Use of a Standardized Procedure to Improve Behavioral Health Patients’ Care: A Quality Improvement Initiative

Use of a Standardized Procedure to Improve Behavioral Health Patients’ Care: A Quality Improvement Initiative

PRACTICE IMPROVEMENT USE STANDARDIZED PROCEDURE TO IMPROVE BEHAVIORAL HEALTH PATIENTS’ CARE: A QUALITY IMPROVEMENT INITIATIVE OF A Authors: Elizabe...

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PRACTICE IMPROVEMENT

USE

STANDARDIZED PROCEDURE TO IMPROVE BEHAVIORAL HEALTH PATIENTS’ CARE: A QUALITY IMPROVEMENT INITIATIVE OF A

Authors: Elizabeth J. Winokur, PhD, RN, CEN, Jeannine Loucks, MSN, RN-BC, PMH, and Glenn H. Raup, PhD, RN, MSN, MBA, CEN, Orange, CA, Los Angeles, CA

Contribution to Emergency Nursing Practice

• A quality improvement, nurse-driven initiative can improve care for behavioral health patients while maintaining staff and patient safety. • Demonstrates how a nurse-driven protocol reduced time to first medication for behavioral health patients from 43 minutes to 5 minutes. • Standardized procedure instituted by nursing reduced use of restraints by more than 50%. Abstract Problem: Meeting the complex needs of behavioral health

(BH) patients in the emergency department is an ongoing challenge. Delays in care can have adverse consequences for patient and staff safety and delay transfer to specialized care.

which focused on improving time to first medication and reduction of restraints. The project used a multidisciplinary team to develop the STP scoring tool and corresponding medications. Improvement was seen in all quality metrics. Time to first medication decreased from 43 minutes to less than 5 minutes. Adopting the STP resulted in a 50% decrease in use of restraints and time in restraints. Staff injuries remained low, with less than 3.6% of staff sustaining physical injuries. Discussion: The STP is an effective method to initiate immediate treatment of patients with signs of anxiety and aggression and thus reduce risk of violence. Additional benefits are reduced time to disposition and earlier initiation of specialized BH care. This process can be replicated in other emergency departments with similar clinical environments through the use of STPs or protocols based on state regulations.

Methods: A quality improvement, nurse-driven initiative using a standardized procedure (STP) was developed and implemented in our busy Southern California Emergency Department,

Key words: Emergency nursing; Restraints; Behavioral health

Introduction

behavioral health (BH) crises. 1 Recent national statistics demonstrate that 1 of 8 visits to an emergency department is for a BH complaint. 2 Further, an even more complex subset of BH patients are those who are homeless, in which case the emergency department is often their only option for care and addressing the types of social concerns that have impact on their health. 3,4 Among this population, initial visits and readmissions to the emergency department for BH complaints far exceed that of the general population, 5,6 and diagnoses representing serious mental illness are more than 8 times higher than those among housed persons. 3 Emergency departments are less than optimal settings for delivering psychiatric care. Assessment and treatment for BH patients may be delayed to provide care to medical patients who are perceived to be more acutely ill. Underlying conditions are often complex among BH patients. Medical histories may be incomplete because of their lack of cooperation or inability to participate in self-care. 4,7 Environmental noise and excessive activity

With the reduction of many inpatient psychiatric beds and the increasing complexity of navigating access to community resources, emergency departments have become the primary source of care for many patients experiencing Elizabeth J. Winokur, Member, ENA, Orange Coast Chapter, is Clinical Educator and Nurse Researcher, St. Joseph Hospital, Orange, CA, and Assistant Professor of Nursing, California State University, Los Angeles, CA. Jeannine Loucks is Department Manager, Emergency Care Center, St Joseph Hospital, Orange, CA. Glen Raup is Executive Director, Emergency Care Center, Behavioral Health, and Observation Services, St Joseph Hospital, Orange, CA. For correspondence, write: Elizabeth J. Winokur, St. Joseph Hospital, 1100 West Stewart Drive, Orange, CA 92863; E-mail: [email protected] J Emerg Nurs ■. 0099-1767 Copyright © 2017 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2017.07.008



