PMH Nurse Improves Behavioral Health Care in Emergency Department

APNA News: The Psychiatric Nursing Voice  |  May 2019 Members' Corner Edition

By standardizing routine procedures, a team including emergency department and psychiatric-mental health nurses in California was able to improve quality of patient care for persons with psychiatric-mental health needs, among other benefits. They shaved 38 minutes from the average time it takes to evaluate behavioral health patients and order medication, earning praise from a national emergency nurses’ organization.

Jeannine Loucks meets with a patient.

The Emergency Nurses Association has named APNA member Jeannine Loucks, MSN, RN-BC, PMH, along with Elizabeth J. Winokur, PhD, RN, CEN, and Glenn H. Raup, PhD, RN, MSN, MBA, CEN, the 2019 Authors of the Year for their article documenting this achievement in the association’s Journal of Emergency Nursing.

The article, in the January 2018 issue, chronicles the development and implementation of the quality improvement, nurse-driven initiative. By implementing a standardized assessment, the time to first medication was reduced, which resulted in fewer patients requiring restraints and a reduction in time in restraints in cases where they were needed.

As psychiatric-mental health nurses, we know emergency departments frequently provide access to care for persons living with mental health disorders. Oftentimes those seeking treatment are without other options. These factors are driving the need to improve the quality of care available.

Loucks, who is Department Manager, Emergency Care Center, St. Joseph Hospital in Orange, California, noticed a disparity between the urgency at which care was given to patients with physical health issues as compared to behavioral health issues. “If this was a full heart arrest you would medicate and go through the protocol right away. You wouldn’t let patients languish for 30-40 minutes unmedicated and uncared for.” She and her colleagues saw that this was a frequent occurrence in behavioral health cases. Loucks explains, “I wanted to reduce restraint use as well as start early intervention for these patients.”

Loucks began to research evidenced-based tools that would allow for a more rapid assessment of patients. She assembled a team comprised of nurses, leadership, and physicians to define the scope of the problem. Consequently, when the study ended each of the stakeholders on the team had realized improved outcomes: Nurses who had felt frustration are feeling empowered; Physicians who were pulled in different directions are facing fewer interruptions; Leadership can report improved safety and regulatory compliance; And patients are experiencing less stress.

Jeannine Loucks with members of her team
Jeannine Loucks (4th from left) and staff.

It is worth noting that in addition to the standard procedures, staff education that went along with implementation may be an important factor in the improved patient outcomes. Receiving training on medication and background on common mental health disorders has given nurses a different outlook. Winokur has noticed, “not just a shift in competence but a shift in attitude,” as the newly acquired skills become a part of the routine for the emergency department nurses.

The benefits for the patients at St. Joseph are significant. The reduced time to medication reported in the article translates to patients waiting about 5 minutes rather than 43 minutes to receive treatment to reduce symptoms. Loucks recalls that in a recent month, of 554 psychiatric patients in the busy ER, only 5 required restraints. In her view, patients who arrive in crisis, rather than being minimalized, are being treated with dignity and in a timely fashion.

Winokur believes reducing use of restraints is the biggest win. “Getting the restraints almost gone gives patients time to get themselves a little more in control.” Intervening earlier and administering medications sooner is the difference.

It is fitting that the authors are being recognized as a team for their article since Winokur and Loucks concur that a team approach would be the best method to achieve these improved outcomes at other hospitals. Psychiatric nurses are encouraged to get out of their departments and bring their unique mental health nursing perspective to the emergency department for the benefit of patient care. As Winokur suggests, “Go make friends.”

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