Accelerating care using a standardized protocol for psychiatric emergency patients

Abstract

<p>Session D presented Friday, September 15, 2017</p> <p><strong>Purpose:</strong> Behavioral health (BH) complaints are a component in one out of every eight emergency department visits.&nbsp; With the closing of many inpatient psychiatric beds, emergency departments are the primary source care for many individuals experiencing a behavioral health crisis. Often assessment and care for BH patients is delayed to provide care to medical patients who are perceived to be more acutely ill.&nbsp; Emergency nurses are frequent recipients of aggression and violence from this population.&nbsp; &nbsp;Research findings demonstrate that most acts of aggression and violence occur within one hour of arrival in ED.&nbsp; Therefore delays in care may exacerbate the risk for aggression or violence.&nbsp; Expediting care for behavioral health and other patients experiencing emotional crises is essential in the emergency department to prevent increasing agitation and/or aggression.&nbsp; This project developed by a multi-disciplinary team used a standardized protocol to provide definitive care, including medications, before being seen by the physician.</p> <p><strong>Design:</strong> This quality improvement project was instituted In response to increasing numbers of BH patients presenting to a busy emergency department.&nbsp; Its goal was to reduce risk of&nbsp; agression and violence through prompt initiation of definitive care.</p> <p><strong>Setting:</strong> Community hospital in Southern California.</p> <p><strong>Participants/Subjects:</strong> All ED staff have been trained and participate in this project.</p> <p><strong>Methods:</strong> A team composed of staff nurses, ED leadership, and physician examined issues and proposed solutions to improve timeliness of care for the BH population with a secondary goal of reducing acts of aggression and restraint use.&nbsp; As allowed by California Board of Registered Nursing, a standardized procedure (STP) allowing ED nurses to assess and order medication for anxiety or aggression was developed.&nbsp; Subsequent to approval by multiple hospital, physician, and interdisciplinary practice committees the procedure was instituted.&nbsp; Emergency staff nurses received extensive education, both in groups and one-on-one to train them in the use of the procedure.&nbsp; Competency was documented prior to the nurse being able to institute the STP.</p> <p><strong>Results/Outcomes:</strong> Time to medication for anxiety and agitation has decreased from 43 minutes to an average of 19 minutes. The implementation of the STP has also resulted in a 50% decline in the number of restraint episodes.&nbsp; For those in restraints, time in restraints has significantly decreased.&nbsp; &nbsp;The number of code grays has demonstrated overall reduction.</p> <p><strong>Implications:</strong> Use of a STP is an effective method for the nurse to autonomously assess and immediately begin treatment of patients with signs of anxiety and aggression, and thus reduce risk for violence.&nbsp; An additional benefit is earlier initiation of therapeutic BH care and reduced time to disposition.&nbsp; This process can be replicated in other emergency departments through the use of a standardized procedure or protocol based on state regulations.</p>