The Reduction of Seclusion & Restraint in the University of Michigan Psychiatric Emergency Services with the Introduction of 24/7 Nurse Staffing

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1 The Reduction of Seclusion & Restraint in the University of Michigan Psychiatric Emergency Services with the Introduction of 24/7 Nurse Staffing Sharon P. Stetz MSN Marvella M. Muzik, MS PMHNP, BC

2 Objectives 1. Gain an understanding of the early identification of agitation with the use of PANNS. 2. Identify non-pharmacologic means to calm and de-escalate agitated patients in Psychiatric Emergency Services (PES). 3. Identify pharmacological measures to calm and de-escalate agitated patients in PES.

3 The Big House

4 Psychiatric Emergency Service Serves Washtenaw County - pop. 350, patients evaluated annually 1400 telephone crisis calls handled monthly Unlocked unit Adjacent to Medical ED Security back-up via telephone/electronic alert Staffed with NP, MSW, Psychiatric Resident & Attending Physician

5 CHANGE "There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things." Niccolo Machiavelli The Prince (1532)

6 Overview Question: How do you introduce Nursing Culture to an established 20 year old program? Answer: Very Carefully!

7 Vision Rachel Glick, MD Medical Director John Kettley, MSW Clinical Director 25 years of Psychiatric Emergency Experience Developed model to align with Medical Emergency Department

8 Psychiatric Population Diagnosis Codes Frequency of Diagnosis Codes Seen In Psychiatric Emergency Services July % 1% 3% 6% 2% 9% Substance Abuse Psychosis 13% Personality Other 62% Mood Eating 2% 1% Cognitive Child Anxiety Adjustment

9 Triage Chief Complaint Suicide Screen Weapon Screen PANNS Universal Screens

10 Medical History Nurse Assessment Review of systems/physical Assessment Medication Review Identify and report untreated comorbidities Skin Assessment Pain

11 Disposition UMHS Adult or Child &Adolescent inpatient units 20 + Hospitals in SE Michigan PES Bridge appointments Transition Clinic

12 Level of Care Decision Points Voluntary Green Band 1:1 Medical Observation Seclusion Restraint

13 Green Band Trends Psychiatric Emergency Services - University of Michigan Percentage of Patients on Moderate Risk Status (Green Band) vs Total Patient Load January 2008 June % of Monthly Patient Load Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

14 Green Band Dispositions University of Michigan Psychiatric Emergency Services Patients on Moderate Risk Status Dispostion (total 170) July % 52% Admitted Discharged

15 Agitation Protocol Utilize PANNS score If cooperative, offer oral meds If non- cooperative, IM injection Repeat PANNS every 30 minutes until patient is calm.

16 Seclusion and Restraint Trends Psychiatric Emergency Services - University of Michigan Number of Patients in Seclusion and Restraint Trends January June Total Patients Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

17 New Physical Space PES Future ANCC Psychiatric & Mental Health Nursing Certification for PES RN staff Care plans for frequent consumers 24 hour Attending Physician

18 QUESTIONS??

19 The Reduction of Seclusion & Restraints in the University of Michigan Psychiatric Emergency Services with the Introduction of 24/7 Nurse Staffing Sharon P. Stetz MSN Marvella M. Muzik, MS PMHNP, BC.

20 Objectives 1. Gain an understanding of the early identification of agitation with the use of PANSS. 2. Identify non-pharmacologic means to calm and de-escalate agitated patients in Psychiatric Emergency Services (PES). 3. Identify pharmacological measures to calm and de-escalate agitated patients in PES.

21 The Big House

22 Psychiatric Emergency Service Serves Washtenaw County-pop. 350, patients evaluated annually 5600 crisis call a month Unlocked unit Free standing Security back up via phone and electronic alert Staffed by NP, MSW, Psychiatric Resident & Attending physician.

23 Overview Question: How do you introduce Nursing Culture in to an established 30 year old program? Answer: Very Carefully!

24 Change There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, then to take the lead in the introduction of a new order of things. ~Niccolo Machiavelli The Prince (1532)

25 Vision Rachel Glick, MD Medical Director John Kettley, MSW Clinical Director 25 years of Psychiatric Emergency Experience Developed Model to align with Medical Emergency Department

26 Psychiatric Population Diagnosis Codes Frequency of Diagnosis Codes Seen In Psychiatric Emergency Services July % 1% 3% 6% 2% Substance Abuse Psychosis 9% Personality 13% Other Mood 62% Eating 2% 1% Cognitive Child Anxiety Adjustment

27 Triage Chief Complaint Suicide Screen Weapons Screen PANSS Universal Screens

28 Medical History Nurse Assessment Review of Systems/Physical Assessment Medication Review Identify and report untreated comorbidities Skin Assessment. Pain

29 Level of Care Decision Point Voluntary 1:1 Medical Observation Seclusion Restraint Green Band

30 Psychiatric Evaluation Psychiatric Nurse Practitioner Mental Health Professionals Resident Attending

31 Utilize PANSS Score Agitation Protocol If cooperative offer oral meds Non cooperative IM injection Repeat PANSS every 30 minutes until patient is calm.

32 Green Band Trends Psychiatric Emergency Services - University of Michigan Percentage of Patients on Moderate Risk Status (Green Band) vs Total Patient Load January June % of Monthly Patient Load Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

33 Green Band Dispositions University of Michigan Psychiatric Emergency Services Patients on Moderate Risk Status Dispostion (total 170) July % 52% Admitted Discharged

34 Seclusion and Restraint Trends Psychiatric Emergency Services - University of Michigan Number of Patients in Seclusion and Restraint Trends January June Total Patients Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

35 Disposition UMHS Adult and Child and Adolescent Units 20 + Hospitals in SE Michigan Bridge Appointments Transition Clinic

36 New Physical Space Future of Psychiatric Emergency Services ANCC Psychiatric & Mental Health Nursing Certification for PES RN staff. 24 Hour Attending 24 Hour Security Electronic Bracelets

37 Questions??

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