July 23, 2006, 6:08 pm

I Got Dem ol’ Triage Blues


Frankly, I think three apple martinis in 2 hours are quite good for the “collywobbles”.

No, actually, I think three apple martinis in 2 hours cause the “collywobbles”.

Not that I would know, of course

But I’ll be darned if Pepto Bismol would be my hangover drug of choice.

The pills maybe, but not that pink bismuth sludge. Blech!

I used to think that Pepto Bismol never worked.

Then I realized I only saw the people it didn’t work on.

I thought of this ad last night when one of my little patients told me his stomach had the ooogly-googlies!

I get the oogly-googlies when I use Google, but I don’t think it’s the same thing.


Sitting at my local (air conditioned) Starbucks and Simple Minds are singing “Don’t You Forget About Me”. Ah, doesn’t get any better than this.

I am so preoccupied with 1985….

Hope my husband doesn’t forget about me, I spend so much time here. It gets my creative juices flowing.

Hmmm….technically I am still boycotting Borders, but when does the boycott become a moot issue because you now like Starbucks better?

Just wait until the new one gets wireless this week. Every seat is plush and there are outlets on the wall every three feet. I may have to move in…..

And now for our feature attraction.


I pulled two twelve hour shifts in a row, and I was the charge nurse both days.

Now in the old days, that meant being the triage nurse and sitting in the triage room coming out in-between triages to help the staff RNs and checking the status of the department. My ER basically runs itself, the staff has been there for decades.



A few posts back, I described immediate/rapid bedding where you place the patient in an available room instead of making them go through triage and registration before seeing the doctor.

It’s supposed to decrease the door-to-doctor times and increase patient satisfaction.

I said it was quite efficient.

I take it back.


While I am all for patient satisfaction, I do not believe this immediate bedding and registration is really all that efficient.

The old system of being triaged, going to registration and having a completed chart when you are roomed was developed for a reason.

  • It worked.
  • Orders were able to be put in immediately.
  • It was a systematic way of controlling the patient flow.
  • The triage/charge nurse had a full overview of the department at all times and knew all the patients and which rooms they were in.
    • The charge nurse could decide which patients went where and could spread the wealth, so to speak.
    • The staff nurses could also room the patients when they had an opening.
    • If you were emergent, you went in immediately anyway.
    • This worked so well for us that we had the reputation of being the fastest ER in the area even before we started immediate bedding.
  • There was some control of how quickly patients were seen and the nurses had some control over their patient load at any given time.
    • Yes, there were nurses that would abuse the system by dragging their feet on discharges or not rooming when they had a spot open and patients were waiting.
    • After all, if you didn’t have an open bed, you didn’t get a new patient.
    • It was up to the charge nurse to recognize and “assist” these nurses with their bedding.

Now here is what is happening with this new “rapid/immediate bedding system”:

  • The charge/triage nurse is triaging at the bedside
    • often getting “stuck” there if the patient is urgent/emergent because
    • the assigned nurse is busy with the two other patients who were just “immediately bedded” in her/his assignment.
    • And the triage nurse must do the now required medication reconciliation form, and if the patient has a two single spaced typed pages of medications (and they do) this can take time.
  • The charge/triage nurse has to remember to let registration know the patient is there so they can run to the bedside with their portable registration computer.
    • Technically, we are supposed to circle the bed number on the board but,
    • The registration clerks are in another room from the board!
  • While you are triaging one patient, two or three others come in.
    • Now these get turfed to the waiting room because the triage/charge nurse is busy triaging in a room.
    • Or, they are put in a bed and then the triage/charge is told they are there.
  • Once the triage is done, the chart is placed in the “to be seen” file for the doc/PA.
    • Which means the only orders that can be carried out are resp tx or med orders because no tests/labs can be ordered without the registration number.
    • The secretary gets a back-up of charts awaiting orders to be placed.
    • The chart “guts” get separated from the main chart.
    • Orders get missed.
    • The nurses can draw bloods but must wait before getting the labels to place on the tubes, increasing the risk of mis-labeling.
    • The registration clerk can only be one place at a time, so the numbers either come one at a time or all at once, depending on how fast they are.
  • In the meantime, the triage/charge nurse has to triage those who are turfed to the waiting room.
    • They can do this in the triage room, then, if a bed is open, they get roomed immediately after and the registration clerk is off and running.
    • Yes, a relative can register the patient but,
    • you get half the registrations waiting for the clerk to get back to the desk while they are still running to get the immediately bedded patients.
    • It can’t be half-and-half. It’s worse that way. Either registration is done only at the bedside or it isn’t.

Now I have been a nurse long enough to know that the world does not fall apart if I don’t get to see the patient first, but add to all of the above that the patient may be roomed by the MD or PA or any other nurse and you can see where confusion may reign.

Now, let me tell you right off that my ER is staffed by on-the-run, movin’ MDs, PAs and RNs who know their stuff and could function in their sleep.

Which is why I love my job so much and it means the door-to-doctor time has been drastically cut (I’ll have to ask to see the stats).

The patients love us even more than before because they percieve it as NO wait time.

It’s just that the waiting is going on behind the scenes and I see it as a potential minefield of confusion and missed orders, especially when it was as busy as it was the last two days.

In an environment where control is a luxury, immediate bedding decreases the amount of control nurses have although I have to admit, it works better for the physicians.

I think the old system was safer for the patients because things were done methodically, but this one makes the patients happier and it’s all about those satisfaction scores.

The door-to-doctor time decrease is definitely positive.

Immediate bedding is here to stay, but I think it’s time to re-evaluate how we can make it less confusing for the staff and safer for the patients.



  • Intelinurse2b

    July 23, 2006 at 7:04 pm

    Door to doctor time decreases and pt satisfaction increases, i.e. making the hospital more profitable IF they can figure out the logistical issues. This is exactly what our local EDs are going through right now, and the logistics is working out. Nicely enough, El Presidente (of the hospital) is much more willing to throw money at something that shows immediate promise in the way of better satisfaction scores and more patients requesting YOUR ED from the ambulance. Thanks for the ED education. Im in awe of what you do.

    btw-I always enjoy your vintage ads and nursing posters. Keep em coming!

  • Mama Mia

    July 23, 2006 at 8:17 pm

    Wow, this actually sounds like a nightmare to me! What happens when you fill your beds to the brim and an emergent patient comes in – someone gets turfed to the waiting room from their immediate bed??

  • MotherJonesRN

    July 23, 2006 at 10:46 pm

    Just goes to show that new and improved isn’t always new and improved. Sounds like a bad deal. Sorry.

    Mother Jones RN

  • MiseryManager

    February 25, 2007 at 3:40 pm

    We have recently had “immediate bedding” forced on the nursing staff. To be successful at all levels it must be thought out prior to implementation. Physician and patient satisfaction may be an initial success, but will not be long lasting without not nursing support and satisfaction.

  • tammyp

    December 18, 2007 at 6:57 am

    Recently got new director who implemented no wait triage. We went from 3 step triage (see the pt/register/bed or wtg rm) to 8 steps and NO DEVIATION ALLOWED. Yes she did yell this at us at another of her mandatory meetings! She never got any input from the staff, doesn’t want feedback and didn’t alter anything else in the process that affects tat. She says this will eliminate the dozen or more in the wtg rm at 7p when I come in to work because the beds are filled more efficiently earlier in the day?! Enjoyed reading your comments as they brought up a lot of the same questions I’ve had but can’t get an answer to from my own personal Hitler.

  • […] collywobbles Posted on Saturday, December 22nd, 2012 at 7:39 am Via Emergiblog […]

About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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