Published in the May 2016 issue of Today’s Hospitalist
LIKE MANY FACILITIES, Chicago’s Swedish Covenant Hospital used to have behavioral health patients linger in the ED for days, waiting for appropriate disposition. But that problem has been dramatically reduced, thanks to a new care model spearheaded by nursing director Ajimol Lukose, DNP, RN-BC.
The model relies on a three-part strategy: making a psychiatric clinician available for psychiatric assessments, setting aside an area specifically for behavioral health patients, and putting new protocols for nursing staff in place.
“An experienced psychiatric staff nurse cannot write orders, but can collaborate with the ED doctor.”
“This helps ED throughput,” Dr. Lukose points out. The program also has reduced sitter use, labor costs, restraint episodes and elopement rates. Best of all, it has cut ED length of stay for behavioral health patients, allowing them to get the services they need more quickly while freeing ED resources for other patients.
Waiting in the ED
After Illinois cut its general fund for mental health services, half the mental health clinics in Chicago closed in 2011 and 2012. That prompted a surge of behavioral health patients seeking treatment in EDs, many of which were not equipped to serve them in a safe setting.
“The ED physicians are not comfortable discharging these patients from the ED before they have a thorough evaluation by a psychiatric clinician,” Dr. Lukose says. Uninsured patients with behavioral health issues who present to the ED and need hospitalization are transferred to a state facility, which can take 70 hours.
Insured patients can be admitted to Swedish Covenant if their condition warrants. But the psychiatrists who have admitting privileges are independent practitioners and are not always physically available for ED patients waiting to be transferred to psychiatric facilities.
“Patients would be waiting in the ED but not under the care of a psychiatrist—and not getting timely and appropriate psychiatric interventions while they waited,” Dr. Lukose explains. “We wanted to come up with a safe care model for managing all psychiatric patients waiting in the ED for appropriate disposition.”
In 2013, Dr. Lukose helped develop a program that changed the way patients with behavioral health symptoms flowed through the ED.
First, an ED physician assessed those patients. If they were medically cleared but needed a psychiatric evaluation, the physician requested a psychiatric consultation and assessment.
Patients were then placed in a special area of the ED that provided a low-stimulation, high-safety environment. They were assessed by members of the hospital’s crisis intervention team, made up of counselors provided by a local social services agency.
Then, a family nurse practitioner with psychiatric experience conducted a psychiatric evaluation and initiated appropriate psychiatric interventions. The psychiatric nurse practitioner was also able to discharge patients with follow-up plans if they did not need hospitalization.
Within six months, the new model had proved its worth: More than 90% of patients had a psychiatric evaluation completed within one hour of the physician’s order and psychiatric interventions initiated within two hours.
The key to success, says Dr. Lukose, was having a psychiatric clinician rounding in the ED to assess patients and help physicians determine the next steps for patients’ care. Even though Dr. Lukose’s vision for the position was a psychiatric nurse practitioner, the family nurse practitioner with psychiatric experience worked out well. She also notes that a psychiatric nurse can be successful.
“An experienced psychiatric staff nurse cannot write orders, but can collaborate with the ED doctor,” says Dr. Lukose. “The doctor might feel more comfortable knowing that a psych nurse has evaluated a patient and determined that the patient is not suicidal, homicidal or in danger.”
The nurse practitioner is available only for eight hours per day on weekdays. Patients who come on weekends or after hours are evaluated by the crisis team and by on-call psychiatrists who can consult via phone.
A safe space
To support the model, ED space was reorganized to create a dedicated area specifically for psychiatric patients. Designed to be a calm environment, the five rooms have minimal equipment and are free of sharp objects, cords and other potential dangers.
Patients wear blue gowns to distinguish them from other patients, which makes them more noticeable if they leave the designated area. Their personal belongings are locked in a cabinet, and security personnel round frequently. Because the psychiatric patients are clustered in one area, one sitter can monitor multiple patients if they don’t require one-on-one monitoring.
Meanwhile, ED nurses were trained in the “Four S” model commonly used by psychiatric nurses:
- Safety: Secure physical and emotional well-being.
- Support: Decrease distress or anxiety and increase the experience of being understood.
- Structure: Restore function.
- Symptom management: Address symptoms and avert negative outcomes.”If your ED nurses are not trained or they don’t have the tools to manage psychiatric patients, things are not going to get any better,” Dr. Lukose says. She worked with the ED nursing director to create nursing protocols and develop a one-page checklist.That checklist reminds the nurses to place psychiatric patients in the designated area, have them don blue gowns, search their belongings and remove contraband items, and provide plastic eating utensils.
Better care at lower cost
In the fourth quarter of 2013, the average ED length of stay for behavioral health patients fell to 8.8 hours, down from a baseline of 12.3 hours the first quarter. While length of stay for insured patients fell only slightly, that of uninsured patients—many of whom were transferred to a state hospital—fell by 7.8 hours.
Improvement continued in 2014, with the average ED length of stay for all psychiatric patients 30% less in fiscal year 2014 than in 2013. For uninsured patients, ED length of stay was reduced 40% and more than 50% for those who needed to be transferred to another facility.
Meanwhile, sitter use fell 46%, reducing labor costs by more than 49% in one quarter. While the project cost more than $217,000 to implement, cost savings the first year were estimated as $214,000.
An expanded model
Case managers in the crisis intervention team work with the psychiatric nurse to implement discharge plans, either transferring patients to a state hospital or psychiatric inpatient unit or discharging patients with appropriate follow-up services.
The care model has also been expanded: If patients can’t access prompt outpatient follow-up, the psychiatric nurse provides up to three free appointments.
“She keeps some time open on her schedule everyday so a patient can walk in during that time and be seen,” says Dr. Lukose. If needed, Swedish Covenant’s pharmacy also arranges for free medications through a funding program.
Lola Butcher is a freelance health care writer based in Springfield, Mo.