Immediate Bedding/Role of Pivot Nurse

1. Immediate Bedding/Role of Pivot Nurse Why do we need to…and how do we do it?

2. Optimize ED Bed Capacity and Utilization • Patients should be in a bed only if it is medically necessary and only for as long as it is medically necessary…

3. Why do we need a “Front Line”? • We need to keep our “Vertical” Patients Vertical and our “Horizontal” patients Horizontal.

4. Vertical Patients • Ambulatory • Arrive by Triage • Well • Younger • Perceived urgency or convenience factor • Value for patient…speed, convenience, financial, other non-medical factors

5. Horizontal Patients • Stretcher bound • Ambulance Arrival • Sick • Older • Perceived serious or life-threatening condition • Value (Traditional Healthcare) speed, safety, preservation of Life/Limb

6. ED patient flow • Triage • Brief RN Assessment (Pivot RN) The patients assigned to this RN are the patients in the waiting room, and the patients in the community who haven’t come in the doors yet.

7. ESI evaluation/ Evaluation of Acuity by Pivot RN • Low Acuity Pathway (ESI 5, 4, and some 3’s) Front line/MEC • Moderate Acuity Pathway (Most ESI level 3’s. Acute VS Front line/MEC • High Acuity Pathway (ESI Levels 1&2) Immediate bed to acute side.

8. Patient Presents to Triage • Greeted by Pivot RN who does an “across the room” assessment, and obtains a brief history, assigning ESI level. Determines if pt can go to Front line/MEC, or is in need of an acute bed.

9. Needs Acute Bed • Pivot nurse is aware of bed availability through use of track board and communication with Charge Nurse. ED triage tech takes patient to assigned room, and Pivot RN contacts primary nurse that patient is on way to room. Any important information is given at this time.

10. Does not need a stretcher…a vertical patient. • Patient is sent to Front Line staff, or immediate bedded to the MEC.

11. Role of Primary nurse • Performing the triage process should be the function of the primary nurse. Remember, the triage nurse does not need to know anything about that patient, but a chief complaint. They are not going to be taking care of the patient. The primary nurse needs all of the triage information to best care for the patient.

12. What if the provider evaluates the patient before the nurse triages? • Remember, the patient is here to see a provider. The triage information can be gathered at any time during the visit. The provider is responsible to gather the information they need if they see the patient before triage is complete.

13. What if I am in with a patient and I get a patient from triage? • If you get a call from the Pivot RN, and you feel the patient needs immediate attention, please stop what you are doing and go see your new patient. Remember, acuity always is a factor in how you prioritize the patients assigned to you. Your priorities may change from minute to minute.

14. “Neighbor Nurse” • If your “neighbor nurse” is in with a patient, and gets an ambulance or immediate bedded patient in their room, and are unable to leave the patient they are with, the neighbor nurse can do some simple tasks without getting themselves “bogged down”.

15. Neighbor Nurse • For example: Neighbor nurse walks into room with ambulance patient: “Hi, I’m Sally, one of the nurses here in the ED. Joe, the nurse assigned to you is in with another patient. I’m going to do a few things to make sure you are safe, and then Joe will be in to finish your triage.” • Sally then arrives pt. in Epic, places on monitor if need be, applies oxygen, delegates EKG to EDT, etc. If patient is in need of immediate care, Sally calls Joe to the room. If pt is safe, Sally returns to her own patient assignment, and Joe will complete the triage and treatment as appropriate.

16. “Pull Till Full” • Remember: Go get a patient! When you have open beds, please go to triage, (or send your tech), and ask the nurse who she would like you to take back to your open bed. It really helps the throughput of patients when we pull patients back, rather than waiting for one triage tech to fill 5 empty rooms. Hint: For those of you who are proactive: if you keep your rooms full, you are unlikely to get the next nursing home ambulance patient!!

17. Don’t be a “Lone Wildebeest” • These are not “my patients” or “your patients”…these are “our patients”. • Don’t try to go it alone. • We all need help at some point! “Don’t worry, I’ll take care of it myself” can be a trap. • The “lone wildebeest”, off on it’s own away from the herd, is the likeliest target to become dinner for the lions! • Work together with your “neighbor nurses”!

18. This is OUR department! • We can accomplish much more together than we can alone!