Immediate bedding

Specialties Emergency

Published

Who's doing it? If room available, no triage, get weight & right into room. Start them like you would a squad. How's it working?

All rooms and most of our hallway spots have tvs. Yep, tv in the hall.
In the hall? That's a bit much . All ers down here have tvs but I do not see the point I have never been in tv watching mode when in the er myself .
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Interesting - do you know why they hate it?

They have a lot of the same objections the nursing staff does- mystery patients plopped in rooms who might wait for triage, inappropriate rooming of patients, is a little chaotic, doesn't allow for spreading of acuity among zones, patients more frequently under or over triaged due to being triaged by less experienced nurses, etc.

There's been enough pushback (ie stubborn noncompliance with that policy) by nursing staff that inbedding is much more limited in scope at my hospital, but when it first came down from TPTB, patients were just being flung in rooms so you might suddenly have several new, untriaged patients in your rooms, as did your coworkers, and the residents are already trying to see patients before they're triaged and they do forever and a day long assessments so that's even longer the patient sits untriaged (or you interrupt the resident).

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Specializes in ER.

We do it on nites where I work, I hate it, because I may not even know I have a pt in a room for 20 minutes if I'm busy elsewhere, but the chart says they were roomed at a certain time, and it ends up looking like I ignored them the whole time.

Plus, my opinion only- to room someone with a very minor complaint immediately after they have walked thru the ER doors is just asking for trouble. I would prefer they wait in the lobby until I am available to spend 10 minutes triaging & settling them,deciding whether or not I really want them to get undressed.

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Who's doing it? If room available, no triage, get weight & right into room. Start them like you would a squad. How's it working?

We are.

Like crap.

What we had: ESI- an internationally recognized, evidence based system complete with training modules, based on patient acuity.

What we have: An untested system, in which none of us are trained, based on the retail model of "customer satisfaction".

Our current system:

1-A patient comes into registration, and tells a clerk a chief complaint, which gets shown on our computer screens. they know to actually call if somebody uses the words "chest pain", or "difficulty breathing". Our registration folks are pretty heads up and will call if somebody loooks bad to them.

2-Charge nurse goes out and gets the patient. This can take up to 30-40 minutes with no medical professional eyeballing the pt. It is usually faster, but not always.

3-In the course of a 2 minute encounter while walking through public space, the charge nurse talks to the pt and gets a sense of the scope of the problem. This usually works.

4-Pt is put in a rm, and is assigned to a nurse.

The problems with the system:

1- Using lay people as part of our safety valve is a truly bad idea. For too many reasons to list.

2- A lot can happen in 30-40 minutes. Some of it bad.

3- This is a terrible liability for the charge nurse. I won't do it. Ever. Not even for that extra dollar an hour.

4- I have never been instructed as to my priorities with this untriaged pt, relative to my other pt's. Triage him, medicate the pain pt, or take the admit up? I have no idea. I will often eyeball the pt, then make my best guess. This does not give me a warm fuzzy feeling.

Also- this pt took none of my time while in the waiting rm. Now, he/she has a reasonable expectaion of care. Or worse, "customer service".

I dooubt this has reduced LOS, but I don't think that was our target. I believe the target was door-to-doc. This has theoretically improved. In reality, much of that improvement comes from what time the doc claims, on the computer, to be with the pt.

This system of rushing the docs in, and evaluating them partly on their times, has resulted in many docs often not reading the triage. Or coming in and interupting the triage. I sometimes "triage" a pt after discharge instructions have been written.

If you are the kind of person who goes to the hospital often, for minor issues, this system is great. You are the kind of person who was healthy enough to actually respond to the surveys that helped create the system, and it will serve you well.

If on the other hand you have a medical emergency, this is not the best system for you. You may be an ESI 2, but I am not going to know it. I'll be getting a blanket for that splinter removal guy who just got our last bed.

I would like to hear from anybody who is doing immediate bedding well. In particular, I would love to see any protocols you might have, and what kind of training was provided. Also, if there is any evidence out there that this is safe, I would like to see it.

