Take steps, avoid self-harm, lawsuits from long waits by psych patients
Take steps, avoid self-harm, lawsuits from long waits by psych patients
Crowded waiting rooms result in 'incredible tension'
Longer wait times than ever before and dramatic increases in numbers of psychiatric patients. These two trends are a dangerous combination, say experts interviewed by ED Nursing.
EDs are seeing increased numbers of potentially suicidal psychiatric patients, and these patients are at risk for self-harm when wait times are increased, says Amy Waunch, MSN, CEN, FNP, advanced practice nurse in the ED at St. Joseph Hospital in Orange, CA. Psychiatric patients often receive inadequate care due to multiple demands on ED nurses, and these patients are at high risk for self-harm or leaving without being seen, she says. "In addition, the bright lights, loud noise, and constant movement in the ED do not provide a calm environment for patients who are already experiencing a high degree of anxiety," she says.
From 2003 to 2004, St. Joseph's ED had a 6% decrease in total ED visits, but a 13% increase in patients presenting with psychiatric complaints. "Wait times for psychiatric patients in the ED are longer, due to an increase in the number of patients with psychiatric complaints combined with a decrease in available psychiatric beds in the county," says Waunch.
If psychiatric patients are held for long periods, their agitation escalates and may result in disruptive behavior, says Dotty Kuell, RN, BSN, CEN, manager of the ED at FirstHealth Moore Regional Hospital in Pinehurst, NC. "Their behavior is seen by other patients as cause for alarm," she says. "Left unaddressed, the tension is incredible for both groups." In 2005, psychiatric patients comprised 13% of the ED's total volume, reports Kuell. "Plans within our state call for a reduction in inpatient psychiatric beds next year, and this is bound to have an adverse effect on the ED, so we are meeting frequently with psychiatric staff to develop a plan," says Kuell.
At Northwestern Memorial Hospital in Chicago, triage nurses attended presentations on anxious, agitated patients, given by psychiatric nurses. "This education helped promote teamwork between ED and psychiatric ED staff in providing safety for the ED patient," says Marilyn Lukitsh, RN, clinical coordinator of the psychiatric ED.
At Northwestern, the average length of stay for patients in the psychiatric ED is about 10 hours, reports Lukitsh. "Wait time of course varies with disposition, but tends to increase when the ED is full," she says.
ED nurses do the following to keep psychiatric patients safe while waiting:
— Panic buttons in patient rooms can immediately alert security staff who are trained to deal with agitated patients.
— When psychiatric ED patients are transferred to the inpatient unit or for procedures such as X-rays, they are escorted by a security officer.
— A camera is used to observe patients in waiting rooms.
"One of our most difficult times is when we have a large number of patients waiting to be seen," says Lukitsh. "Psychiatric patients often become more anxious the longer they wait."
To improve safety of psychiatric patients waiting in your ED, do the following:
• Have security remain with the patient.
At Northwestern's ED, if triage nurses believe a patient is a danger to self or others, unable to care for themselves, or psychotic, a security officer stays with the patient at all times, says Lukitsh. The hospital's psychiatric ED has its own area within the main ED, with two beds adjacent to the nursing office. Patients are watched for early signs of agitation and medicated as needed while they wait for definitive treatment, she adds.
At FirstHealth Moore, committed patients are under direct supervision of a sheriff's deputy, and other psychiatric patients wait in the ED's post-triage waiting area. "It is in direct view of the triage nurses so they can do follow-up checks," says Kuell.
• Do repeat assessments.
Always take the time to do a thorough suicide and homicide risk assessment when indicated, says Lukitsh. "There are no shortcuts. Never assume that the patient is safe. From the time a patient comes into triage until disposition of the patient, nurses continue to visually assess level of anxiety or agitation on a regular basis."
As of Jan. 1, hospitals must comply with the Joint Commission's National Patient Safety Goal 15A, requiring you to identify patients at risk for suicide.
If the patient comes to the ED after a suicide attempt, find out how the patient attempted suicide and the lethality of the attempt, Lukitsh says. If the patient has a suicide plan, you must ask what the plan is and determine how feasible it would be to complete, she advises. "Past attempts of suicide can be a predictor of future attempts," Lukitsh says. "It is also important to ask if any family member has completed a suicide."
