About a year ago, a 49-year-old patient awaiting medical attention died on the floor of the waiting room of the psychiatric ED at Kings County Hospital Center in Brooklyn, N.Y. Disturbing footage from the hospitals security surveillance cameras played on newscasts around the world and cast a spotlight on the need for special attention in hospital EDs for patients with behavioral health issues.
Since that incident, Pam McDonnell, director of media relations for NYC Health & Hospitals Corp., the parent company of Kings County Hospital Center, says the hospital has radically changed the psychiatric ED experience.
Better coordination with EMS and other components of the mental health system, adequate staffing ratios, more expeditious triage, assessment, and treatment have led to a dramatic reduction in overcrowding, McDonnell says. The average length of time patients stay in the [Comprehensive Psychiatric Emergency Program] which includes triage, evaluation, treatment, and disposition to the next level of care is down to less than eight hours compared to an average of 27 hours one year ago.Lee Anne Xippolitos, RN
McDonnell also emphasizes an added reliance now for a cooperative effort with hospital security to provide a safe environment for patients and staff.
Reliance on hospital police to manage patients in crisis has been greatly reduced with the deployment of new specially trained personnel who have crisis intervention and security skills, McDonnell says. Training in crisis intervention techniques was expanded to all front-line staff to better manage care and treatment of agitated patients and patients at high risk for violent behavior. Dedicated staff check on patients every 15 minutes to determine if patients require any immediate assistance. Peer counselors full-time employees who have been mental health patients themselves and now serve as mentors help engage patients and support the assessment team. The goal of these changes is to develop a culture that supports a recovery and rehabilitation model of care focused on empowering patients to actively participate in sustainable recovery.
Other facilities in the Greater New York area practice similar approaches to psychiatric care in the ED.
Lee Anne Xippolitos, RN, PhD, chief nursing officer for Stony Brook (N.Y.) University Medical Center and interim dean for the universitys School of Nursing, credits her facilitys use of CPEP in the ED as the foundation of the care and training that allows the hospital to handle even the most extreme of patient circumstances.Jatoopon Kiki Singpracha, RN
At the time I started at Stony Brook in 1990, CPEP began as a state-run program from the Office of Mental Health, originally funded from grant money, Xippolitos says. It began with the intent to provide needed focus and specialized care for such patients in the ED, and then, as the grant funding diminished over the years, we at Stony Brook have made a commitment to continue to support this program.
Xippolitos says patients who have psychiatric issues in the ED are triaged in a private examination area for assessment by a psychiatric nurse who is highly trained and specialized in crisis situations. The patient is provided one-on-one constant care during the process, as part of a team effort that includes social workers, a psychiatrist, mental health therapy aides, and clinical medical assistants. Debbie Sue Tlockowski, RN, an ED nurse educator, works with the nursing staff to develop the skills they need during these delicate situations.
The ED triage RN determines whether the patient is appropriate for CPEP based on the subjective and objective assessment, Tlockowski says. He or she will then call and give a verbal report to the CPEP RN that includes reason for visit, past medical history, allergies, medications, and vital signs. This report also gives the CPEP RN an opportunity to ask any questions about the patient.
Once the patient arrives from the ED, the CPEP team takes over. We reassure the patient that he or she is in a safe and therapeutic environment, says Jatoopon Kiki Singpracha, RN, BSN, a CPEP staff nurse. Our goal is to restore quality of health in every aspect mentally, physically, emotionally, and spiritually.Tasha Henneberry, RN
Ultimately, Xippolitos says, the patient is managed and discharged with follow-up steps, or transferred to a hospital psychiatric unit.
CPEP can provide rapid stabilization, keeping patients for 72 hours in what are called extended observation beds to treat and discharge, thereby avoiding an inpatient stay, says Tasha Henneberry, RN, MS, APRN, assistant director of nursing. CPEP can also arrange for follow up within five business days to a community organization for patients who are not presenting in treatment.
Stony Brooks CPEP evaluates between 4,500 and 5,000 patients of all ages each year, Henneberry says.Cassundra Forbes-Jewell, RN
At St. Vincents Catholic Medical Centers, a health system serving many areas around New York, an emphasis on security and monitoring in the psychiatric ED helps ensure a smooth process for patient care and safety.
Cassundra Forbes-Jewell, RN, clinical nurse manager for St. Vincents, says even the hospital staffs description of patients needs includes carefully chosen terms.
When patients are identified in the ED, we dont use words like mental illness or psychotic, she says. Its considered behavioral health issues.
She says the process begins with the triage nurse who makes an assessment, emphasizing its not a diagnosis.Barbara B. ONeill, RN
Michele Galbo, RN, manager of quality and nursing for the ED for St. Vincents, says while areas of concern are identified during patient assessment, security personnel are alerted to patients in the ED with behavioral health issues. The triage nurse must determine whether the patient is suicidal or homicidal, and notes if the patient requires constant observation. Before assessment begins, the patient also is asked to remove all clothing and given a hospital gown.
Galbo says security knows no patient with behavioral health issues is allowed to leave the hospital without proper paperwork providing proof of discharge or arrangements to be taken to another facility.
At St. Catherine of Siena Medical Center in Smithtown, N.Y., renovations to the ED in 2002 included the addition of one private examination room accommodating at least two people for use for patients with psychiatric issues.
We realize patients with added mental concerns are at higher risk and need to be cared for immediately in a quiet and safe area, says Jamie Donnelly, RN, assistant nursing care coordinator for the ED at St. Catherine of Siena Medical Center. Persons with a mental disorder are approached with a very specialized, humanistic manner by trained staff in this area.Jamie Donnelly, RN
Barbara B. ONeill, RN, nurse manager of psychiatry at St. Catherine of Siena Medical Center, says the key to the hospitals ED success is a collaborative team effort between all departments to mobilize resources.
She says the EDs safe room for patients with mental issues provides privacy and a calm environment which has helped foster an extremely low incidence of necessary physical restraints and need for seclusion.
Its our responsibility as nurses to treat every patient with a calm and understanding respect, despite the pressures of the ED environment, and provide a knowledgeable approach to serve the needs of others, ONeill says.