APNA 29th Annual Conference Session 4021: October 31, 2015 - - PDF document

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APNA 29th Annual Conference Session 4021: October 31, 2015 - - PDF document

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APNA 29th Annual Conference Session 4021: October 31, 2015 Disclosure No Conflicts of Interest The University of Maryland Medical Center approves the use of its logo for this presentation, as well as the pictures of the

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APNA 29th Annual Conference Session 4021: October 31, 2015 Noll 1

Recovery Founded Interventions in a Psychiatric Emergency Department Results in a Near Restraint Free Environment for Patients: It IS Possible!

APNA 29th Annual Conference 10/31/15

Connie Noll MA, MSN, PMHNP-BC, CRNP Zelda Ann Falck, MS, BSN, RN-BC Kimberly Sadtler, MSN, RN, PMHCNS-BC

Disclosure

  • No Conflicts of Interest
  • “The University of Maryland Medical Center approves the use
  • f its logo for this presentation, as well as the pictures of the

Psychiatric Emergency Services area. This presentation may not be repurposed without review and written permission by representatives of the Medical Center.”

Karen Lancaster, Director of Media Relations and Corporate Communications

Acknowledgements

Eric Weintraub MD, Division Director, Addictions and Psychiatric Emergency Services, University of Maryland Medical Center Greg Raymond MS, MBA, RN Director of Neuroscience, Behavioral Health Nursing, and Clinical Practice and Professional Development, University of Maryland Medical Center Patrick Mc Mahon MBA, Psychiatric Admission and Referral Specialist, University of Maryland Medical Center Patrick Brown MS, MA, RN, Clinical Nurse II Psychiatric Emergency Services, University of Maryland Medical Center

Objectives

  • Identify unique clinical challenges posed by the

emergency department environment that impact the use

  • f seclusion and restraint
  • Describe recovery oriented nursing interventions that

result in positive patient/staff rapport and patient engagement in treatment

  • Identify evidence-based alternative measures for

seclusion and restraint in an ED setting

Brief snapshot of UMMC

FY15 Statistics

  • 720 licensed beds
  • 8,200 employees
  • 1200 Attending physicians
  • 900 Resident physicians
  • 30,500 Admissions
  • 73,300 Emergency visits
  • 333,000 Outpatient visits
  • 22,100 Surgical cases
  • 10,400 Maryland Express

Care transfer admissions

We Heal, We Teach, We Discover, We Care

UMMC Psychiatric Emergency Services (PES)

 Separate area adjacent from the Adult Emergency Department  Locked and unlocked areas, staff work room, treatment room &

  • ffices

 Staffed 24/7

  • 3 RNs
  • 1 Mental Health Associate
  • Resident physician
  • Attending physician (13 hours/day)
  • 2 Psych NPs (8 to 12 hours, Monday-Friday)
  • Social Work (on call for Pediatric ED consults)

 FY15 volume 2773

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APNA 29th Annual Conference Session 4021: October 31, 2015 Noll 2

Environmental & Community Factors

Violence- UMMC is located on the west side of Baltimore City

Baltimore is in the top 10 cities with the highest crime rates per 100,000 residents

Flint, MI 827.0 Lubbock, TX 808.3 Pine Bluff, AR 793.0 Las Vegas, NV 763.4 Little Rock, AR 755.8 Baltimore, MD 685.3 Wilmington, DEL 634.8 Philadelphia, PA 551.8 New York, NY 496.0 New Orleans, LA 466.5

(Federal Bureau of Investigations, 2010)

Environmental & Community Factors

Substance Abuse

  • Baltimore has been named as the top city for

heroin addiction in the nation

  • In 2014, more people in Maryland were killed

by heroin than were murdered

  • Overdose deaths increased 88% in 2014

(Johnson, 2014; State of Maryland, Office of the Governor, (n.d.).

