Bridging the Gap Between Crisis and Care: How to Effectively Integrate Psychiatric Emergency Care Within a Community Hospital Emergency Department. Jeannine Loucks, MSN, RN BC PMHN Laura Derr, BSN, RN CEN Brenda Talley, BSN, RN Conflict of Interest Speakers have no conflict of interest to disclose. Derr 1
Objective 1: Identify at least 2 strategies in which the psychiatric mental health nurse can implement to collaborate with the emergency care nurse in order to bridge crisis stabilization with crisis management. Objectives Objective 2: Articulate the program evaluation metrics related to a psychiatric emergency stabilization and crisis management program based in the Emergency Department (ED). Objective 3: Distinguish the unique and complimentary roles that psychiatric and emergency nurses have in providing emergency stabilization and crisis management. 463 Licensed beds St. Joseph Hospital Orange, CA Employees 3,100 Physicians on staff 971 Volunteers 80 Magnet Nursing Facility ED visits 9,600 per month Derr 2
Decrease in psychiatric inpatient/outpatient services results in greater use & longer stays in emergency departments (ED) (Owens, Mutter, Stocks, 2010). Background Psychiatric complaints are a component of 1 of every 8 ED visits (National Center of Health Statistics, 2012; Owens et al., 2010). ~41% of mental health ED visits are hospitalized (Owens et al., 2010). Elopement associated with increased risk of suicide &/or self harm (Barr, 2005). Safety Concerns ENAs Emergency Department Violence Surveillance Study found more than half (54.8 percent) surveyed experience physical or verbal abuse at work in the last seven days (Emergency Nurses Association (ENA), 2012, ENA, 2010). Every week, between 8 and 13% of ER department nurses are victims of physical violence (2010). Derr 3
Increased wait for all ED patients Impact on Emergency Services Staff dissatisfaction Increase in number of patients leaving without being seen Increased labor hours for continuous observation for at risk patients Isolation by ED staff may worsen psychiatric symptoms (Barr Gilbert, 2009). Impact on Mental Health Patients Staff attitude demeaning, judgmental, increasing stigma (Loucks et al, 2010). Patients experience restrictions, coercing, and unnecessary force (Nadler Moodie, 2010). Derr 4
Provide a safe, therapeutic environment for psychiatric patients (Winokur & Senteno, 2009). Guesting Area 2007 2013 ED resources (human and physical space) utilized for other patients. Reduce use of restraints & risk of elopement in ED. BHS Guesting Area Derr 5
St. Jospeh Hospital Current Problem ED volume increasing State hospital closures Funding sources Increase in homelessness Economy changes Orange County has reduced psychiatric inpatient beds Extended LOS in ED 20+ hours Psychiatrist in ED Mon. to Fri. (9 4) Strategies implemented by ECDU Psychiatric Nurse Manager Identified unused space 16 beds Psychiatric patients waiting disposition & medical admit holds Improved patient flow Psychiatric manager facilitated six 4 hour trainings on mental health for ED nurses Developed treatment & medication protocols Collaborated w/team on medical & psychiatric care Collaboration for disposition community resources Mental Health Association Two other psychiatric hospitals Derr 6
Medical screening examination has been completed in the main emergency department Criteria for ECDU Patient is 18 years of age or older Patient is not actively violent ECDU Unit opened January 31, 2014 JAN (1 day) FEB MAR APR MAY JUN* JUL Metrics : Volume Total # psych pts in ER Total # psych pts moved to ECDU 18 334 374 384 398 348 336 9 130 190 201 205 102 125 *New EMR rolled out within hospital. Derr 7
Guide nursing care in 5 areas: Activities of Daily Living Treatment Protocols Physiological Safety Psychiatric Medication Management Protocols for Treatment of Agitation Associated w/psychiatric Disorder s Oral 2 nd generation antipsychotic: olanzapine zydis 5 20 mgs Oral 1 st generation antipsychotic: haloperidol 2 10 mg w/bzn Parenteral 2 nd generation antipsychotic: olanzapine 10 mg IM ziprasidone 10 20 mg IM Parenteral 1 st generation antipsychotic: haloperidol 2 10mg IM w/bzn (Stahl, 2007; Zeller, 2010) Derr 8
Protocols for Treatment of Agitation Associated w/intoxication CNS Stimulant Oral Benzodiazepines lorazepam 1 2 mg diazepam 5 10 mg Parenteral Benzodiazepine lorazepam 1 2 mg IM CNS Depressant (e.g. ETOH) Avoid BZN if possible Oral 1 st generation antipsychotic haloperidol 2 10 mg Parenteral 1 st generation antipsychotic haloperidol 2 10 mg IM (Stahl, 2007; Zeller, 2010) 45% of our psychiatric patients are on involuntary holds (W&I 5150 s) Ostaff injuries in ECDU Metrics : Safety Code Gray in ER JAN (1 day) FEB MAR APR MAY JUN* JUL 3 20 13 13 15 16 6 Code Gray in ECDU 0 1 4 2 5 6 1 *New EMR rolled out within hospital. Derr 9
Future Department manager submitted a grant to develop a Psychiatric Emergency Services Unit Blending of psychiatric nurses and emergency department nurses Psychiatric and Emergency Nurse Practitioners Emergency Care Psychiatrists Contact Information Jeannine Loucks, MSN RN BC PMH Department Manager ECDU jloucks27@earthlink.net Cell 714 335 3831 Work 714 771 8113 Derr 10
Questions References Barr Gilbert, S. (2009). Psychiatric crash cart: Treatment strategies for the emergency department. Advanced Emergency Nursing Journal, 31(4), 298 308 Emergency Nurses Association (2010). Emergency department violence surveillance study. Des Plaines, IL: Author. Emergency Nurses Association (2012). Rates of violence against emergency department nurses. Des Plaines, IL: Author. Available at: http://www.ena.org/media/pressreleases/pages/rateofviolence.aspx Loucks, J. Rutledge, D. N., Hatch, B., Morrison, V. (2010). Rapid response team for behavioral emergencies. Journal of the American Psychiatric Nurses Association, 16(2), 93 100 Nadler Moodie, M. (2010). Psychiatric emergencies in med surg patients: Are you prepared? American Nurse Today, 5(5), 23 28. National Center for Health Statistics, Emergency Department Visit Data (2012). http://www.cdc.gov/nchs/about/major/ahcd/ercharts.htm Owens, P. L., Mutter, R., & Stocks, C. (2010). Mental health and substance abuse related emergency department visits among adults, 2007. HCUP Statistical Brief #92. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup us.ahrq.gov/reports/statbriefs/sb92.pdf Stahl, S. M. (2007). Essential psychopharmacology. New York. Cambridge University Press. Winokur, E. J., Senteno, J. M. (2009). Guesting Area: An alternative for boarding mental health patients seen in emergency departments. Journal of Emergency Nursing, 35:429 433. Zeller, S. L. (2010). Treatment of psychiatric patients in emergency settings. Primary Psychiatry 17(6), 35 41. Derr 11