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

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 Psychiatric Emergency Services area. This presentation may not be repurposed without review and written permission by Recovery Founded Interventions in a Psychiatric representatives of the Medical Center.” Emergency Department Results in a Near Karen Lancaster, Director of Media Relations and Corporate Communications Restraint Free Environment for Patients: It IS Possible! APNA 29 th 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 Acknowledgements Objectives Eric Weintraub MD , Division Director, Addictions and Psychiatric Emergency Services, University of Maryland • Identify unique clinical challenges posed by the Medical Center emergency department environment that impact the use of seclusion and restraint Greg Raymond MS, MBA, RN Director of Neuroscience, Behavioral Health Nursing, and Clinical Practice and Professional Development, University of Maryland • Describe recovery oriented nursing interventions that Medical Center result in positive patient/staff rapport and patient engagement in treatment Patrick Mc Mahon MBA, Psychiatric Admission and Referral Specialist, University of Maryland Medical Center • Identify evidence-based alternative measures for seclusion and restraint in an ED setting Patrick Brown MS, MA, RN, Clinical Nurse II Psychiatric Emergency Services, University of Maryland Medical Center UMMC Psychiatric Emergency Services (PES) Brief snapshot of UMMC  Separate area adjacent from the Adult Emergency Department FY15 Statistics  Locked and unlocked areas, staff work room, treatment room & • 720 licensed beds offices • 8,200 employees • 1200 Attending physicians  Staffed 24/7 • 900 Resident physicians - 3 RNs • 30,500 Admissions - 1 Mental Health Associate • 73,300 Emergency visits - Resident physician • 333,000 Outpatient visits - Attending physician (13 hours/day) • 22,100 Surgical cases • 10,400 Maryland Express - 2 Psych NPs (8 to 12 hours, Monday-Friday) Care transfer admissions - Social Work (on call for Pediatric ED consults) We Heal, We Teach, We Discover, We Care  FY15 volume 2773 Noll 1

APNA 29th Annual Conference Session 4021: October 31, 2015 Environmental & Community Factors Environmental & Community Factors Violence- UMMC is located on the west side of Substance Abuse Baltimore City • Baltimore has been named as the top city for Baltimore is in the top 10 cities with the highest crime rates heroin addiction in the nation per 100,000 residents Flint, MI 827.0 Lubbock, TX 808.3 • In 2014, more people in Maryland were killed Pine Bluff, AR 793.0 Las Vegas, NV 763.4 by heroin than were murdered Little Rock, AR 755.8 Baltimore, MD 685.3 Wilmington, DEL 634.8 • Overdose deaths increased 88% in 2014 Philadelphia, PA 551.8 New York, NY 496.0 New Orleans, LA 466.5 (Johnson, 2014; State of Maryland, Office of the Governor, (n.d.). (Federal Bureau of Investigations, 2010) Restraint Prevalence in Emergency Restraint Prevalence in Emergency Department Settings Department Settings National Hospital Ambulatory Medical Survey 1. Simpson et al, 2014 -14% restraint/seclusion rate - Conservative estimate of 53M mental health related visits - 5335 PES encounters to EDs nationally between 1992 & 2001 - 12 month period in - U.S. urban, academic medical center Survey of Medical Directors in Psychiatric Emergency Services 2. Gerace et al, 2014 - rate of 0.77 patients restrained per 100 mental - 8.5% are restrained for a period of 3.3 hours per episode health presentations - median incident duration 3.3 hours Translates into 4.5M patients in restraint events and - Australia metropolitan area nearly 15 million hours - Four general hospitals (Currier, Walsh, & Lawrence, 2011) Psychiatric Emergency Settings: Risks of Seclusion & Restraint : Clinical Challenges Traumatization of Coercive Restraint Differs from both inpatient and ambulatory areas Psychological sequlea for patients*  Feelings of terror • Patients present with acute distress & agitation • Often in a state of poor functioning  Humiliation • Often with altered perceptions  Experience of powerlessness • May have no diagnosis or unclear diagnosis • No previous relationship with staff *patients with a history of trauma have an increased risk • May be intoxicated • May arrive involuntary (Simpson et al., 2014) (Simpson, Joesch, West, & Pasic, 2014) Noll 2