About a month ago:

PT in NAD comes in complaining of shoulder pain. 32 minutes after registration, the charge nurse is walking her back to Quick Care. PT looks fine. In the short discussion, pt mentions jaw pain. We had a STEMI in our waiting rm for 32 minutes.

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We were given no training. To sit out at triage at my hospital you need experience, to be deemed as "ready", and to pass an educational program that includes a short preceptor ship. To in bed triage you apparently need none of that because as our administrators liked to tell us "its just an initial assessment you're doing."

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Well-

Any takers?

There must be somebody out there who has seen this well implemented.

There has got to be a set of written protocols based on evidence that this is safe.

Anybody?

BTW- I do believe it could be done perfectly safely if:

  • All pt's are triaged promptly- or at least as promptly as they were prior to the switch.
  • PT's are triaged by a nurse who is qualified to do so. i.e. : If prior to moving to immediate bedding triage required 1 yr experience and ESI competency, it is still required.
  • A certain amount of beds are left open. If you triage a an ESI 4-5 in your last room, send them out to the WR.

I could see a system like that being reasonably safe. But- getting a bunch of ESI 4-5's in bed and causing ESI 2-3's to wait is dumb.

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Honestly, I think it only works well when you don't need to triage patients, when the department is empty and patients are just coming in in a trickle, the nurse can see them immediately, and the doctor is going to see them momentarily because nothing else is going on. Triage and acuity doesn't matter because your level 5 is the only thing happening at the moment.

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I agree, from what I ahve seen.

But, somewhere, somebody must have had to show some evidence that there is a safe way to do this.

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Specializes in ED.

We are doing it too. Only for a few months now. It is great for the door-to-doc time, if being roomed is considered the doc time.

But I too worry that someone has not been triaged and I am just getting started on someone else in the next room. I may not see that pt for 15-20 minutes if the pt I am already with has a lot of work to do to get them started.

Before we were doing this, if I am with an ESI 3 pt and am told an ESI 2 pt is being roomed, I can drop the 3 or see if my teammate can cover the new 2 for me for a few. But when I don't even know its and ESI 2 being roomed...

DC :-)

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Specializes in ED.
Honestly, I think it only works well when you don't need to triage patients, when the department is empty and patients are just coming in in a trickle, the nurse can see them immediately, and the doctor is going to see them momentarily because nothing else is going on. Triage and acuity doesn't matter because your level 5 is the only thing happening at the moment.

Even if pts are trickling in it doesn't always work. If I am gone, off to the floor with another pt, for 10+ minutes, that STEMI that we don't yet know is a STEMI that someone walks back waits that 10+ minutes because they haven't been properly triaged. Then, when I get back, and I have a bag of vanco and a syringe of rocephin to give to my septic pt, all I am going to be able to do is eyeball the unknown STEMI. If they are sitting up in bed on their phone watching tv chatting away, how much longer before they are triaged by anyone, RN or Doctor?

DC :)

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Specializes in ED.

BTW- I do believe it could be done perfectly safely if:

  • A certain amount of beds are left open.

Are you kidding? The whole point of this system is to get pts back to the room instantly to improve the door-to-doc times. They will never do that.

Just two years ago charge nurses were leaving 1-2 rooms open for ambulances in our 21 bed (plus up to five in the hallway) main ED. Now, under the new system, ambulances routinely go the hallway because that is all there is.

DC :-)

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Specializes in Gerontology, Med surg, Home Health.

I recently had the not so pleasant need to go to the ER. Heart rate 140 with chest pain. Trouble was the first "triage" people were not nurses. It was more like taking a number at the deli counter and waiting to buy a pound of bologna.After the pathetic attempt at what they called triage, you had to wait in the hall, no chairs, to see the intake nurse. Silly me, I thought my tachycardia with chest pains was a more emergent situation than the woman in front of me who had hurt her thumb three weeks earlier, but what do I know.....just have 30 years of nursing experience. When the room started to spin I thought it best to leave my usually polite self behind so I marched up to the window and told them I really needed some attention. This is a large hospital, not some Podunk place. Even on Cape Cod we have NURSE triage people who actually know what the word means. I will now stop my rant.

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