Immediate Bedding. Thoughts?

babynurselsa, RN · Nov 17, 2008

We do this to some extent. The patient will be brought to a room by either a tech, or a nurse. Either will at least get vs, give them a gown, and sent to collect a u/a if applicable.

Trauma Columnist · Nov 17, 2008

Yes, its done at our local hospitals too. However, the techs then go in and get vitals, pt placed on monitor, EKG done if needed.

BrnEyedGirl, BSN, MSN, RN, APRN · Nov 17, 2008

Wow,..so they are getting rid of the triage nurse? What happens if you don't have an open bed? That would be 95% of the time, where I work. How do you know the pt is stable enough to sit in the waiting room?

Altra, BSN, RN · Nov 17, 2008

My ER is starting "immediate bedding". For those of you who don't know what this is, it's when the patients walk in, state their symptoms, and are immediately placed into an available bed without being triaged by the triage nurses. The bedside nurse is then responsible for doing the triage in addition to the full bedside assessment. The triage includes an extensive med reconciliation where you need to get all names, dosages, etc of all meds (can take quite a bit of time if you have someone on hoards of meds). Our manager says immediate bedding is here to stay and we have a committee working on making the transistion easier. Right now its a bit of a disaster. Patients are being plopped into beds, the bedside nurse is busy and doesn't find out she has a new patient until 20 minutes later. The docs end up seeing the pt before the nurse does, they are confused because the pts are not gowned, not on monitors, have no initial vitals, and there is no nursing assessment to look at.
My question is do any of you have experience with successful immediate bedding at your facility? Can you tell me what components make it work successfully? I'd like to bring some ideas to the table when the committee meets.
Thanks, D

The principle behind this is, if rooms are available, there really is no need to "triage" patients or by definition, sort them according to priority. Until your rooms are full, everyone goes straight back. When this works well it really streamlines the process - the nurse who will actually care for the patient is the one getting the patient's story, vitals, seeing what they look like on the monitor, etc. ... all at the same time.

Where this seems to be breaking down at your ER is that no one is responsible for obtaining vitals on arrival, or seeing that the patient is ready to be examined. I assume that if someone is in some distress they are followed into the room by at least one nurse and/or tech. A lot depends on the layout of your ER and how patients are assigned to nurses. Are nurses assigned to a block of rooms in close proximity to each other, so that even if you're in one room you can probably hear that someone is being walked back into the next room? Can other nurses see someone being walked back, and is the culture at your ER such that people are inclined to step in and help without being asked? Your charge nurse also needs to be active in this process, ensuring that someone gets vitals immediately and patients requiring an EKG are getting that immediately or within whatever time frame your policy requires.

The downfalls to this process are what you have described, and those patients who initially don't identify their symptoms accurately. As in ... a complaint of SOB out at the front desk, who later morphs into vag discharge ... :icon_roll This can lead to frequent room changes for availability of appropriate equipment.

Communication among staff is key - patients can't be walked back from triage into rooms intended for incoming ambulance patients. And when the ER is down to 2-3 open rooms, it's probably time to revert back to completing the triage process out at triage.

Immediate bedding can work at non-busy times of the day, where there is good cooperation among all staff. But if your ER is anything like mine - full beyond capacity for at least half of each 24 hour period - immediate bedding becomes a moot point.

twinmommy+2, ADN, BSN, MSN · Nov 17, 2008

We tryed to go to that this year. It was supposed to be used to appease the press-gainey crowd, that this was supposed to increase patient satisfaction since they would see they were being put in a bed right away. It did not last long at our facility. I just don't see how there could be an easier transition to this. Not only did it not go well for the person with a 4 room assignment in the acute side, but the person (the one person) assigned the minor emergency side has 9 rooms to herself. A little overwhelming is putting it mildly.

I mean, what is the triage nurse there for in the first place. Might as well lose her position and have her in the back to help with all the triaging that hasen't been done. Me personally, I hope it doesn't come back.

Sorry, I know this doesn't help you, because you wanted to know about positives regarding immediate bedding. But there you have it.

bjaeram · Nov 17, 2008

We do a modified version of this. We have one nurse and one tech at triage. The nurse enters the patient in the computer and gets a chief complaint and does a brief over the desk assessment to decide if they look stable, need a monitor, can wait in the lobby, ect. We don't actually do a real assessment just an eyeball. We don't fill out the med rec, hx, or assessment at triage. The tech will then grab a set of vitals letting the triage nurse know if they are abnormal. The tech then takes them to a room, gets them undressed, and puts them on the monitor.

Then the nurse in back goes in and does the full assessment, med rec, history ect.

I think this works pretty well. I think you are running into trouble if the patient doesn't get an eyeball from a nurse pretty quickly. Some people need to be immediatly on the monitor and treated and this could be significantly delayed if a nurse doesn't get to them quickly.

mwboswell · Nov 18, 2008

How do the docs know that there is a pt in the room even if you don't????

mwboswell · Nov 18, 2008

Give the RN's radios - triage can tell them when a pt is in their room, or if there are any IMMEDIATE needs (monitor, ekg, o2 etc)

mwboswell · Nov 18, 2008

Couple of points/thoughts on this...

1) This does require a culture of change mindset. People will either have to find a way to integrate it into their practice and come on board, or need to quit complaining and look for another job....

2) Get active with your unit council or unit committee. If you don't have one, START ONE! Too many staff RN's are complacent to sit on the sidelines and second guess new policies and procedures without getting involved actively in the decision making process

3) Get the material or attend a course put on by Triage First. They address things like "immediate bedding" and the "new" traige role - "rapid" triage....it lends itself to implementation of this.

4) While I am not sold on the rationale that it improves patient satisfaction to bring them straight to a bed, just to wait for 2 hours to be seen....but I do believe it helps improve ER flow better - which, should in theory, help the ER to deliver it's services more efficiently. It decreases what I call "dead time" in the rooms - time when a treatment room is empty and could potentially be in use by a patient.

But my biggest thought is to GET INVOLVED and be a part of the implementation rather than griping about it. :twocents:

mmutk, BSN, RN, EMT-I · Nov 18, 2008

We do that occasionally here too. It doesn't work for the benefit of the patient though in my opinion.

Next thing I know, I look up and I have had a chest pain in my room for the last 10-14 minutes, and the triage isn't even done. I'm behind from the start after that.

mmutk, BSN, RN, EMT-I · Nov 18, 2008

How do the docs know that there is a pt in the room even if you don't????

It's real simple the docs' sitting at thier desk and see it pop up on the tracking board, but you are in one of your other rooms starting an IV, doing an EKG, giving meds, ect, ect. And by the time you get done the doc's gone in to see the patient.

Then you can't triage them b/c you can't ask them triage questions, because the doc is talking to them, ect, ect, ect.