(BH) patients; Psychiatric patients; Violence reduction; Standardized procedure (STP)

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associated with a normal emergency department is the converse of the quiet, calm setting that is most beneficial to a patient struggling with an acute BH crisis. Emergency nurses are frequent recipients of aggression and violence from the BH population. 8,9 Identified among the top conditions associated with ED physical assaults are “under the influence of alcohol/drugs,” “drug seeking,” and “mental health issues or mental health patient.” 8,10 Research findings demonstrate that many acts of aggression and violence occur within 1 hour of arrival in the emergency department. 11,12 Therefore, delays in care may exacerbate the risk of aggression or violence. Our Southern California community hospital emergency department struggled with an increasing volume of BH patients, totaling more than 5,000 annually. Recent interpretation of county requirements dictated that community psychiatric crisis teams preferentially transport patients to emergency departments in hospitals with inpatient psychiatric units (eg, designated facilities). Law enforcement was strongly encouraged to do the same. Our county, with greater than 3 million inhabitants, has 4 such facilities. Southern California, like many other temperate regions of the country, has a disproportionate number of homeless patients, many of whom struggle with BH problems. 13 This population comprises a significant proportion of BH patients requiring emergency care. As a result, it became evident that the ED in this designated facility needed to find a solution to provide better expedient care to those afflicted with BH disorders.

Methods

A team composed of emergency staff nurses, ED leadership, and physicians met to define the scope of the problem and identify issues associated with providing care to BH patients. At project initiation, time to initial physician evaluation with medication ordered was often in excess of 40 minutes after patient arrival. Data demonstrated that many patients progressed to “Code Gray” (significant aggression or violence) or required restraints before medication was administered or took effect. Occasions when multiple BH patients arrived within a short time of each other magnified the problem. An agitated patient often incited others to agitation. All these issues led to risky clinical situations. Input was sought from nursing and medical staff. Emergency nurses reported feeling hindered in caring for these patients while waiting for physician evaluation and medication. They expressed frustration as patients’ behav-

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iors escalated despite verbal interventions. Physicians identified that the highest-acuity emergency patients were their initial priority for assessment and treatment; these patients were most often those with traditional medical concerns. Generated reports were evaluated, and project goals were developed. The primary goal was to improve timeliness of care for the BH population. Additional goals were to reduce acts of aggression and use of restraints. It was postulated that prompt assessment and administration of medication would reduce the need for restraints and Code Grays. After a review of the literature, possible solutions were evaluated by the team. Development and implementation of a standardized procedure (STP) was selected to meet the goals.

An Evidence-Based Solution

In California, STPs are legally sanctioned processes that allow registered nurses to “perform functions which would otherwise be considered the practice of medicine” (California Code of Regulations 1470). 14 Standardized procedures must be developed collaboratively within the organization with the input and approval of nursing, medicine, and administration. 15 Experience of the nurse, including training or education that must be completed before use of the STP, must be defined explicitly. 14 Rigorous monitoring is required to ensure compliance. 15 Although terminology may differ, other states have legal mechanisms to provide expanded scopes of practice for clinical nurses (eg, protocols in Georgia). 16–18 Because STPs are prescriptive, nurses can perform clearly defined actions only in specific circumstances. A consistent method for assessing, treating, and evaluating patients needed to be developed. Historically, valid instruments assessing for agitation in the emergency setting have been limited. However, a recently developed scale, the Agitation Severity Scale, 19 was identified during a review of the literature. This observation-based instrument was designed to measure a range of behaviors—indicating movement along a continuum of behaviors—ranging from mild to severe agitation. Clinical staff members observe the patient for 17 behaviors and rate the frequency of each behavior from “not at all (0)” to “always present” (3). Scores are calculated by summing the value assigned to each observed behavior; higher scores indicate higher levels of agitation. Psychometric evaluation of the scale demonstrated internal consistencies of 0.88 and 0.91 on 2 separate measurement intervals; convergent validity was established

