Triage Desk

Our urban ED has been undergoing a remodel. This shop is the real deal--busiest in the state, blocks away from war zones, full to the brim on a daily basis with a stew of people gravely injured or sick, shoulder to shoulder with those that have colds or need a refill but don't have a doctor. As with any similar population, even though a majority of patients are well intentioned, violence breaks out on a relatively regular basis.

We have these flashing 'blue lights' in the ceiling--leading to the inevitable comparison to K-Mart--that go off if the front of the hospital isn't safe, usually due to a ghetto ambulance, someone's car dropping off a shooting or stabbing. Prior to the remodel, we had moved towards a plexiglass security corral with security guards in it as a greeting when you walk through the door.

That's all gone. With the remodel, there is a wide, new, fancy triage desk, with warm, wood grain paneling, recessed lighting, and the feel of a spa, consistent with our group's suburban outpatient centers.

The triage nurse is supposed to sit behind the desk and greet new patients, and is exposed to everyone still in the waiting room. There is a security desk, but it's over on the far side of the lobby, unobtrusive, and a great distance from the nurse triage desk.

Leave aside for a second that they aren't doing a thing to the arena, where we actually take care of patients, siding is falling off the cubicles, there are a bunch of curtained stalls where they always place the combative psych patients only three feet from the RN/doc area, and the overhead lights only work sometimes, and ask--was that really a good idea? I mean, taking the plexiglass OFF the front of the ED. This, in a place where security guards have quit mid-shift and left. I asked some of the nurses, and the general comment was 'thank God I don't work triage anymore'.

A quick Google search on healthcare workplace violence provides some interesting backstory. A post on KevinMD from 2 years ago illustrates the difference in a primary care setting and an ED setting. The most interesting read is the comments section where things quickly get out of hand. JAMA has a commentary noting that simple assaults are four times more likely to occur in healthcare, with ED nurses at high risk. A fact sheet from the International Council of Nurses notes that nurses are more likely to be assaulted than police officers and prison guards.

More likely to be assaulted than police officers and prison guards? The numbers bear out the sense I have, and that most people have that I talked to, that there is an undercurrent of danger in the healthcare workplace. Now, if you read the comments on KevinMD's post, it seems as though some (probably a minority, and not all the posters) feel that our callous disregard for patients somehow balances that out, or that nurses are somehow abusing patients right back. It's hard not to take offence at this; mainly because almost all of us that work in urban EDs honestly do try and do our best. We get socks, and towels, and blankets, and sandwiches, often without complaint, and often in response to shockingly rude requests (as in 'go get me a sandwich now' as I walk by a room where a very not sick patient is standing outside glaring at staff). We deal with drunk people who routinely slap, kick, and punch people, and high people, and crazy people, all of whom are unpredictable. I've been cussed at, yelled at, spit at, my life threatened by a convicted felon for not giving antibiotics (FYI, if someone says 'do you KNOW who I am?' it's probably not a good idea to actually check the state registry of convictions). And that's last year alone. Somehow I find it hard to believe that I and the staff around me are so callous, cruel, and unfeeling that I deserve this treatment.

I'm not even the vulnerable one. I talked to a number of nurses about that triage desk, putting a shiny, trendy face out to the parking lot in one of the worst neighborhoods in the city. Now, statistics say that she (or he) is no more likely to be the victim of gun violence than any other healthcare worker--which I suppose, statistically, I can take at face value. But what about the torrent of abuse otherwise? What about the verbal abuse, the pushes, and all the rest? Because I'm pretty darn sure almost none of that gets reported. Imagine, if you are an ED nurse, filling out an incident report for every incidence of violence or threat that you are subject to on a regular shift. I'm not sure what the solution is, but I'm pretty sure a new waiting room isn't it; sounds like lipstick on a pig to me.