Planning for Behavioral Emergencies on a Non-Psychiatric Unit
Hospital staffs are trained to deal with minor behavioral problems because they often occur when someone has some type of traumatic injury or occurrence. Especially patients who are confined to an ICU have issues which may cause them to exhibit adverse behavioral issues. Tesar and Stern (1986) list what should be examined as "(1) the presence of delirium or psychosis; (2) the type of ICU setting (e.g., coronary, surgical, respiratory, or medical); (3) a history of psychiatric disorder; (4) a history of central nervous system disorder; and (5) patients' personalities, which affect their reactions to illness and its treatment." Of course, there are many reasons why the staff in the ICU scenario was unprepared for the disruption caused by Mr. X, but by using the FOCUS model (Find a process to improve, Organize a team that knows the process, Clarify current knowledge, Understand causes of process variation, and Select the process improvement) it will be clear exactly what needs to be done to make sure that the next time such an incident occurs staff can handle it with greater knowledge and available resources.
The first part of the FOCUS plan seems easy because it is evident from the scenario that the process that needs to be improved is the ICU staff's ability to deal with patients who have unknown behavioral issues. Of course, it can be assumed that the patient has a psychiatric diagnosis that was not apparent to the staff, but that cannot be assumed initially. The evidence states that Mr. X begins the disruption by yelling while he is on his bed on all fours. The yelling seems nonsensical as he is saying "Help, Help" when there is no apparent reason for distress and "I don't know" when no question has been posed. Psychiatric staff may have seen that the patient was disoriented and seemed to be speaking to someone other than the staff, which would lead one to think that there may be a psychological cause for the outburst. Therefore, to make the process as simple as possible initially, it would seem that the staff needs to understand the signs of someone who has a possible psychiatric disorder, and how they can effectively deal with that emergency (even if that means calling a rapid response team trained to deal with such emergencies (Loucks, et al., 2010). Therefore, the identified process is that all staff in the hospital needs to understand when they have a psychiatric emergency, and there needs to be either sufficient training among all staff members, or a team who is qualified to deal with this emergency.
It is no secret that all hospitals will treat individuals in their emergency rooms who have psychiatric disorders (American Hospital Association, 2007b). So, there has to be a plan in place when this happens. In the case of Mr. X, he was in the ICU and had not been identified, from previous history, to have a behavioral disorder, but that does not mean that it was not true. To make sure that staff have a recourse when an emergency such as that in the scenario occurs again (as it most likely will) a team needs to assess the needs of the hospital. The investigation team must have a leader who coordinates the meetings, staff members from the various departments, a member from hospital security to give recommendations, and members from the hospitals legal and financial departments. The leader should be someone from hospital management who is, hopefully also very familiar with behavioral health issues. This means that the director of the behavioral health division would be perfect for this position. Since a behavioral emergency can happen anywhere in the hospital, it makes sense to include at least one senior staff member from all departments. A representative physician from behavioral health should be a member, and physicians who are responsible for other specialties which incorporate ailments which can have a behavioral piece (such as the cardiac ICU (American Hospital Association, 2007a)). Besides these medical staff members, the legal representative can apprise the staff as to the legal ramifications of actions, and the financial staff member can go over the costs could be to the hospital.
The first issue the team has to address is what happened, and why did the incident occur. From the scenario, the staff was not prepared for there to be such a reaction from a patient, and they were not sensitive to the concerns of the patient. Not one time during the incident did the staff ask for a member of the psychiatric team to be called. This means that they were either completely unprepared for such an eventuality or they were unaware of the resources within the hospital. The unpreparedness and the inability of the staff to understand the incident helped to escalate the patient. Also, the fact that the staff was unaware how to deal with the problem made them reluctant to help the patient the next day.
Understanding the possible causes of the incident is the next step in the FOCUS model. Now that the causes have been identified (unpreparedness and inaction), it is necessary to delve deeper to see what were the antecedents of the incident. By using a model suggested by cause and effect diagrams it is possible to see some of the root problems that occurred and why. The first issue was that the patient was not identified in the chart as having a behavioral diagnosis. This can be ascertained from the fact that the doctor had the patients chart, and was asking the nurses questions about the patient, but seemed to both parties seemed to be confused about why Mr. X was acting the way he was. It is possible that Mr. X did not have a psychiatric history, or that the proper history had not yet been sent from his psychiatrist yet. Using a cause and effect diagram, the problem is that hospital staff did not know how to respond to a behavioral Those affected by the problem are all of the staff in the hospital who have direct care responsibility for patients, and the patients themselves. The problem occurs when there is a patient with a behavioral health issue that has not been recognized. The issue also has the possibility of occurring anywhere in the hospital because it is difficult to determine when a person will be overcome by a psychiatric illness.
The final piece of the FOCUS model is to select a process improvement. For the purposes of this essay, it is best to keep the improvement simple. Even though the eventual solution would most likely involve more than one area of improvement, only one will be examined here. To this end, it is noted that the training program at the hospital is definitely lacking. The entire staff needs to be made aware of how the different psychiatric and behavioral disorders exhibit themselves and how they can be separately dealt with. The training program should be conducted by the behavioral health staff, and it needs to be designed specifically to the individual needs of the departments in the hospital (DMHRM, 1997). The training program has to be intensive enough that it reminds staff of the training that they have already received on the subject, but it should also consider specific scenarios that may occur in a department.
The plan to be developed is to be designed and implemented based on the popular PDCA model (of course, the Act, or last, portion of the intervention will be deleted because this is just an exercise). This model is an acronym for plan, do, check. Separately this means that a plan should be formulated which will address not only the specific situation which occurred, but be malleable enough that it can be applied to other, similar situations. Once the plan is written, it needs to be acted upon; that is it has to be implemented. Finally, there has to be some sort of evaluation of the plan once it is in place to determine whether it was effective, and, even if it was, what can make the intervention more successful in the future. This section will be devoted to determining what type of plan will work for the scenario given.
The incident occurred in the ICU, so this part of the essay will deal exclusively with what can be done for the staff of the ICU to make sure that they can respond correctly if such an incident occurs again. When the incident begins a member of the "Respiratory staff, physicians, physician's assistants, an ICU nurse, and unit staff are all standing there watching Mr. X scream for help." This is not the desired action when a patient is screaming for help, but it occurs because all of the staff involved have no idea how to resolve the situation. This is an issue of training more than anything. With sufficient…