You need to address unique needs of psychiatric patients
When a 50-year-old woman told an ED triage nurse that she hadn’t slept or eaten for two weeks, she also reported depression and a previous psychiatric history. After waiting for more than an hour, the woman left without being seen. Immediately afterward, she committed suicide by jumping off a bridge. The incident triggered an investigation by the state department of health and set off warning bells in EDs nationwide.
Do you worry that a psychiatric patient may fall through the cracks in your ED? If so, you should take steps now to avoid tragedies and lawsuits. Here are ways to improve care of psychiatric patients:
• Ensure that patients are appropriately triaged.
Your triage system may not be set up to ensure that agitated patients are treated as quickly as possible, which disregards the urgent nature of psychiatric crises, according to Kathy Emde, RN, MN, CCRN, CEN, trauma service coordinator at Overlake Hospital Medical Center in Bellevue, WA.
Psychiatric patients must be a top priority in your ED, stresses Hartmut Gross, MD, FACEP, associate professor for the department of emergency medicine at Medical College of Georgia in Augusta. "Until they are calmed, they can be disruptive to the entire ED," he notes. Gross explains that psychiatric patients are brought straight back or kept in the triage evaluation room until a room is available. "They do not go back to the waiting room to wait," he says.
Emde says the ED’s triage system specifically must address psychiatric complaints and assessments to avoid underestimating the severity of a psychiatric crisis. Staff should elicit information during the initial triage interview to be sure an accurate triage classification and appropriate care are given, she explains. For example, if the patient divulges thoughts about self-harm, the triage nurse should probe further, Emde says. "If the patient answers, I am planning to shoot myself next Thursday, but I do not have access to a gun,’ this gives a different message about urgency than if the patient says, I am going to shoot myself, and I have a gun in my purse now,’" she says.
Due to limited coping skills, patients may be unable to tolerate long waiting periods, Emde notes. "I think that the time required for a patient to move through the usual ED is problematic for many psychiatric patients," she says.
To expedite care, use a social worker to assist in evaluation and assessment of patients with psychiatric issues, she suggests. She explains that after initial triage, the social worker often takes the patient to a quiet office or quiet room for further assessment. "This should not hinder the patient from being seen by the ED physician," she says. "The goal is to enhance the assessment during any necessary waiting time."
• Find a quiet place for patients to wait.
Gross says that psychiatric patients should be kept out of noisy, crowded waiting rooms if at all possible, because this atmosphere can worsen anxiety. "Make a room available," he recommends. "Put the back pain patient into the hallway if you have to."
Emde says you may have to be creative to find a quiet area where a troubled patient can wait, such as a family room or a room isolated from the main waiting area. "Keep in mind that whatever space is used, psychiatric patients need to be accessible to the triage nurse for repeated assessment and observation while waiting," she notes. A patient may be triaged initially as nonurgent or urgent, but he or she should be re-categorized if changes occur, such as increasing agitation, worsening anxiety, pacing, and other behavioral signs, she explains.
Some psychiatric patients cause unacceptable noise levels themselves, by yelling or banging on the walls, Gross adds. However, he cautions managers to resist the urge to place the lockup room in the most remote corner of the ED. "These patients are precisely the ones you need to watch the closest," he says.
• Use alternatives to restraint.
According to Emde, ED staff may resort to restraints too often and need to find other ways to deal with agitated patients. At Overlake’s ED, a goal was set to avoid restraint use except when absolutely necessary.
Training teaches de-escalation techniques
An eight-hour training program was developed for all ED nurses and technicians on managing agitated patients, including de-escalation techniques and alternatives to restraint. Instructors included Emde and the ED director, and all staff members were required to attend the course. "We urged the staff to try less-restrictive approaches in all but the most out-of-control patients," she says. As a result of the training, the number of ED patients restrained decreased from an average of 20 per month to seven, Emde reports.
• Document restraint use appropriately.
When restraints are used, staff members need to document the frequency of observation required, care required by the restrained patient, and reassessment of the need for physical restraints, she emphasizes. (See the ED’s Restraint/Seclusion Flowsheet. For more information about documentation and restraint use, see "New restraint standards will change your practice," ED Management, August 2000, p. 93.) "This organized and monitored approach helps staff to make informed, appropriate decisions about patient care and ensures that our psychiatric patients receive appropriate and humane care," says Emde.
• Prevent patients from harming staff or themselves.
Gross warns that staff must be aware of items they are carrying as they enter a psychiatric patient’s room. "We had a staff member receive a minor wound when a patient grabbed their pen and struck them in the face with it," he says. "It easily could have been worse."
The ED uses two seclusion rooms exclusively for psychiatric patients, with beds bolted to the floor and no other equipment in the room, Emde says. Previously, equipment was left in the room, such as metal IV poles or oxygen cylinders on stretchers, which the patients then used as weapons, she says. "We had experience with patients picking up stretchers and bashing holes in walls and doors," Emde says.
The rooms are under continuous surveillance to ensure patient safety, she says. Equipment needed for patient assessment, such as otoscopes, blood pressure cuffs, and stethoscopes, is stored outside the room in a cart accessible to the physician and nursing staff but away from the patient, she says.
Gross emphasizes the need to make sure a locked room is monitored. "The last thing you want is to be trapped in a room with a dangerous patient," he says.
• Prevent patients from eloping.
Elopement of the patient is not only embarrassing, but it’s also a medical/legal disaster waiting to happen, Gross says. For that reason, psychiatric patients are asked to disrobe and put on a patient gown, then their belongings are removed from the room, he says.
The ED’s lockup room has a bathroom shared with the next room, Gross says. "While it is supposed to be locked, you can guess that the inevitable happened," he says. "A patient fled through that egress, flashed the poor patient and family and children in that room, and bolted out of the facility." The idea is to be proactive and avoid elopement from occurring in the first place, he emphasizes. However, if psychiatric patients elope before you’ve seen them or while you’re still in the work-up stage, alert law enforcement officials, he adds.
Making every reasonable effort to get the patients back will reduce your liability risk, Gross says. "It is the right thing and the only thing you can do at that point," he adds. "If you just wave and let them go and there is any kind of bad outcome, you legitimately don’t have any defense," Gross adds.
Sources
For more information on psychiatric patients, contact:
• Kathy Emde, RN, MN, CCRN, CEN, Trauma Service Coordinator, Overlake Hospital Medical Center, 1035 116th Ave. N.E., Bellevue, WA 98004. Telephone: (425) 688-5683. Fax: (425) 688-5101. E-mail: [email protected].
• Hartmut Gross, MD, FACEP, Associate Professor, Department of Emergency Medicine, Medical College of Georgia, 1120 15th St., Augusta, GA 30912. Telephone: (706) 721-3332. Fax: (706) 721-7718. E-mail: [email protected].
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