We're screwed.

So we have this new thing at work: Bedside triage. Previously, when a patient came in by ambulance, they stopped at a station at the entrance to be evaluated by the ambulance triage nurse. S/he would get the history from the patient and EMS personnel, and then decide where to send the patient: a cardiac bed with a monitor, the asthma chairs, or a non-monitored bed.

Ambulance triage was stocked with a monitor, computer, ID bands, first-aid supplies, and was next to the trauma/resus room in case the patient was really sick. There was plenty of room to move around the patient and if the patient was vomiting, or bleeding, or aggressive, there was room to get out of the way. There was privacy: the patient could tell the nurse about their private medical problems without the person in the next curtain hearing them.

Now, the patient is rolled in, registered, and the charge nurse sends the patient to the bed to be triaged there, either by the nurse in the area or by the "roving ambulance triage" nurse. EMS personnel is dismissed the minute the patient's butt hits the stretcher.

Does anyone see the problems here?

Formerly, the ambulance triage nurse had everything in one place. Now she has to run around the ED dragging her equipment and supplies with her, hoping to find a free computer with which to enter the information. While she's at the bedside, other ambulances are coming in and being sent to beds; the ambulance triage nurse can't stop what she's doing to ask what's up with the other patients in case one of them is sicker than the one she's triaging at the moment.

When EMS is dismissed immediately upon placing the patient in a stretcher, the triage nurse loses a valuable source of information about the patient in the event that the person is nonverbal, or speaks another language, or has some kind of altered mental status. The nurse is forced to rely on the nursing home paperwork, or the EMS written report, which can be sadly deficient.

Here's an example of what happened the other night when I was zooming around like an idiot doing this bedside triage that illustrates the two above statements:

I was at the bedside of a non-English-speaking patient. His family was there, but they didn't speak much English either. The complaint EMS gave the registrar was "vomiting for one hour." The patient was retching uncontrollably in the stretcher and looked much more sick than I expected. No one could give me any information about him, and as I approached him, he belched and I smelled a strange smell: pine-scented cleaner. The front of his shirt was soaked with it. I asked the family, "Why does he smell like this?" "Because he drank some floor cleaner," was the response I got.

Great.

Meanwhile, another patient had been put in another bed and I headed over there, dragging all of my equipment. The complaint was "cough, previous history of pneumonia." While I was spending time figuring out what was wrong with the man who had drank the floor cleaner, this woman was in a bed--with florid pulmonary edema, complete with pink frothy sputum, an 02 sat of 67% on a nonrebreather mask, and a pulse of 144. If I had seen her, I would have yelled for help and sent her to the resus room to be intubated. Instead, EMS put her into a bed, pulled the curtain, and left. Her companion was clueless about what was going on, and was calmly sitting by the bedside reading a magazine. The nurse in the area was completely overwhelmed with his 8 other patients and hadn't gotten a chance to even stick his head into the curtain to see what was up--he was waiting for the triage nurse (me) to tell him what was up.

Asking the nurse in the area to triage her own patients is asking for trouble. We have 52 beds in the adult ED, and we have SIX nurses assigned for patient care. Actually, about half the time we only have five nurses assigned for patient care, now that I think about it. Also, most of those areas can be doubled up when it gets crazy. I've been in a high-acuity area with TWELVE patients--ICU, telemetry, you name it. When would the RN in the area be able to leave her patients to triage another one? In addition, the new protocol calls for the nurse in the area to do her own EKGs. We have an EKG tech--why do we have to do them ourselves?

Management loves bedside triage. It makes our statistics look great: people get into beds immediately, EMS turnaround times are super fast. The director of the ED said, when a nurse pointed out that it was going to be tough for her to do her own EKGs, "So you used to have three things to do. Now you have four. Work faster. So what."

According to one of the managers, the powers-that-be based our new bedside triage protocol on two studies that showed it improved patient outcomes. One of the studies was done in California, where no nurse has more than four patients BY LAW, and the other? Done in a 30-bed ED where there were 15 nurses on staff at all times. Give me two patients and not only will I triage them, do their EKGs, scrub their butts, and care for them, I'll freaking teach them to speak French and give them a mani/pedi to boot.

In our ED, this new bedside triage is unsafe and unfair to the nurses. And it will go on and on, until someone gets overlooked and dies. And then a nurse will lose her job and maybe her license, and THEN we'll go back to regular ambulance triage.