May 1st, 2013

Hospital ER improves psychiatric care

The patient brought to Cape Cod Hospital’s Emergency Center in Feb. 2011 with self-inflicted left wrist lacerations denied being suicidal. But after sutures and a behavioral health assessment, a social worker requested further psychiatric evaluation. Before a doctor or nurse could sign off, the patient fled the Hyannis hospital without anyone noticing.

It’s understandable how the case could happen. Cape Cod Hospital sees 92,000 Emergency Center patients a year, making it one of the region’s busiest ERs. In the months of July and August, when the Cape’s summer population triples, the ER averages 350 patients daily. Psychiatric patients can languish in busy hallways for several hours up to several days.

The elopement – when a patient flees the ER without proper discharge – was documented in an inspection report the Centers for Medicare and Medicaid Services released to the Association of Health Care Journalists, which posted it online. The patient may have been less likely to elope just a few months later when Cape Cod Hospital opened the emergency room’s “purple zone.”

Since this $1.2 million nine-bed unit with its own nursing station and privacy curtains set off from the chaos of the regular ER opened in June 2011, staff members have seen fewer elopements, though they still occur. Patients trying to leave the secure purple zone have to press a button, wait 15 seconds for the doors to open and even then, an alarm sounds.

“It’s a locked unit so patients have a harder time getting out. They’re less inclined to elope because they get less frustrated. Our elopements have definitely gone down,” says Craig Cornwall, M.D., chief of the hospital’s emergency department.

Nothing is actually purple in the purple zone; the color scheme is soft beige and blue-green. The ER has blue, green, red and yellow zones. But another color was needed when plans were made to move upstairs a pediatric inpatient zone formerly off the ER and reconfigure the space to accommodate psychiatric patients.

“Purple and orange were left,” says Emergency Center Nurse Manager Elizabeth Kelley, BSN, MA, RN. “Orange is kind of a scary, angry color.”

The purple zone coincided with a new approach to managing aggressive patients. When a “Code S” is called, a team immediately responds to an escalating patient, keeping security in the background. That’s because the appearance of security personnel usually triggers a violent outburst, Kelley says. Security would have to force the patient down on the floor to subdue and move the individual to a locked observation room containing only a mattress on the floor.

Now an escalating patient is surrounded by nurses, alerted by the Code S, Kelley says. One patient in his twenties threatening to elope and hurt anyone in his way retreated to his stretcher without incident after being encircled by nurses of a certain age, saying “I’m not going to beat up a bunch of grandmothers.”

“We used to have takedowns every single day,” Kelley says. “We have them once a month now.”

In August 2008, Kelley found 37 percent of the hours behavioral health patients spent in the ER involved locked observation. In August 2009, the figure dropped to 13 percent. By the time the purple zone opened, it dropped to 1.5 percent and has remained under 2 percent ever since.

Perhaps the biggest change has involved staff attitudes. Two full-time equivalents are devoted to the purple zone which has natural light unlike other ER areas. “The staff at first was like, ‘I don’t want that assignment. I don’t want to be over there with all psych patients,’” Kelley says.

“Now the nurses, they actually enjoy working over there. Some of them, we can’t drag them out of there.”

By Janine Weisman

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