Restraint Prevalence in Emergency Department Settings

National Hospital Ambulatory Medical Survey

  • Conservative estimate of 53M mental health related visits

to EDs nationally between 1992 & 2001

Survey of Medical Directors in Psychiatric Emergency Services

  • 8.5% are restrained for a period of 3.3 hours per episode

Translates into 4.5M patients in restraint events and nearly 15 million hours

(Currier, Walsh, & Lawrence, 2011)

Restraint Prevalence in Emergency Department Settings

  • 1. Simpson et al, 2014
  • 14% restraint/seclusion rate
  • 5335 PES encounters
  • 12 month period in
  • U.S. urban, academic medical center
  • 2. Gerace et al, 2014
  • rate of 0.77 patients restrained per 100 mental

health presentations

  • median incident duration 3.3 hours
  • Australia metropolitan area
  • Four general hospitals

Psychiatric Emergency Settings: Clinical Challenges

Differs from both inpatient and ambulatory areas

  • Patients present with acute distress & agitation
  • Often in a state of poor functioning
  • Often with altered perceptions
  • May have no diagnosis or unclear diagnosis
  • No previous relationship with staff
  • May be intoxicated
  • May arrive involuntary

(Simpson, Joesch, West, & Pasic, 2014)

Risks of Seclusion & Restraint : Traumatization of Coercive Restraint

Psychological sequlea for patients*

  • Feelings of terror
  • Humiliation
  • Experience of powerlessness

*patients with a history of trauma have an increased risk

(Simpson et al., 2014)

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APNA 29th Annual Conference Session 4021: October 31, 2015 Noll 3

Risks of Seclusion & Restraint

Potential Physical Consequences for patients

  • Musculoskeletal & orthopedic injuries
  • Thrombosis
  • Asphyxia, strangulation
  • Rhabdomyolysis
  • Death

(Simpson et al., 2014)

PES Approach Seclusion & Restraint Reduction

 Use of Recovery oriented First Person Language  Use of Recovery principles in engaging patients into treatment  Caring Rounds  Weekly S&R review

  • post results graphically with minutes of reviews for

staff  Space organized as milieu area vs individual beds or pods

Use of Recovery Oriented First Person Language

Orient, mentor, and coach multidisciplinary staff to consistently approach patient with optimism and hope

  • Greeting & welcoming patients
  • Emphasis on what can be done
  • Using humanistic principles
  • Avoiding stigma, especially among staff

communications

  • Educational reinforcement of recovery oriented

principles in daily huddles

Use of Recovery Principles: Engaging Patients in Treatment

Multidisciplinary commitment and communication for dispositions mutually agreeable with the patient and family as feasible

  • Consistently meet patients ‘where they are’
  • Avoid coercion and passivity
  • Exhaustive list of community resources
  • Continuous relationship building with community

resources

  • Ability for external agencies to meet with the

patient in PES prior to discharge

Caring Rounds

Modification of the hourly rounds concept

  • RN driven rounding, minimum 4-6X’s per 24 hours

(minimum staffing 3 RNs/shift)

  • Questions
  • Comfort
  • How are you feeling?
  • Safety concerns
  • Understanding of meds, recommended treatments,

disposition

  • Is there anything else I can do for you now?

Weekly Review S&R Events

Departmental review of events on each unit with Behavioral Health nursing leadership and staff

  • Occurs weekly
  • Minutes distributed with feedback & graphs
  • Posted in clinical area
  • Discussed at staff meetings & huddles
  • Staff know how their unit is doing
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APNA 29th Annual Conference Session 4021: October 31, 2015 Noll 4

PES Space: Milieu

.

