, Nursing triage indispensable to ED care: “Zero waitiniroor6 time” has been proved a fad Dear Editor:

Prompted by a recent Journal article on triage by Gilboy et al (1999;25:468-73), I write to share with Journal readers some triage-related experiences. I have managed emergency departments in New York and Arkansas and currently work in a community hospital in Illinois. Medical directors at all 3 institu- tions have sought to eliminate the triage function be- cause of the perception that this function causes an unnecessary delay in the treatment process. They en- vision a system in which the patient is met by a nurse in the reception area and is immediately brought back to the appropriate stretcher.

If the patient is brought back to the appropriate stretcher, then the director has not eliminated triage, but rather has just redefined it.

Triage was developed in the military as a means of effectively distributing resources inadequate to the task at hand. In emergency departments we used to do it by eyeball, then progressed to chief complaint; temperature, pulse, and respiration/blood pressure/ oximetry; medical history; allergies; and medications. We did it to enable the more efficient operation of an emergency department that is not a delicatessen and that often lacks the resources to provide immediate down-front seating for all guests. Now, in the interest of superficial patient satisfaction, marketing, favor- able quality improvement statistics, and apparent ap- propriateness in the sequencing of treatment and billing, we are abandoning the concept of sorting in favor of “have it your way.”

Accomplishing zero waiting room time (ZWRT) necessitates having ED physical and human re- sources capable of expanding to accommodate N + 1 patients, where N equals the busiest day you ever had. Facilities that lack these resources (flexible staff re- sources being particularly expensive) will eventually

J Emerg Nurs 2000;26:6-7. Copyright 0 2000 by the Emergency Nurses Association 0099-1767/2000 $12.00 +0 18/84/104311

have to resurrect triage, presumably without the re- sources to do so, because, in eliminating triage, the space and staff to perform it will have been eliminated.

I believe that ZWRT is a fad, a product of poor ad- vice from attorneys, marketers, and quality improve- ment consultants in the age of managed care and the Emergency Medical Treatment and Active Labor Act. Customer satisfaction is certainly related to ZWRT, but it is also related to good outcomes in the emer- gent and critical categories of ED care. Achieving ZWRT is difficult without sacrificing the resources necessary for cases of these categories within the physical and budgetary constraints of most emer- gency departments.-Mike Brennan, MS, RN, Staff Nurse, Emergency Department, Holy Family Medical Center, Des Plaikes, Ill

Lyme vaccine: Some caveats Dear Editor:

The Food and Drug Administration has recently approved a Lyme disease vaccine. However, use of this vaccine has some caveats of which nurses should be aware before suggesting it to patients, es- pecially in an emergency department. 1. Being vaccinated may allow Lyme disease to de-

velop without the characteristic rash, and thus the first symptoms may be arthralgias and arthri- tis, or worse, cardiomyopathy or encephalitis. In this case, the diagnosis and treatment will almost certainly be delayed or entirely missed.

2. The vaccine’s efficacy of 78% pales next to the 95% to 98% effectiveness of early treatment with various antibiotics. A very reasonable and per- haps preferable course to take is to treat a patient for Lyme disease when one has a high index of suspicion.

3. The vaccine course is expensive-about $300, with discounts.

4. The vaccine has adverse effects, many of which are probably unknown at present. Thanks for your kind attention.-David Davis,

MD, JD, Emergency Physician, North Arundel Hospi- tal, Glen Burm’e, Md

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