At FirstHealth Moore, ED nurses perform a risk assessment for patients who are potentially suicidal or homicidal patients, and patients remaining in the waiting room are reassessed by the assessment team and the triage nurse. (See questions asked by ED nurses.)
When psychiatric patients are left waiting for long periods in a crowded ED, there is an increased risk of ED nurses failing to perform reassessments or document those reassessments, says Denise Atwood, RN, a consultant specializing in compliance with the Emergency Medical Treatment and Labor Act and trauma coordinator at Maricopa Medical Center in Phoenix. "Nursing liability is always an issue," she says.
Atwood gives the following as a likely scenario for an ED nurse to be sued by a psychiatric patient who is kept waiting: The ED physician writes an order to put a patient into leather restraints. The nurse is required by hospital policy to document visualization of the patient and assessment of circulation and sensation of the patient's restrained extremities every 15 minutes, but the nurse fails to document assessments per facility protocol. When this patient demonstrates she is no longer a danger to self or others, the restraints are removed, and the patient immediately begins complaining of pain and tingling to the right upper extremity that does not resolve. She is found to have permanent nerve damage to the right wrist.
To avoid a scenario like this one, you must document your reassessment of circulation, sensation, and movement of restrained extremities and visualization of the patient. "Offers of food, water, and bedpan or urinal must also be documented, along with the patient's response to the treatments and medications," says Atwood.
• Have a separate waiting area.
At St. Joseph's ED, psychiatric patients are held in the "guesting area," a temporary holding area consisting of a large room with reclining chairs and a television. "It is staffed by a licensed psychiatric technician who provides a safe environment and begins therapeutic conversation to reduce the patient's anxiety," says Waunch. "The purpose of the guesting area is to relocate psychiatric patients from the ED to a safe, therapeutic area, while freeing ED services for other patients."
The room is used for medically stable ED patients who are a danger to self, others, and/or gravely disabled and who are awaiting final disposition of admission or transfer. To be eligible, a patient must meet the following criteria:
— 18 years of age or older;
— medical screening examination completed and the patient deemed medically stable;
— no requirement for any intravenous fluids, indwelling catheters, or physical restraints;
— all diagnostic tests ordered, completed, and results reviewed by the ED physician.
While patients are waiting, a nurse obtains and documents vital signs and assesses each patient every two hours. A physician reassesses the patient at least once every eight hours and upon transfer. "All orders for additional treatment while the patient is in the guesting area are provided by the ED physician," Waunch says. "In the event the patient's medical condition deteriorates, the patient will be transferred back to the ED."
As a result of the new system, the number of hours of security personnel spend watching over psychiatric patients in the ED decreased from 347 hours per month to 65 hours. "Attempted or actual elopements from the guesting area have been nonexistent, which compares to an average of five attempted or actual elopements that occur each year from the ED," says Waunch. "In addition, feedback from ED nurses has been very positive, since it frees up ED beds for other patients."
Sources
For more information about caring for psychiatric patients in the ED, contact:
- Denise Atwood, RN, Trauma Coordinator, Maricopa Medical Center, 2601 E. Roosevelt St., Phoenix, AZ 85008. Telephone: (602) 344-5753. E-mail: [email protected].
- Dotty Kuell, RN, BSN, CEN, Emergency Department, FirstHealth Moore Regional Hospital, 155 Memorial Drive, Pinehurst, NC 28374. Telephone: (910) 715-1118. E-mail: [email protected].
- Marilyn Lukitsh, RN, Clinical Coordinator, Psychiatric Emergency Department, Northwestern Memorial Hospital, 240 E. Ontario St., Suite 450, Chicago, IL 60611. Telephone: (312) 926-1878. Fax: (312) 926-5014. E-mail: [email protected].
- Amy Waunch, MSN, CEN, FNP, Advanced Practice Nurse, Emergency Department, St. Joseph Hospital, 1100 W. Stewart Drive, Orange, CA 92868. Telephone: (714) 771-8000, ext. 7136. E-mail: [email protected].
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.