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Assessment findings indicate patient is a candidate for early medication administration as part of stabilization treatment. Nurse completes the 17-item Agitation Severity Scale Decision Scoring Grid and selects the appropriate medication based on the scores Agitation Severity Scale Scoring Criterion: Anxiety / Agitation Spitting 4 x Red in the Face 4 x Darting Eyes 1 x Yelling, louder than baseline 2 x Demanding 2 x Speaking more quickly than baseline 1 x Angry tone of voice 2 x Persistent disruptive verbalizations 4 x Physical violence towards self or others 4 x Violating Self or Others 3 x "In your face" 3 x Decreased self-control, impulsiveness 4 x Puffed up, chest out, threatening posture 3 x Tapping, clenching, involuntary movement of hands 1 x Restless 1 x Confrontational 2 x Unable to be calmed 2 x

Results/Criterion 0-1 Anxiety 2-3 Anxiety 4+ Anxiety

Action reassess per routine medicate mild anxiety medicate mod. anxiety

0-1 2-3 4+

reassess per routine medicate mild agitation medicate mod. agitation

Agitation Agitation Agitation

FIGURE 1 Anxiety/agitation scoring sheet.

between the Agitation Scale and the Pittsburgh Agitation scale (r = 0.90, P b 0.01). 19 After obtaining permission to adapt the scale, our institution’s team met to determine which patients would be cared for using the STP, the behavioral thresholds on the anxiety/agitation scale necessary to medicate patients, and which medications would be used. Expert consensus was used to develop the adapted scoring tool. The adapted tool is called the Anxiety/Agitation scoring sheet (Figure 1). Each behavior was assigned a point value ranging from 1 to 4; higher numbers indicated more severe behaviors. Points are summed to indicate degree of anxiety or agitation. Selection of patients for the STP was limited to those presenting with psychiatric emergency conditions; this was further restricted to BH patients presenting with mild (anxiety/minor acting-out behaviors) to severe agitation (violent actions/behaviors) on the Anxiety/Agitation scoring sheet. Items on the original scale were subdivided into behaviors that indicated anxiety or agitation. Patients received medication for anxiety only when no medication for agitation is indicated. Three possible score-medication options were determined for both anxiety and agitation. First, an anxiety or agitation score of less than 2 indicated that no medication



would be given, and the patient would be reassessed. Next, an anxiety score of 2 to 3 was defined as mild anxiety; in the absence of contraindications, the patient would be medicated as directed within the STP (Figure 2). Finally, an anxiety score of 4 or greater indicated that the patient was experiencing moderate anxiety and would be medicated accordingly. The adapted tool was determined to have face validity among clinical experts in that the tool could assess anxiety and agitation. Concordance was obtained following review by psychiatric nursing experts, psychologists, and emergency psychiatrists. Before use, further testing of the tool during 5 sessions with emergency nurses demonstrated interrater reliabilities of 0.9 or higher. To institute an STP, approval must be received from several hospital committees. In addition to the ED Medical Committee and Behavioral Health Medical Committee, this policy was presented at and approved by pharmacy, nursing, and interdisciplinary practice committees. Once approved, forms were developed, and education of staff began. Emergency nurses received extensive education (N = 125). All were required to attend a 2-hour didactic training session. Content included an overview of anxiety and agitation and the

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FIGURE 2 Decision grid based upon anxiety/agitation scores.

relationship between these conditions along with content on violence and hospital policies regarding the use of restraints. Medications used in the STP were presented, and indications, contraindications, appropriate dosing, and routes of administration were discussed. Emergency nurses applied the procedure to unfolding case studies; the manager reviewed answers to determine consistency in scoring. This allowed for immediate feedback, correction of misperceptions, and provision of rationale for specific scoring. A medication test containing STP medications was given following the session. Following group education, the department manager responsible for BH emergency services provided 1-on-1 training with each nurse. She reviewed procedures for assessing

patients for anxiety and agitation, specifics about medications, and answered questions. Once the STP was implemented, the manager, educator, or charge nurse provided additional support and “just in time” coaching/training for its appropriate use.

