‘Psych ED’ helps speed throughput time by 9%
Psych ED’ helps speed throughput time by 9%
Improvement seen despite increase in patient volume
A new, separate area for psych patients within the ED has helped Forsyth Medical Center in Greensboro, NC, cut its average throughput time by 9% — from 201 minutes to 189 minutes for all patients, according to department’s manager. This reduction was accomplished while the department was facing a growing influx of psych patients, she notes.
The area, part of a new $18 million ED opened in October 2004, is staffed by one psychiatric nurse each shift, with 24/7 coverage, as well as by one or more members of the "access" staff: mental health workers, human service clinicians, social workers, or advanced degree psychiatric services providers. Access staffing varies with patient volume.
In designing the new department, "we had to evaluate what population was coming into the ED," recalls Robin Voss, RN, MHA, director of emergency and trauma services. Not only was the department starting to see a significant increase in psych patients coming to the ED, but it was taking a fairly lengthy time to determine the type of care they would need, notes Voss, who was in charge of the redesign effort.
The change couldn’t have been soon enough, notes Jo Haubenreiser, executive director for post-acute services. "In the first 10 months of 2005, we saw 4,088 psych patients, while for the same period in the previous year it had been 3,766," she reports.
Prior to the change, the behavioral health department had behavioral health clinicians working in the ED along with staff handling these patients, notes Haubenreiser.
"We pulled in all the key stakeholders, including psych people, to determine what would help most with throughput," Voss shares. "In the old department, we just put these patients in the midst of everything else. We decided we wanted a new area out of the hubbub."
Triage unchanged
These patients come in the main entrance and go through triage like any other patient, says Voss. "They see a triage nurse, they’re asked the same questions as anyone else," she notes. Then, they are brought back to have their emergency medical screening exam.
"If they are determined to have a psych issue [typically the patient self-identifies] as well as a medical issue, they must be admitted as a regular emergency department patient," Voss explains. "If they are determined not have a medical emergency, then the access process gets started."
That means that the access staff is contacted to initiate a process to determine what level of care the patient needs. "What we do is see they are placed at the right level of care — such as being admitted to the psych unit or triaged down to the psych outpatient unit — and not just filling beds in the hospital," explains Haubenreiser.
Patients who did not have an emergency medical condition, but whose emergency condition was psychiatric, are moved back to the ED behavioral health area, which is adjacent to the main ED, says Voss. The area, which is located in one corner of the large, rectangle-shaped department, includes a sitting area with a television where patients who are acting out can sit while they de-escalate.
The rooms have hardly any equipment, so the patients can’t find items that they can use to hurt themselves, Voss says. "The bathrooms are set up the same way, and the patients can’t lock themselves in," she adds. "The whole area is monitored on closed-circuit TV in the security surveillance room." Bathrooms are not monitored, to allow the patients privacy, Voss says. However, she has no privacy concerns about the other cameras in the area, "because it’s obvious they are there."
Cross-training eases burden
The cost to the hospital of the additional ED staff is minimized through cross-training the psych nurses in minor emergency care, says Voss.
"If they do not have patients in their area they could float to the other area to help out," she explains. "Or, they can go to the psych floor and help in behavioral health."
What’s more, ED staff also are trained to expand their traditional roles. There is very extensive crisis prevention training given to the ED staff to effectively manage behavioral inappropriateness, Haubenreiser notes. For example, they’ve been very successful in calming down overly excited individuals, she reports.
No added cost for ED
In reality, having a separate area represented no additional cost to the ED, Voss says. "We were going to have the rooms and these patients either way," she notes, "So it’s more a matter of what’s best for the patients."
The critical benefit of the new arrangement, says Voss, is that the ED nurse can focus primarily on triage, while the psych nurse cares for the mental health and well-being of psych patients.
Theoretically, says Voss, any ED could do what hers has done, as long as they have enough space available to create a separate area. "Clearly, it’s a much more ideal situation when your hospital has an inpatient unit, because that’s where the psych staff can come from," adds Haubenreiser. "But you could also use specially trained master’s-level social workers from the hospital to handle the process."
Sources
For more information on psychiatric EDs, contact:
- Robin Voss, RN, MHA, Director, Emergency and Trauma Services, and Jo Haubenreiser, Executive Director, Post-Acute Services, Forsyth Medical Center, 3333 Silas Creek Parkway, Winston-Salem, NC 27103. Phone: (336) 718-7000.
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