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Psychiatric patients are flooding EDs: Ensure safety with these solutions
Problem has reached crisis level in emergency departments nationwide
(Editor’s note: This is the first of a two-part series on psychiatric patients in the ED. This month, we cover ways to improve care, ensure safety, and maintain throughput. Next month, we give strategies for reducing risks of chemical and physical restraints.)
Patients with psychiatric emergencies are being held in hallways for hours or even days, wreaking havoc on throughput. Delusional patients are assaulting nursing staff. Nurses are unable to care for sick and injured patients because they are required to observe a violent schizophrenic in restraints.
Sound familiar? These dangerous scenarios are commonplace in many EDs, as the number of psychiatric patients skyrockets, report emergency nurses interviewed by ED Nursing. According to a recent report from the Hyattsville, MD-based National Center for Health Statistics, 2.05 million ED patients had a chief complaint of psychological or mental disorders in 2002, nearly double the 1.1 million psychiatric patients treated in EDs in 1994.1
At Northwest Community Hospital in Arlington Heights, IL, a significant surge in this patient population was first noticed two years ago, with 3,579 psychiatric patients seeking care at the ED in 2003, which was more than a 12% increase over the 3,136 psychiatric patients seen in 2001, reports Rosemary Kucewicz, RN, BSN, ED manager. "In the beginning, we thought it was just us," she says. "Now we know all parts of the country are struggling with this." As hospitals close inpatient units and beds in state facilities decrease, more and sicker psychiatric patients are seeking care in EDs, she says.
At St. Rose Dominican Hospital’s ED in Henderson, NV, psychiatric patients have increased by approximately 30%-40% in the past few years, estimates Pamela S. Rowse, RN, quality/risk consultant and former assistant nurse manager for the ED and hospital representative for the Southern Nevada Coalition for Mental Health.
Reductions in state funding have "created a monster," Rowse says. "If you are an average 25-bed ED holding anywhere from five to 10 psychiatric patients at a given time, that is consuming 20%-40% of your bed capacity, not to mention nursing resources and ancillary services," she says. "This compounds our already critical capacity problem a hundredfold."
The influx of psychiatric patients is having an adverse impact on the care other patients receive, reported 60% of 340 ED physicians surveyed by the Dallas-based American College of Emergency Physicians (ACEP) in 2004.2
In Rowse’s conversations with nurses about this problem, they repeatedly convey this message: "We can’t give them what they need."
"These patients need acute psychiatric intervention, not sitting around in special gowns eating — and watching TV," she says. "This can endanger not only us, but the rest of our patients."
To dramatically improve care of psychiatric patients in the ED, do the following:
"Though I am quite positive that over the past several years we have had quite a large increase in psychiatric patients, the sad truth is that we have no statistics to back it up," says Annia Taylor, RN, BSN, ED nurse at Durham (NC) Regional Hospital.
The health care system doesn’t track numbers or percentages of patients presenting to the ED with various complaints, she explains.
The ED is in the process of rewriting its psychiatric protocols and revamping the way these patients are cared for, reports Taylor. "It is obvious to us that problems will ensue if we do not," she says. "However, as we have tried to change things, not having statistics to back up the need for these changes has been a problem when dealing with upper management and getting the needed support."
At triage, an additional information sheet with a basic psychiatric history is now completed. "We hope to be able to make a record of these triage sheets and collect data on numbers of patients, as well as look at other trends and characteristics such as the numbers of suicidal patients," says Taylor.
At St. Rose Dominican, charge nurses complete productivity sheets listing numbers of psychiatric patients and their length of stay for every shift, with monthly data reported electronically to the Southern Nevada Mental Health Coalition.
"This tracks not only numbers but repeaters,’" reports Rowse. Recidivism is rampant in the mental health diagnostic group, she says. "Tracking of the frequent flyers’ will boost our case with the state legislature to show that there are insufficient outpatient services for this patient population," Rowse says.
According to the ACEP survey, psychiatric patients routinely are being held in EDs twice as long as other patients.2 If even a single patient is held for three days in the ED, that means that 72 hours of nursing care and resources are taken up, says Rowse.
This patient isn’t the same as the one on the medical/surgical floors, she says. "We’re talking about an individual that has the potential for violence and self-destruction," she says. "Patients can bolt at any time and possibly injure or kill themselves as well as others."
Patients must have sitters to ensure safety, with some requiring 1:1 observation to help reduce the time that they are in restraints, in addition to ongoing nursing care requiring frequent medication administration and assessments, says Rowse.
"When you are using all these resources on psychiatric holds, what is left for the other ill and injured patients?" says Rowse. To improve patient flow, the ED implemented a "capacity alert" system, activated by specific volume and acuity triggers.
"Code Lavender" is the first stage and calls for early interventions by all hospital departments to free inpatient beds. If this action isn’t enough to break up the bottleneck, a "Code Purple" is implemented, which results in elective surgeries being rescheduled and ED "hold" patients moved to hallways upstairs on the inpatient units.
The needs of the psychiatric patient are easily overlooked in a busy ED, notes Taylor. "These patients often sit in the ED for many hours before admission or transfer to a mental health facility," she says. "It is during these long wait times that patients are at highest risk for elopement."
Many depressed and potentially suicidal psychiatric patients have left the ED without treatment, which presents a possible liability risk for the hospital, says Taylor.
She recommends having a trained sitter or nursing assistant remain with the patient, or providing patients with materials such as books, music, and movies to pass the time. Taylor points to a study that showed ED psychiatric patients who were kept occupied during the long wait were more satisfied and perceived their wait time as being less.3
"One of the things that we have learned in our trials and tribulations is that most of these patients escalate because they haven’t taken their psychiatric medications, either because they can’t afford them or because they have poor outpatient support services," says Rowse.
Standardized psychiatric hold orders allow for immediate administration of medications and medical management of patients. The orders address nicotine patches, prevention of deep venous thrombosis from immobilization, and dietary needs. "We discovered that the better our baseline management is, the less likely restraints will be needed," she says.
1. McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2002 Emergency Department Summary. Advance Data from Vital and Health Statistics; No. 340. Hyattsville, MD: National Center for Health Statistics; 2004.
3. Roper JM, Manela J. Psychiatric patients’ perceptions of waiting time in the psychiatric emergency services. J Psychosoc Nurs Mental Health Serv 2000; 38:18-27.
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