![Patients who presented to the emergency room for a mental health associated visit were multiple
times more likely to require inpatient placement. These patients then proceed to board for
increased lengths of stay relative to non-psychiatric patients during which undesirable events often
occur, including missing home medications. These may lead to symptom exacerbation and
worsening agitation, putting the patient and staff at risk of additional harm. Also during this time,
other underlying medical problems may go unaddressed such as managing insulin needs for
patients with diabetes.
Background
Pre-intervention survey distributed to nursing, resident, and faculty (N=49). Respondents were
asked about the frequency in which information regarding NMI charting, restraint orders,
medication reconciliation, and diabetic care were communicated during transitions of care. This
was performed less than half the time according to more than 50% of those surveyed.
Current State: Identify Target / Actual / Gap
[not actual GEMBA, just pending my own observations]
Patients do not often stay long enough to require oncoming ED physician to manage scheduling of home meds since many
are dosed only once or twice daily, meaning that the typical patient will not require any home meds in the time during
which they are seen in the emergency room. Therefore, a common scenario in the emergency room is for home meds to
be ordered only once the patient has notified the ED physician that they are due for a dose, which is something a psych
patient may be unable to do. Given that most patients will not require or miss doses for home meds during a typical ED
visit, engaging in the potentially time-consuming process of reconciling and then scheduling medications is not common
practice in the emergency room.
Another observation. Sign-out at shift change is frequently interrupted and/or delayed making it difficult to for the
finishing shift to leave in a timely fashion. In response, sign-outs are kept quick and brief in order to complete as many as
possible prior to the next interruption. Reviewing home meds is then, unsurprisingly, not a standard element of sign-out.
GEMBA Analysis – GEMBA TO BE COMPLETED
Psychiatric patients are more likely to have extended boarding times in the emergency department,
often waiting several hours and sometimes days for placement at outside facilities, during which
time they are at risk for poor outcomes from interruptions in home medications and other lapses in
care.
Problem Statement
Improving Transition of Care for Psychiatric Patients
Sponsor(s): Haley Manella, MD, MS Last updated: 03/2023
Project Leader(s): Obert Xu, MBBS; Kendra Henderson, MD;
Manuel Gonzalez MD, MBA
Team Members: Leah Calvert, MHA
HOUSESTAFF QUALITY
and SAFETY COUNCIL
Liu, S. W., Thomas, S. H., Gordon, J. A., Hamedani, A. G., & Weissman, J. S. (2009). A pilot study examining undesirable events among emergency
department–boarded patients awaiting inpatient beds. Annals of Emergency Medicine, 54(3), 381–385.
https://doi.org/10.1016/j.annemergmed.2009.02.001
Nicks, B. A., & Manthey, D. M. (2012). The impact of psychiatric patient boarding in emergency departments. Emergency Medicine International,
2012, 1–5. https://doi.org/10.1155/2012/360308
O’Neil, A., Sadosty, A., Pasupathy, K., Russi, C., Lohse, C., & Campbell, R. (2016). Hours and Miles: Patient and health system implications of
transfer for psychiatric bed capacity. Western Journal of Emergency Medicine, 17(6), 783–790. https://doi.org/10.5811/westjem.2016.9.30443
Pearlmutter, M. D., Dwyer, K. H., Burke, L. G., Rathlev, N., Maranda, L., & Volturo, G. (2017). Analysis of emergency department length of stay for
mental health patients at Ten Massachusetts emergency departments. Annals of Emergency Medicine, 70(2).
https://doi.org/10.1016/j.annemergmed.2016.10.005
References
Goal: Have greater than 50% of respondents in a post-survey communicate the above items during
transitions of care more than half the time
SMART Goals for MH-related ED sign-outs by 2024:
- Home meds reconciled and ordered >50% of the time
- Diabetic diets and CBG checks ordered at >50% of sign-outs for patients with DM
- Restraints renewed, if needed, >80% of the time
- NMI filing status charted at 100% of signouts
Target State: SMART Goal
We suggest the creation and implementation of a care checklist to be utilized for all pysch patients
similar to the FASTHUGS bundle used in ICUs. This would ensure a standardized approach for all
residents, fellows, and faculty to follow when providing care to patients presenting for mental
health related visits and should ideally be reviewed during handoffs of care, thus reducing
frequency of missed home meds and increasing situational awareness for patients likely to spend
considerable time.
We propose the mnemonic “SHEDS” for our Psychiatric Care Checklist:
• S - Sugar Control [CBG checks, Diabetic diet, Insulin orders]
• H - Home Medications
• E - Expiration Time [renew restraints, seclusion, 1:1 monitoring]
• D - Documentation [confirm and scan NMI into EMR]
• S - Social Work and Psych [place consults as necessary for further management]
Interventions/Countermeasure
Involvement of multiple groups to participate in the Psychiatric Care Checklist Project (PCCP)
Physicians
- SHEDS to be pre-filled for Pysch I-PASS notes or made into a dot-phrase pre-shared to all EPIC users
Pharmacists
- Prompted to assist with medication reconciliation once an NMI is placed
Nurses, Social Workers, or Psychiatry?
- (nursing) Encouraged to verify that SHEDS was completed and included in IPASS
- (SW or Psych) Consulted as necessary?
