Risk is great if you don't reassess psych patients

Patients may wait 2 or 3 days in the ED

(Editor's note: This story is part two of a two-part series on care of psychiatric patients in the ED. This month reports on the best ED nursing practices for reassessment during long waits. Last month, we gave tips for identifying underlying medical conditions.)

As psychiatric patients wait in EDs for hours, their condition can suddenly worsen — as it did for one woman who died on the waiting room floor of a New York City ED recently. ED nurses nationwide say this is a growing problem with safety concerns for patients and staff.

Although the ED at MetroHealth Medical Center in Cleveland has four psychiatric rooms that allow nurses to institute seclusion if necessary, there are sometimes six or eight psychiatric patients in the ED. "The calm ones end up in the hall many times. Naturally, this poses risks for the psych patients, the other ED patients, and for staff," says Barbara Wolfe, RN, charge nurse/quality improvement facilitator for the ED.

Other patients are in the ED exam room and already have been determined to need inpatient psychiatric care, but there are no beds available, sometimes for two or three days, says Wolfe. "Another scary thought is that we are seeing younger and younger cases with psychiatric issues. There are even less resources for children," she says.

At the Cleveland Clinic, "our ultimate goal is to expedite patient treatment in the exam area and to minimize the number of patients in the waiting area," says Barbara Morgan, RN, director of emergency services. "Having said that, due to capacity restraints, it is often necessary for patients to wait. In this case, it is extremely important to reassess patients during the waiting period." To keep patients safe:

• Create a specific protocol for psychiatric patients who are waiting for inpatient beds.

ED nurses at Bixler Emergency Center in Tallahassee created a special order set for these patients. "We use this when patients have been medically cleared but are awaiting psych bed placement," says Freda Lyon, RN, BSN, MHA, service line administrator. (See the "Emergency Center's Orderset for Patients Awaiting Disposition,".)

"I am working on setting up a 'care plan' or 'routine care protocol' to address this, because more patients are being held longer due to inability to find placement," says Wolfe.

Wolfe says she hopes that her ED's protocol will include frequency of assessments, medication administration, meals, showers, diversionary activities, frequency of documentation, and reportable behaviors. "I have been working with the unit manager and clinical nurse specialist of our inpatient psych unit and using their 'routine care' protocol for their unit as a reference," she says.

• Give electronic reminders for nurses to reassess.

"Our Emergency Center has an electronic tracking board with reminders for the nurse to reassess and document every two hours on all patients," says Lyon. If the ED nurse wants the patient to receive a psychiatric assessment, this goes on the tracking board.

• Have a psychiatric nurse evaluate the patient while in the ED.

On the day and evening shifts, a "crisis nurse" trained in psychiatric nursing evaluates the patient and, with the ED physician, decides on course of treatment, medications, admission, and transfer to another facility if necessary. Nancy Bennett, RN, MSN, ED educator at The Hospital of Central Connecticut in New Britain, says, "Our crisis nurses work very hard to get these patients into a facility where they can be helped, but there just aren't enough facilities to care for mental illness. [Lack of] insurance is a major issue."

The ED nurse's primary concern is for patient safety, nourishment, toileting, and attempting to keep the patient calm using medication and communication as needed, says Bennett. "If you keep the patient updated as to what's going on, and what they are waiting for, it helps to lower their agitation," she says. "If a nurse has time to sit and listen to a patient, he or she will, but that's not as often as we'd like. Our main concern is safety for all until a disposition or transfer can be made."

• Have a clinical technician round on patients in the waiting room.

"This enables the patient to have access to staff should they have a question or issue. Similarly, the tech can observe patients and report any concerns to the triage nurse," says Morgan. "Behavioral changes such as restlessness, anxiety, agitation, or despondency require attention and reassessment by the nurse."