Dear Desperate

Question:

Hello -
I am desperate for help. Within the past 6 weeks our hospital has instituted a form of immediate bedding. I have researched and fully understand the concepts, as well as the benefits of the initiative. I have done this completely on my own, as my employer has not given us any information on what we are doing other than the initial "effective next Monday we will switch to using a Pavilion Coordinator" (basically a greeter). Our ER nurses are operating in confusion and chaos.

The greeters are non medical, non technical, non patient care educated individuals. They greet the patient upon presentation to the ER, get a chief complaint, and assist with the quick reg process. They then walk the patient to the treatment area, tell the charge nurse "I have an ABC complaint here where should I put them?" The charge nurse tells them where to put the patient, clicks the patient into XYZ bed in the computerized tracking board and then may or may not tell the nurse assigned to that bed that there is a patient there. They also may or may not tell someone to get vitals, get the patient undressed, etc. There is also no real attempt on the part of the charge nurse to assess the acuity of the patient prior to the patient being assigned to you - nor is there an attempt to ascertain if you, as the nurse being assigned are able to take responsibility for the patient.

Are there determined protocols for how to manage this type of (non) triage assignment making/delegation of duties? Or are most of these initiatives implemented ad hoc? Please point me in the right direction to find the answers. I have worked as a registered nurse in this ER for the past 18 years and this is the first time that I feel as if my ability to practice my profession safely has been jeopardized.

Desperate in the ED

Answer:
Dear Desperate in the ED,

Many hospitals have found success in using an unlicensed person (UAP) in the role of a "greeter" at the point-of-entry, for ambulatory (walk-in) patients.

In our work in evaluating emergency department processes, we have seen an improvement in effective patient flow when UAPs are used in an assistive role.

The proper roles and functions are best described and supported by accessing varied available resources : State Boards of Nursing usually provide literature and position statements outlining the scope of practice for RNs, LPNs, unlicensed assistive personnel(UAPs) and Licensed Individual Practitioners (LIPs) such as Nurse Practitioners and Physician Assistants. Most states clearly define who can perform an assessment. When a presentation is clear cut and there are no complicating factors, an unlicensed person may very well be able to properly elicit a chief complaint and communicate adequately with a licensed caregiver to determine appropriate disposition and acuity. However, many patients arrive with occult (hidden) presentations. The critical fact to remember is: Correlation does not necessarily show cause! e.g. An elderly patient arrives, whose family members have all recently had colds. She is feeling weak and dizzy, and says, "I think I have a cold or the flu!" Her chief complaint is written as "Possible cold or flu". This woman is actually suffering from Acute Coronary Syndrome (ACS). When questioned by a person properly trained to elicit a symptom led chief complaint (C/C), it is recorded as Weakness and fatigue x 3 hours. This concern then prompts ìInformedî Immediate Bedding, to an available bed and available care provider who can also obtain vital signs and initiate treatment/interventions in this Acuity Level 2 patient! If no bed and caregiver is available, the triage nurse must notify the charge nurse of the patient and the need for placement in the treatment area. If the charge nurse is unable to facilitate the immediate placement of this patient in the treatment area the triage nurse must begin the comprehensive triage assessment and initiate appropriate diagnostic protocols (e.g. ECG).

There are many situations in which the patient does not realize the gravity of their condition; such as
1. A fall with medical etiology. The patient just says "I fell", but an expert triage nurse knows ìfell" cannot stand alone; it is their responsibility to pursue whether the patient experienced a fall with a medical etiology or whether they are there because of injury suffered in the fall.
2. The high risk factor of patients who return within 72 hours of a previous ED visit or hospital discharge.
3. Rechecks status post injury or illness.
4. Triage is both an art and a science and therefore requires both experience and education specific to this arena and practice.

Many unlicensed persons can be properly trained to elicit the chief complaint and begin initial basic quick registration procedures, but this should not be done if it in any way DELAYS the medical screening exam, and is a clear EMTALA violation.

The problem occurs when patients are made to complete registration when there are beds AND caregivers available to begin that patientís ED exam and treatment.

While the process of Immediate bedding should occur whenever possible, and the patients not be made to queue or jump through hoops as a delaying tactic, there are certain criteria that should be used to ensure safe and efficient use of this patient flow strategy. Immediate bedding criteria are:

• Patient is obviously sick and correct acuity and disposition can be ascertained immediately
• Beds are available, or one can be made available immediately
• Caregiver is available

Excellent communication is the key component! Any immediate bedding strategy without a well thought out process of communication for continuity of care, is a potentially deadly strategy.

When an immediate bedding strategy is employed without these criteria and good communication, a nursing nightmare often results: simply moving the bottleneck from triage to the treatment area. However, the opposite is equally disconcerting, when an ED chooses to keep all the patients in the lobby with the triage nurse being responsible for comprehensive assessments on all the patients, resulting in a dangerous nurse to patient ratio.

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