Three-Pronged Approach
Results to be included
Post-Survey Analysis – POST-SURVEY TO BE COMPLETED](https://image.slidesharecdn.com/pccpa32023-04-03updatewip-230403223927-f1ea9191/85/PCCP-A3-1-320.jpg)
PCCP A3
- 1. Patients who presented to the emergency room for a mental health associated visit were multiple times more likely to require inpatient placement. These patients then proceed to board for increased lengths of stay relative to non-psychiatric patients during which undesirable events often occur, including missing home medications. These may lead to symptom exacerbation and worsening agitation, putting the patient and staff at risk of additional harm. Also during this time, other underlying medical problems may go unaddressed such as managing insulin needs for patients with diabetes. Background Pre-intervention survey distributed to nursing, resident, and faculty (N=49). Respondents were asked about the frequency in which information regarding NMI charting, restraint orders, medication reconciliation, and diabetic care were communicated during transitions of care. This was performed less than half the time according to more than 50% of those surveyed. Current State: Identify Target / Actual / Gap [not actual GEMBA, just pending my own observations] Patients do not often stay long enough to require oncoming ED physician to manage scheduling of home meds since many are dosed only once or twice daily, meaning that the typical patient will not require any home meds in the time during which they are seen in the emergency room. Therefore, a common scenario in the emergency room is for home meds to be ordered only once the patient has notified the ED physician that they are due for a dose, which is something a psych patient may be unable to do. Given that most patients will not require or miss doses for home meds during a typical ED visit, engaging in the potentially time-consuming process of reconciling and then scheduling medications is not common practice in the emergency room. Another observation. Sign-out at shift change is frequently interrupted and/or delayed making it difficult to for the finishing shift to leave in a timely fashion. In response, sign-outs are kept quick and brief in order to complete as many as possible prior to the next interruption. Reviewing home meds is then, unsurprisingly, not a standard element of sign-out. GEMBA Analysis – GEMBA TO BE COMPLETED Psychiatric patients are more likely to have extended boarding times in the emergency department, often waiting several hours and sometimes days for placement at outside facilities, during which time they are at risk for poor outcomes from interruptions in home medications and other lapses in care. Problem Statement Improving Transition of Care for Psychiatric Patients Sponsor(s): Haley Manella, MD, MS Last updated: 03/2023 Project Leader(s): Obert Xu, MBBS; Kendra Henderson, MD; Manuel Gonzalez MD, MBA Team Members: Leah Calvert, MHA HOUSESTAFF QUALITY and SAFETY COUNCIL Liu, S. W., Thomas, S. H., Gordon, J. A., Hamedani, A. G., & Weissman, J. S. (2009). A pilot study examining undesirable events among emergency department–boarded patients awaiting inpatient beds. Annals of Emergency Medicine, 54(3), 381–385. https://doi.org/10.1016/j.annemergmed.2009.02.001 Nicks, B. A., & Manthey, D. M. (2012). The impact of psychiatric patient boarding in emergency departments. Emergency Medicine International, 2012, 1–5. https://doi.org/10.1155/2012/360308 O’Neil, A., Sadosty, A., Pasupathy, K., Russi, C., Lohse, C., & Campbell, R. (2016). Hours and Miles: Patient and health system implications of transfer for psychiatric bed capacity. Western Journal of Emergency Medicine, 17(6), 783–790. https://doi.org/10.5811/westjem.2016.9.30443 Pearlmutter, M. D., Dwyer, K. H., Burke, L. G., Rathlev, N., Maranda, L., & Volturo, G. (2017). Analysis of emergency department length of stay for mental health patients at Ten Massachusetts emergency departments. Annals of Emergency Medicine, 70(2). https://doi.org/10.1016/j.annemergmed.2016.10.005 References Goal: Have greater than 50% of respondents in a post-survey communicate the above items during transitions of care more than half the time SMART Goals for MH-related ED sign-outs by 2024: - Home meds reconciled and ordered >50% of the time - Diabetic diets and CBG checks ordered at >50% of sign-outs for patients with DM - Restraints renewed, if needed, >80% of the time - NMI filing status charted at 100% of signouts Target State: SMART Goal We suggest the creation and implementation of a care checklist to be utilized for all pysch patients similar to the FASTHUGS bundle used in ICUs. This would ensure a standardized approach for all residents, fellows, and faculty to follow when providing care to patients presenting for mental health related visits and should ideally be reviewed during handoffs of care, thus reducing frequency of missed home meds and increasing situational awareness for patients likely to spend considerable time. We propose the mnemonic “SHEDS” for our Psychiatric Care Checklist: • S - Sugar Control [CBG checks, Diabetic diet, Insulin orders] • H - Home Medications • E - Expiration Time [renew restraints, seclusion, 1:1 monitoring] • D - Documentation [confirm and scan NMI into EMR] • S - Social Work and Psych [place consults as necessary for further management] Interventions/Countermeasure Involvement of multiple groups to participate in the Psychiatric Care Checklist Project (PCCP) Physicians - SHEDS to be pre-filled for Pysch I-PASS notes or made into a dot-phrase pre-shared to all EPIC users Pharmacists - Prompted to assist with medication reconciliation once an NMI is placed Nurses, Social Workers, or Psychiatry? - (nursing) Encouraged to verify that SHEDS was completed and included in IPASS - (SW or Psych) Consulted as necessary? Three-Pronged Approach Results to be included Post-Survey Analysis – POST-SURVEY TO BE COMPLETED