Results

Audits were begun immediately after institution of the STP in March 2015. All medical records for which the STP was initiated were identified. As part of the ongoing mandated quality review, records were assessed to determine if criteria were met for use of the STP. Reasons for use documented in

TABLE 1

Average time (minutes) to first medication for behavioral health patients

Time to first medication

4

2014

2015

Q1-4

Q1

Q2

Q3

Q4

2016 Q1

Q2

Q3

Q4

2017 Q1

43

Train staff

30

20

15

22

14

5

5

4

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TABLE 2

Use of restraints for behavioral health patients

Patients in restraints (%) Time in restraints (minutes)

2014

2015

2016

Q1-4

Q1

Q2

Q3

Q1-4

Q1

Q2

Q3

Q1-4

Q1

9% 286

Train staff

5.6% 219

2.7% 214

4% 157

4% 235

4% 159

4% 137

3.8% 192

4.8% 142

the medical record were compared with those indicated on the Anxiety/Agitation scoring sheet to determine adherence by staff to the STP. Medication dose, route, and absence of contraindications were evaluated to ensure that medication selection concurred with the STP. Quality oversight is achieved through nursing practice audits completed by the manager, which are compiled for an annual report to the Interdisciplinary Practice Council. Reports generated indicated that time to anxiety or agitation medication averaged 43 minutes in 2014. After initiation of the STP in March 2015, time to medication in the second quarter demonstrated an average decline to 30 minutes. This rate continued to decrease, stabilizing in the third quarter of 2016 at 5 minutes or less (Table 1). A benefit of early initiation of medication was reduction in numbers of restraint episodes and length of time patients were in restraints. Before initiation of the STP, approximately 9% of BH patients were restrained; after initiation, restraint episodes decreased substantially with the last 8 quarters, demonstrating a mean of 4.1% (Table 2). This occurred despite an increase in overall numbers of BH patients presenting to the emergency department. Of those who were placed in restraints, time in restraints decreased from 286 minutes before initiation of STP to 196 minutes in 2015, to 142 minutes during the first quarter of 2017 (Table 2). Staff injuries are essentially unchanged (Table 3). Two staff members in each year between 2014 and 2016 sustained injuries that required medical care. None of these

2017

cases required time off from work. Most Employee Health contact was to “report incident only” (a notification to Employee Health in the event that an injury developed at a later time). These are noninjurious incidents that are recorded in Employee Health in the event that an employee has a delayed reaction related to an incident. Code Grays, a coordinated physical response instituted for combative patients, demonstrated an initial decrease in the year following initiation of the STP from 4.7% to 3.5%. The rate increased in the second year to 4% (Table 4).

Discussion

A comprehensive approach to management of BH patients is imperative for patient and staff safety and optimal functioning of any emergency department. The use of STPs is an additional resource in meeting this need. The adapted Anxiety/Agitation scoring tool assists with early recognition of the condition of BH patients, and early medication reduces the risk of untreated agitation escalating to a Code Gray, restraints, and/or staff injuries. Decreased time to initial anxiety/aggression medication is associated with an improvement across multiple indicators of care for BH patients. Those patients who arrive with heightened levels of anxiety and agitation are more likely to injure staff, 8,20,21 be unresponsive to verbal de-escalation, and require behavioral restraints. 7 The percentage of patients requiring restraints, as well as time in restraints,

TABLE 3

Employee injuries Type of incident

2014 2015 2016



Injury necessitated time off from work

Report incident only

First aid

Medical care

4 1 4

2 4 1

2 2 2

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TABLE 4

Code Grays 2014 2015 2016

Total

Percent of BHS volume

190/4004 179/5002 209/5108

4.7% 3.5% 4.0%

BHS = Behavioral health services

has demonstrated a substantial reduction since initiation of the STP, despite increasing volume and acuity. Data demonstrate that before initiation of the STP, 9% of BH patients required restraints; this decreased to an average of 4% during the subsequent 24 months. Also, BH patients can have prolonged lengths of stay in many emergency departments, related, in part, to difficulty arranging inpatient admission or outpatient referrals. 1,2 Use of restraints compounds this phenomenon. Weiss et al 7 reported that restraints can add 4 to 6 hours to an ED length of stay. In our experience, by reframing the Code Gray response, numbers of patients moving to aggressive episodes have decreased. The department has adopted a more proactive stance for the use of the Code Gray team. Code Grays are now called earlier with agitated or aggressive patients. This “show of support” or standby provides ready assistance for staff and encourages cooperation by patients. 9,22 Thus, despite only a slight decrease in recorded Code Grays, fewer have led to the need for physical contact and restraint.