APNA 29th Annual Conference Session 4021: October 31, 2015 PES Approach Risks of Seclusion & Restraint Seclusion & Restraint Reduction  Use of Recovery oriented First Person Language Potential Physical Consequences for patients  Use of Recovery principles in engaging patients into  Musculoskeletal & orthopedic injuries treatment  Thrombosis  Caring Rounds  Asphyxia, strangulation  Weekly S&R review - post results graphically with minutes of reviews for  Rhabdomyolysis staff  Death  Space organized as milieu area vs individual beds or pods (Simpson et al., 2014) Use of Recovery Principles: Use of Recovery Oriented Engaging Patients in Treatment First Person Language Orient, mentor, and coach multidisciplinary staff to Multidisciplinary commitment and communication consistently approach patient with optimism and hope for dispositions mutually agreeable with the patient and family as feasible • Greeting & welcoming patients • Emphasis on what can be done • Consistently meet patients ‘where they are’ • Using humanistic principles • Avoid coercion and passivity • Avoiding stigma, especially among staff • Exhaustive list of community resources communications • Continuous relationship building with community • Educational reinforcement of recovery oriented resources principles in daily huddles • Ability for external agencies to meet with the patient in PES prior to discharge Weekly Review Caring Rounds S&R Events Modification of the hourly rounds concept Departmental review of events on each unit with Behavioral Health nursing leadership and staff • RN driven rounding, minimum 4-6X’s per 24 hours (minimum staffing 3 RNs/shift) • Occurs weekly • Minutes distributed with feedback & graphs • Questions • Posted in clinical area - Comfort • Discussed at staff meetings & huddles - How are you feeling? • Staff know how their unit is doing - Safety concerns - Understanding of meds, recommended treatments, disposition - Is there anything else I can do for you now? Noll 3

APNA 29th Annual Conference Session 4021: October 31, 2015 PES Space: Milieu PES Space: Milieu Space organized as milieu • Staff workroom has complete visibility into . group areas • Patients not assigned to beds • Freedom of movement possible, allows for ability to • 12 camera views and monitors pace Alternative Measures: Overcoming Obstacles Avoiding S&R Evidence-based Alternative Measures used • Educate all of the multidisciplinary team in the PES Setting together • 1:1 interaction • Regular discussions using available data • Verbal interventions • Decrease in stimulation, use of more private areas • Food & drink • Positive feedback for S&R avoidance • Identify champions (Downey et al, 2007) PES Results: PES S&R Statistics S&R Statistics Patient number of minutes in S&R: FY13 to FY 15 Number of S&R Events Pt Volumes FY 13 2753 FY 14 2849 FY 15 2773 FY 13 64 FY 13 3,843 FY 14 21 FY 14 607 85% FY 15 20 69% decrease FY 15 315 48% 99.2% Noll 4

APNA 29th Annual Conference Session 4021: October 31, 2015 PES PES S&R Statistics S&R Statistics Number of Stat Medications per Quarter PES Rate of Seclusion & Restraint FY 15 0.7% Average Duration of S&R 15.8 minutes PES Number of Patient /Staff Injuries* S&R Statistics Number of Minutes S&R and Number of STAT Meds FY 13 4 FY14 0 FY 15 5 * Reported to Risk Management Questions? Summary An organizational approach to Recovery oriented multidisciplinary care in a Psychiatric ED setting Thanks for the opportunity to present resulted in: • Sustained low use and duration of S&R Questions? • Without a significant increase in patient or staff injuries • Or a significant increase in use of sedating medications Noll 5