Pivot Nurse

1. Pivot Nurse Roles and Responsibilities

2. What is a Pivot nurse’s role? • The Pivot nurse is assigned to any and every patient who has yet to come in to the Emergency Department, as well as those patients in the waiting room. • Primary communication with the Charge Nurse, monitoring the status of open beds, directing placement of patients into rooms, and when the department is full, based on staffing, either taking the triage role, or working with the triage nurse to triage by acuity.

3. Patient presents to triage… • The pivot nurse greets every patient as they arrive. Introduce yourself. “I’m ________, one of the nurses here in the ED. How can we help you today?”

4. We want to make sure that they patients know they are speaking to a nurse. • Ask chief complaint, getting as much information as you need to determine a quick ESI level. Look at the patient, evaluate their appearance. • Make a decision about where the patient needs to be sent: Acute or Front Line?

5. Decision Point • If patient needs acute bed, and a bed is available, immediate bed the patient. The pivot nurse is to call the nurse directly using VOCERA to communicate that a patient is coming to their room for immediate bedding. Inform the nurse the patient’s chief complaint.

6. Chest Pain in Triage • If your patient c/o chest pain, send them into a triage bay immediately with your tech for an EKG. Contact POCT for a bedside troponin draw. If Front Line staff is available to assist, this should occur. • AFTER the patient has had EKG and Blood drawn, then immediate bed to the designated room, informing the nurse of the above.

7. Front Line Appropriate • If the patient is appropriate to be seen in the Front Line, inform that staff. We can see ESI level 3 patients in some circumstances in this treatment area. • Don’t make your decision based on ESI level here. Rather, can the patient be seen and possibly dispositioned by the provider in the Front Line. If so, start there, and let them determine if further evaluation is needed.

8. What do I do if all Beds are Full? • In the event that all beds are full, or reserved for ambulance patients, the role of the pivot nurse changes. Rather than directing patients to the back, they direct those patients to the triage nurse. • Determine, after evaluating all patients who present, which patient needs to be triaged next. If triage nurse is busy, have tech start VS in an open room. The triage nurse will move to that patient next, when they have completed current triage.

9. Team in Triage • This will allow the triage nurse the confidence that the patients are safely being sent to her/him by priority. They can focus on the patient in front of them, rather than what is coming in the doors. • The pivot nurse is in communication with the charge nurse as to who needs a bed sooner than later, when ambulances are assigned to open beds, and when there is an urgent need for a bed. • The triage nurse communicates with the pivot nurse to inform her/him of who needs the next bed, based on their triage.

10. Emergent Patient? No bed? • The pivot nurse will contact the charge nurse on VOCERA, and inform them about the patient and their need. Simultaneously, the pivot nurse with the triage nurse will administer any intervention necessary until the patient is able to go to the back. The patient can be triaged by the triage nurse, if no bed is available.

11. Interventions • The pivot nurse will provide all appropriate patients waiting for triage, excluding Front Line patients, with urine collection cups, and can order urine dips and UPT’s from the pivot desk, making sure to document in Epic that specimens were collected and sent.

12. Monitoring Bed Availability • A large role of the Pivot nurse is to monitor the available beds in the department. They should be checking continuously the ED Manager in Epic to understand which beds are open, up for recheck, ready for discharge, etc. It is also important that they be aware each nurse’s room assignment, and will distribute patient load as evenly as possible.

13. Critical Rooms • Rooms 14, 15, and 32 should not be used for minor things, without consulting the charge nurse. She or he will let you know when the “last bed” should be filled. Never immediate to the last bed without notifying the charge nurse and consulting. • Remember ESI…would you give this patient your last bed?!

14. Your Last Bed… • Rooms 14, 15, and 32 should be utilized for severely ill patients, including but not limited to CP, SOB, possible sepsis, etc. These patients may present through triage or by EMS. Keeping at least one of these rooms available for this type of patient, allows for quick treatment.

15. LPN assigned to acute beds • Be aware…if one of our LPN’s are assigned to an acute assignment, do not immediate bed to that room without first discussing with the charge nurse. If your Triage nurse is available to triage this patient in the back, so long as you remain in the Pivot area, that is acceptable.

16. Immediate Bedding • It is our standard to immediately place patients in rooms when beds are available. • Keep in constant communication with your charge nurse, who will also be in contact with you regarding beds. They are to inform you when EMS is using an open bed. • It is the responsibility of the Pivot nurse sending the patient to a bed to notify that primary nurse. Do not delegate this task to a tech.

17. The Pivot nurse is the “safety net” for our patients in triage, especially when all beds are full. They can monitor changes in condition, deal with any emergencies that come through the door, and help the department flow smoothly. • It is imperative they be present for the patients who have yet to arrive. • DO NOT leave your area without having coverage. If you need a break, contact the charge nurse, or have triage nurse cover you.

18. Again, constantly monitor the ED Manager in Epic to note which beds are empty, which nurses have sick patients, and which rooms will be available next. • You should know which room you are going to send your next patient to before they even arrive.

19. First Impression • Remember! The Pivot nurse is likely the first person the patient will come in contact with. • The entire ED visit, or even hospital stay, can be impacted by the encounter you have with your patient. A professional, caring nurse is who our patients should encounter.