Initial and ongoing staff education may be responsible for augmenting outcomes. In 2015, staff received education specific to the STP and medication used to manage psychiatric disorders. In 2016, further education focused on an intensive review of schizophrenia, bipolar disorder, depression, and risk factors associated with suicide. In 2017, all nursing staff received education on identification and management of substance abuse. Reports of ED staff in the United States who sustained injuries from violent patients are plentiful in the literature. 8,10,21,23,24 In a recent study conducted in 3 emergency departments, Gillespie et al 21 reported that, over an 18-month period, 55% of ED staff sustained injuries from physical assaults. Most physical assaults were attributed to patients exhibiting psychiatric symptoms (34%) and substance abuse (18%). Speroni et al 8 reported that 97% of ED nurses had experienced workplace violence. In contrast, staff injuries at our institution have remained at a consistently low level, with 3 to 6 (1.8% to 3.6%) ED staff members injured annually and none requiring time off from work. This may be in part due to California’s mandated Management of Assaultive Behavior classes. All ED staff members attend this 4-hour course annually. Among the required content are signs and predictors of aggression/ violence, the assault cycle, verbal and physical, techniques to de-escalate violent behavior, and the legal requirement to report incidents of violence. 25 In addition, 2 security officers are assigned to each shift in our emergency department. This staffing model may reduce risk by providing staff support for potentially violent patients. 9

TABLE 5

Use of standardized treatment protocols for behavioral health patients in emergency departments: Implications for key stakeholders Stakeholders

Implications for practice

Patients

Assists in preserving patient dignity by decreased use and time in restraints Facilitates ability to regain control of self-management behaviors Decreases disruptions/stress for medical, nonbehavioral health patients Improves regulatory compliance through reduction of restraints Improves staff safety through reduction in injury related to patients with escalating agitation Improves patient safety through increased awareness of therapeutic interventions Improves time interval quality of care metrics Empowers staff with tools for earlier and ongoing intervention for patients with behavioral health emergencies Improves staff safety through reduction in injury related to patients with escalating agitation Improves overall satisfaction related to care plan for patients in behavioral health crises Decreases disruptions/stress for managing mixed patient load of medical and behavioral health patients Improves time interval quality of care metrics Improves overall satisfaction related to care plan for patients in behavioral health crises

Leadership

Staff

Physician

6

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Implications for Emergency Nursing

Meeting the complex needs of the BH patient in an ED environment presents a continuing challenge. Developing a coordinated approach that involves all stakeholders using an STP to focus interventions and responses provides optimal chances for success in achieving progress toward key performance outcomes (Table 5).

8. Speroni KG, Fitch T, Dawson E, Dugan L, Atherton M. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors. J Emerg Nurs. 2014;40(3):218-228. quiz 295. 9. Wyatt R, Anderson-Drevs K, Van Male LM. Workplace violence in health care: a critical issue with a promising solution. JAMA. 2016;316(10):1037-1038. 10. Gillespie GL, Gates DM, Berry P. Stressful incidents of physical violence against emergency nurses. Online J Issues Nurs. 2013;18(1):2. 11. Pich J, Hazelton M, Sundin D, Kable A. Patient-related violence against emergency department nurses. Nurs Health Sci. 2010;12(2):268-274. 12. Crilly J, Chaboyer W, Creedy D. Violence towards emergency department nurses by patients. Accid Emerg Nurs. 2004;12(2):67-73.

Conclusion

Use of a STP is an effective method for the nurse to assess autonomously and immediately begin treatment of patients who demonstrate signs of anxiety and aggression and thus reduce risk of violence. An additional benefit is earlier initiation of therapeutic BH care and reduced time to disposition. This process can be replicated in other emergency departments with similar clinical issues through the use of a standardized procedure or protocol.

