreases in reimbursements for the publicly funded, more and more physicians are opting out to treating these patients, thus leading to an increase in emergency department utilization. According to a study conducted by Rhodes, Bisgaier, Lawson, Soglen, Krug, and Haitsma, this is becoming a greater concern for the

There are several potential risks to the company with the introduction of the new triage level 4 & 5 care center. These are patients won’t use the new service and continue to utilize the emergency department for their lower level of care needs. Matching staffing and demand is another risk. The clinic will be a mix of self-scheduling and walk in appointments. Making sure there are enough appointment slots available when patients need them. If this does not happen, patients will have long wait times and will cause them to have a negative experience and not utilize the service for future needs.

Since the inception of the Nurse Practitioner (NP) role in the 1960s, NPs have thrived in the delivery of primary healthcare and nurse case management. Despite patient satisfaction with NPs ' style of care, nurses have been critical of NPs, while physicians have been threatened by NP encroachment on MD practice. Balancing assessment, diagnosis, and treatment with caring defines NPs ' success as primary care providers. Understand the role and Scope of Practice of NPs is sometimes difficult for some to understand. The purpose of this paper is to define the role and history of NP, compare and contrast licensure versus certifications, understand NP Scope Of Practice and Standards of Care, discuss how the State Practice Acts regulate FNP practice, discuss credentialing and privileging, and differentiate between legislative and regulatory processes.

If patients were truly offloaded to NP’s by the triage system it would be cost effective based upon the service rate. But this did not happen. In fact, the percent of patients seen by NPs decreased from 40% to 28%, and the percent patients seen by MDs increased from 41% to 48% (excluding patients that requested a particular provider).

During the second week, I had the opportunity to accompany Mr. Price to meetings that he had with the managers of the nurses and schedulers. During those meetings, the managers discussed the ideal approach of how to accommodate patients who call the schedulers to acquire appointments for urgent medical concerns. There seemed to be a problem with patients taking up appointment slots when they do not have a true need to be assessed by their doctor. It was ultimately concluded that the schedulers would coordinate communication between the patient and the registered nurse. The nurse would then triage the patient’s concerns over the phone and provide medical guidance,

This can include cases of perceived “pain-seeking” patients or “frequent flyers”. It can be difficult to treat those we see as trying to “use the system” for pure personal gain equally to those we may see as “truly ill”. It is important to remember to treat everyone in the same manner. Another important provision is provision 3. This provision states, “The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.” This means that nurses must always do everything thinking of the patient’s best interest first. This includes making sure they are fully informed before signing any consents for procedures and questioning any orders that may seem inappropriate for said patient. It is the nurse’s job to be the patient’s advocate and to always provide a safe environment for the patient.

As resistant as some states’ legislative and regulatory bodies are to grant APNs autonomy of practice, the damage being done by over-regulation is clear (Safriet, 1992). Physicians are forced into a position to either supervise the APN’s practice or be constantly consulted for approval of their practice decisions. Safriet (1992) described that in and of itself, this constant supervision may appear to patients that the APN is not competent to provide adequate or care equivalent to that of a physician. If the role of the APN is to bridge gaps in health care by relieving the medical establishment of some of the patient load by performing the same function as a physician in a primary care setting, it seems wholly unnecessary to restrain their scope of practice in those areas. This type of restrictions affect cost and patient care accessibility (Safriet, 1992). This was a problem stated in the article, however 25 years later, populations of patients remain unseen or cared for and APNs continue to be underutilized (Safriet, 1992). Rigolosi and Salmond (2014) cite the American Association of Nurse Practitioners (AANP) when they state that not utilizing nurse practitioners due to practice restrictions costs $9 billion annually in the US (p. 649).

Wholeheartedly agree with your assessment on the Veterans as a major issue, and an issue that will unfortunately continue to grow in the coming years.

In late October of 2013, changes took affect in BC through what is called the Medical Priority Dispatch System (MPDS). The MPDS is a recognized system used to dispatch appropriate aid to medical emergencies and is used in almost 3000 jurisdictions. The main change made was downgrading 74 different patient acuity classifications, such as serious falls and some motor-vehicle injuries from emergency dispatch to routine dispatch.

meant that patients could not be seen unless they were showing signs of a severe illness. This

This, in turn, means that the patients that are in the hospital are more acute and require intensive nursing care. The role of the registered nurse must now include greater professional judgment, management of complex systems, and greater clinical autonomy (Lippincott, 2003). The pressure to contain costs and meet the needs of the rising levels of severe illnesses of inpatients make it imperative for hospitals to seek out ways to redesign delivery of care without compromising quality of care (Tappen, 2004). The structure, organization and financing of health care are rapidly changing. Patients previously hospitalized are now treated on an outpatient basis, relying on care through different delivery systems. Hospital communities are trying to increase health care services while raising prices as little as possible.

Who is affected? Triage is the first patients to find. The responsibilities for these nurses are high. Nurses who care for patients in trauma or medical emergency, midwives who bring babies in the world, working with the mentally ill, or who enter a customer's house pose liability problems.

Several existing problems precipitated the creation of the triage system implemented by Kathryn Angell in an effort to deliver improved medical care. The main problem was a lack of coordination in service delivery. This lack of coordination caused excessive wait times on the order of anywhere from 23 to 40 minutes to see a nurse, 40 to 50 minutes to see a doctor, and as long as 55 minutes to get a prescription filled. The practice of all nurses being involved initially in seeing all patients caused duplication of efforts, including repeating questions and examinations, and resulted in procedural bottlenecks. Additionally, there were inconsistent levels of service and extreme variation in treatment because of the different experience

The emergency room has become the new primary care facility for the millions of uninsured in the United States. Thanks to an “unfunded mandate passed into law in 1986,” hospitals that participate in the Medicare program must “screen and treat anyone with an emergency medical condition” (Stephens & Ledlow, 2010). This unfortunately leads to emergency rooms full of people who may have something as simple as a sinus infection which then makes it really difficult for someone with a real emergency that did not require ambulatory transport to be seen in a timely manner. Another unfortunate result of this is that “over 1,100 emergency departments closed over the past decade” (Stephens & Ledlow, 2010).