Space organized as milieu

  • Patients not assigned to beds
  • Freedom of movement possible, allows for ability to

pace

PES Space: Milieu

  • Staff workroom has complete visibility into

group areas

  • 12 camera views and monitors

Alternative Measures: Avoiding S&R

Evidence-based Alternative Measures used in the PES Setting

  • 1:1 interaction
  • Verbal interventions
  • Decrease in stimulation, use of more private areas
  • Food & drink

(Downey et al, 2007)

Overcoming Obstacles

  • Educate all of the multidisciplinary team

together

  • Regular discussions using available data
  • Positive feedback for S&R avoidance
  • Identify champions

PES Results: S&R Statistics

Patient number of minutes in S&R: FY13 to FY 15

FY 13 3,843 FY 14 607 85% FY 15 315 48% 99.2%

PES S&R Statistics

Pt Volumes FY 13 2753 FY 14 2849 FY 15 2773 Number of S&R Events FY 13 64 FY 14 21 FY 15 20 69% decrease

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APNA 29th Annual Conference Session 4021: October 31, 2015 Noll 5

PES S&R Statistics

PES Rate of Seclusion & Restraint FY 15 0.7% Average Duration of S&R 15.8 minutes

PES S&R Statistics

Number of Stat Medications per Quarter

Number of Patient /Staff Injuries*

FY 13 4 FY14 0 FY 15 5 * Reported to Risk Management PES S&R Statistics

Number of Minutes S&R and Number of STAT Meds

Summary

An organizational approach to Recovery oriented multidisciplinary care in a Psychiatric ED setting resulted in:

  • Sustained low use and duration of S&R
  • Without a significant increase in patient or staff

injuries

  • Or a significant increase in use of sedating

medications

Questions?

Thanks for the opportunity to present Questions?

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APNA 29th Annual Conference Session 4021: October 31, 2015 Noll 6

References

Allen, M. H., Currier, G. W., Hughes, D. H., Reyes-Harde, M. & Docherty, J.P. (2001). Treatment of behavioral emergencies. The Expert Consensus Guideline Series, 7, 1-27. Currier, G. W., Walsh, P. & Lawrence, D. (2011).Physical restraints in the emergency department and attendance at subsequent outpatient psychiatric treatment. Journal

  • f Psychiatric Practice, 17(6), 387-393. doi: 10.1097/01.pra0000407961.42228.75

Downey, L. A., Zun, L. S., & Gonzales, S. J. (2007). Frequency of alternative to restraints and seclusion and uses of agitation reduction techniques in the emergency

  • department. General Hospital Psychiatry, 29, 470-474. doi:

10.1016/j.genhosppsych.2007.07.006 Federal Bureau of Investigation. (2010). Crime in the United States: Uniform Crime

  • Reports. Retrieved from: http://www.fbi.gov/about-us/cjis/ucr/crime-in-the-

u.s/2010/crime-in-the-u.s.-2010/tables/table-6 Ferguson, J. & Leno-Gordon, D. (2008). Crisis prevention team calms agitated patients in psychiatric units, leading to a reduction in the use of restraints and seclusion and fewer injuries. AHRQ Health Care Innovations Exchange. Retrieved from http://www.innovations.ahrq.gov/content.aspx?id=2813

References (con’t)

Gerace, A., Pamungkas, D., Oster, C., Thompson, D. & Muir-Cochrane, E. The use of restraint in four general hospital emergency departments in Australia. Australian Psychiatry, 22(4), 366-369. doi: 10.1177/1039856214534001 Johnson, J. (2014, December 6). Hogan will declare heroin ‘emergency' once sworn in as governor. The Washington Post. Retrieved from http://www.washingtonpost.com/local/md-politics/in-maryland-hogan-says-he-will- declare-heroin-emergency-once-sworn-in-as-governor/2014/12/06/5f2ce320-7cc7- 11e4-84d4-7c896b90abdc_story.html Pestka, E. L., Hatteberg, L. A., Zwygart, A. M., Cox, D. L., & Borgen, E. E. (2012). Enhancing safety in behavioral emergency situations. MedSurg Nursing,21(6), 335-338. Simpson, S. A., Joesch, J. M., West, I. I., & Pasic, J. (2014). Risk for physical restraint in the psychiatric emergency services. General Hospital Psychiatry, 36, 113-118. doi: 10/1016/jgenhosppsych.2013.09.009 State of Maryland, Office of the Governor. (n.d.). Crime Control and Prevention: Crime

  • Statistics. Retrieved from http://www.goccp.maryland.gov/msac/crime-statistics-

county.php?id=25