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.
Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
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.
WOW your docs must be pretty good if they are that free to see pt's that quick!
But what happens when you've filled all your rooms with sprained ankles and abdominal pains, and you have a respiratory distress or STEMI come in? Do you leave critical rooms open in case that happens?
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?
Well, there is some confusion about this. Apparently we will still have triage nurses but they will act more like traffic cops. If we have a bed the pt goes into it. It's all very new right now and horribly confusing. I think the triage nurses feel kinda useless with this new system.
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?
yes, each nurse has a 4 room block with most rooms next to each other. but its extremely busy and noisy so unless you happen to see a new pt come in or be told you could easily not know.
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?
yes, everyone tries to help everyone else out but our er is so busy usually you can't do that. with traumas, flights, multiple cardiac alerts, strokes etc at any given moment most nurses have their hands full with their own pts.
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.
we have an any bed any patient policy. so not having appropriate equipment is not a problem and no room changes needed. it just bites when you end up with 3 icus and a cardiac alert.
But what happens when you've filled all your rooms with sprained ankles and abdominal pains, and you have a respiratory distress or STEMI come in? Do you leave critical rooms open in case that happens?
We have a separate area just for minor stuff. Although now with this immediate bedding going on we've had a few patients who really needed to be in our main ER because their conditions were more serious than initially thought. Again, this seems to be a snafu of immediate bedding.
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.
That's exactly how it happens now. I'll be in a room assisting with an intubation and bam, another pt rolls in and I have no idea. There are two computer systems we document in. One is the hospital system and the other is our ER exclusive tracker/doc system. The triage nurse puts the pts name into both systems under immediate bedding and that's it. So now I have a doc seeing the new pt who is not gowned, no vitals,etc. because I'm in another room. And its so busy that there is no one to help because the triage nurses are trying to help the flights and/or EMS coming in.
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.
Thanks for the resources and advice. I'll check it out.
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
We have what's called quick reg.....where the patient meets with an RN in triage the ESI, vitals, and chief complaint are obtained. If there is an available room they go immediately back to a room. If there is not an available bed they wait in triage. If it's a stroke or CP, they go directly back to the room....again if there isn't a bed available, a tech does an EKG, shows one of the ER docs and they determine if the patient comes back and we "make room" to put the patient in a bed. Like get an admission up to the floor or a discharge...STAT.
That's exactly how it happens now. I'll be in a room assisting with an intubation and bam, another pt rolls in and I have no idea. There are two computer systems we document in. One is the hospital system and the other is our ER exclusive tracker/doc system. The triage nurse puts the pts name into both systems under immediate bedding and that's it. So now I have a doc seeing the new pt who is not gowned, no vitals,etc. because I'm in another room. And its so busy that there is no one to help because the triage nurses are trying to help the flights and/or EMS coming in.
Why aren't the patients in a gown? We vital during the quick reg process, so then the Doc or the PA has some idea of why they're there and can begin ordering treatments without me in the room. (We have CERNER charting system and it's all throughout our hospital. If they come by squad our policy is someone HAS to take report from them before they can leave the patient. If it's my assigned patient then another nurse does it for me if I can't....and I do it for them....It's called teamwork and it's a must with this system! Change is sometimes hard.....and our computer system has gone down and we've had to revert to the old charting system...But the quick reg. still rules.
Why aren't the patients in a gown? We vital during the quick reg process, so then the Doc or the PA has some idea of why they're there and can begin ordering treatments without me in the room. (We have CERNER charting system and it's all throughout our hospital. If they come by squad our policy is someone HAS to take report from them before they can leave the patient. If it's my assigned patient then another nurse does it for me if I can't....and I do it for them....It's called teamwork and it's a must with this system! Change is sometimes hard.....and our computer system has gone down and we've had to revert to the old charting system...But the quick reg. still rules.
PTs don't get put into gowns until they come back to a room. The triage area is too open of an area to put them in a gown out there. As for how the triage process is to go, I think that's where all the confusion is coming from. It used to be that pts were triaged in the triage area and those not needing an immediate bed placed back into the waiting room until called. Now the triage nurses are supposed to eyeball each pt coming in, get the chief complaint and put them in both computer systems, then send them back to a bed. The assigned nurse then is responsible for gowning, obtaining vitals, and getting all data the triage used to get (previous med hx, med rec, etc). We do try to help each other out but often it is simply not possible. Its not unusual for each nurse to be getting 1-2 admits and/or discharges at the same time. I like the idea someone mentioned of having techs gown and obtain initial vitals. Any other suggestions?
When the triage nurse escorts a patient to a room they really need to report to someone. Leaving a patient in a room when no one knows about them sounds like abandonment, and frustrating for all staff.
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mwboswell
561 Posts
WOW your docs must be pretty good if they are that free to see pt's that quick!