Pediatric Community

Our Level I Trauma Center is launching a "Pull Until Full" initiative to improve patient flow. Currently, we use a traditional model where a Sorter assigns an initial ESI level, followed by triage in a designated booth before patients are placed in rooms. As part of this initiative, we're exploring transitioning to a direct-to-room model where triage occurs at the bedside.

We'd love to learn from other institutions that have successfully implemented this model. I have a few questions about how your facility handles this workflow:

1. Who is responsible for completing the triage?
   Do you have dedicated triage nurses who float between rooms, or does the bedside nurse take on this responsibility?

2. Have you noticed any changes in how quickly protocol orders are initiated or completed?

3. If a patient's acuity changes between arrival and triage, how is that typically managed?
   Is there a system in place to escalate care or reassign ESI levels efficiently?

We appreciate any insights or experiences you're willing to share. Thank you in advance for your time and help!

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James Kelly MSN, RN
Emergency Department Professional Development
St. Christophers Hospital for Children
Philadelphia PA
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Hello,

We have been doing "pull till full" for years. It tends to be more of a summer initiative because of volumes. I am curious how you have a sorter assigning an ESI without vital signs? Is it more of a PAT?

1. The bedside (primary) nurse completes the triage if able and if we have the numbers for a triage nurse they can help.
2. We have SMDOs that can be ordered by the nurse before a provider picks up the patient and these haven't really changed a ton. Patient satisfaction goes up with being in a room faster. 
3. Per ESI an acuity can be upgraded before a provider sees them if there is a change in presentation or anything warranting it. We have a separate acuity change form aside from our triage form, so people do not change another person's triage. Then when they have been seen by a provider they fill out a medical status change form, but it does not change the triage acuity.

Hope this helps. Please let me know if you have any other questions.

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Becca Mielke, MSN, RN, CPEN, TCRN

RN Practice Specialist
Emergency Department
Dell Children's Medical Center
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Thank you for your insight! We are thinking this is mostly going to be a summer thing for us too. Our initial ESI level is usually based on the PAT and then a quick rundown of what brings the patient in, as well as any past medication history. Once the triage nurse gets vital signs, the ESI level can change based on that. The issue we are trying to prevent is placing patient in our fast track area based on this initial ESI but then once we get the vitals or more of a story, needing to move them to one of our acute care areas. 

Thank you again for all your information!

Jim

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James Kelly MSN, RN
Emergency Department Professional Development
St. Christophers Hospital for Children
Philadelphia PA
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Original Message:
Sent: 08-06-2025 09:36 AM
From: Becca Mielke
Subject: Immediate Bedding until Fill in a Pediatric ED

Hello,

We have been doing "pull till full" for years. It tends to be more of a summer initiative because of volumes. I am curious how you have a sorter assigning an ESI without vital signs? Is it more of a PAT?

1. The bedside (primary) nurse completes the triage if able and if we have the numbers for a triage nurse they can help.
2. We have SMDOs that can be ordered by the nurse before a provider picks up the patient and these haven't really changed a ton. Patient satisfaction goes up with being in a room faster. 
3. Per ESI an acuity can be upgraded before a provider sees them if there is a change in presentation or anything warranting it. We have a separate acuity change form aside from our triage form, so people do not change another person's triage. Then when they have been seen by a provider they fill out a medical status change form, but it does not change the triage acuity.

Hope this helps. Please let me know if you have any other questions.

------------------------------
Becca Mielke, MSN, RN, CPEN, TCRN

RN Practice Specialist
Emergency Department
Dell Children's Medical Center
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