13. Larson S. Orange County’s 2015 point in time count and survey: Commission to End Homelessness. 2015; http://www.211oc.org/images/Reports/ PointInTime/2015_pit_results_c2eh__final_7-30-15_funders_2125.pdf. 14. California Code of Regulations. Standardized Procedure Functions (1470; 1472). 1976; https://govt.westlaw.com/calregs/Document/ I285B26D05F7C11DF976784F95795F04E?viewType=FullText &originationContext=documenttoc&transitionType=CategoryPage Item&contextData=(sc.Default). 15. California Board of Registered Nursing. Standardized Procedure Guidelines. 2011; http://www.rn.ca.gov/pdfs/regulations/npr-i-19.pdf. 16. Alabama Board of Nursing. Practice. n.d.; https://www.abn.alabama. gov/practice.

REFERENCES 1. Nesper AC, Morris BA, Scher LM, Holmes JF. Effect of decreasing county mental health services on the emergency department. Ann Emerg Med. 2016;67(4):525-530.

18. Oregon Department of Corrections. Nursing treatment protocols. n.d.; https://www.oregon.gov/DOC/OPS/HESVC/pages/protocol.aspx.

2. Owens PL, Mutter R, Stocks C. Mental health and substance abuse-related emergency department visits among adults, 2007. HCUP Statistical Brief No.92, Agency for Healthcare Research and Quality: Rockville, MD; 2010.

19. Strout TD. Psychometric testing of the Agitation Severity Scale for acute presentation behavioral management patients in the emergency department. Adv Emerg Nurs J. 2014;36(3):250-270.

3. Albert M, McCaig LF. Emergency department visits related to schizophrenia among adults aged 18–64: United States 2009–2011. NCHS Data Brief, No. 215. 2015, September; https://www.cdc.gov/ nchs/data/databriefs/db215.pdf.

20. Wolf LA, Delao AM, Perhats C. Nothing changes, nobody cares: understanding the experience of emergency nurses physically or verbally assaulted while providing care. J Emerg Nurs. 2014;40(4):305-310.

4. Shefer G, Henderson C, Howard LM, Murray J, Thornicroft G. Diagnostic overshadowing and other challenges involved in the diagnostic process of patients with mental illness who present in emergency departments with physical symptoms: a qualitative study. PLOS ONE. 2014;9(11):e111682. 5. Lam CN, Arora S, Menchine M. Increased 30-day emergency department revisits among homeless patients with mental health conditions. West J Emerg Med. 2016;17(5):607-612. 6. Ku BS, Fields JM, Santana A, Wasserman D, Borman L, Scott KC. The urban homeless: super-users of the emergency department. Popul Health Manag. 2014;17(6):366-371. 7. Weiss AP, Chang G, Rauch SL, et al. Patient- and practice-related determinants of emergency department length of stay for patients with psychiatric illness. Ann Emerg Med. 2012;60(2):162-171.e165.



17. Georgia Department of Public Health. Guidelines for nurse protocols for registered professional nurses. 2012; https://dph.georgia.gov/sites/dph.georgia. gov/files/related_files/site_page/Guidelines%20for%20Nurse%20Protocols.pdf.

21. Gillespie GL, Gates DM, Kowalenko T, Bresler S, Succop P. Implementation of a comprehensive intervention to reduce physical assaults and threats in the emergency department. J Emerg Nurs. 2014;40(6):586-591. 22. Roca RP, Charen B, Boronow J. Ensuring staff safety when treating potentially violent patients. JAMA. 2016;316(24):2669-2670. 23. Wolf LA, Perhats C, Delao AM. US emergency nurses' perceptions of challenges and facilitators in the management of behavioural health patients in the emergency department: mixed-methods study. Australas Emerg Nurs J. 2015;18(3):138-148. 24. Emergency Nurses Association. Emergency Department Violence Surveillance Study. https://www.ena.org/practice-research/research/ Documents/ENAEDVSReportNovember2011.pdf. 25. California Department of Health and Safety. Codes 1257.7 and 1257.8 n.d.; http://codes.findlaw.com/ca/health-and-safety-code/hsc-sect-1257-8.html.

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