Psychiatric emergencies in medical settings may be particularly challenging since the staff does not encounter them frequently and may not have experience dealing with behavioral crisis intervention. The purpose of this exercise is to help staff improve understanding and coping with nonmedical emergencies that occur in medical settings using the PDCA cycle.
X is a 41-year-old male admitted to a medical unit with a diagnosis of possible stroke. The patient is ambulatory, 5'10," and 350 lbs. Mr. X presented to the emergency department the day before after apparently losing consciousness at home. The initial CAT scan of his head was negative. It is suspected that Mr. X may be an IV drug user since his urine toxicology screening came back positive for opiates. The medical staff thinks that Mr. X had a seizure prior to admission, but he has shown no abnormal signs or symptoms within the last 24 hours. Mr. X was moved to an acute care unit where he sits in bed wearing only a pair of ill-fitting boxer shorts and no shirt. He is able to communicate without any signs of aphasia. The medical staff is still not sure what is wrong with Mr. X.
As the nurse administrator of the day, you hear a Rapid Response called overhead for this patient. As you enter the room, you see Mr. X screaming and on all fours in his bed. He is saying "Help, help" and "I don't know" repeatedly. Respiratory staff, physicians, physician's assistants, an ICU nurse, and unit staff are all standing there watching Mr. X scream for help. They all seem paralyzed. Finally, one of the staff nurses asks Mr. X to turn over so that respiratory staff can administer oxygen via a facial mask. He complies and at that time the ICU nurse hooks him up to the cardiac monitor as per protocol in a Rapid Response.
Mr. X remains quiet and still for about 60 seconds and then proceeds to rip off the oxygen mask and the EKG leads attached to his chest. He climbs over the side rails and stands there in a daze, saying "I don't know, I don't know."
The staff reacts negatively to Mr. X's behavior in front of him. The respiratory therapist says, "If you think I'm going in to get an ABG from him, you're crazy." Speaking to Mr. X, the ICU nurse repeats over and over in a stern impatient voice, "What don't you know?" Mr. X seems overwhelmed and can't answer. The physician looks through the chart and asks the nurses questions about the patient. The other nurses stand there staring at Mr. X. The ICU nurse leaves a few minutes later stating that the patient's EKG is normal.
All at once, Mr. X bolts from the room towards the elevator, which has just opened, and gets on. One of the nurses calls a security code, but it is too late; Mr. X has disappeared. The county police are called and hours later they find Mr. X at his nearby home. They try to encourage him to return to the hospital, but since he has not been deemed a danger to himself or others, they have no choice but to leave him alone.
The next morning Mr. X returns to the Emergency Department with "severe chest discomfort and a headache" and is admitted back to the same unit. When the staff see him, they are apprehensive and somewhat angry that he is back. After about three hours on the unit, Mr. X starts yelling that his stomach is hurting. His nurse calls the physician about his symptoms but she and the rest of the staff avoid extended contact with him because of what happened the day before.
The FOCUS-PDCA model provides a model for improving processes and the model's name is an acronym that describes the basic components of the improvement process. The steps include (i Six Sigma, N.d.):
F ind a process to improve
O rganize an effort to work on improvement
C larify current knowledge of the process
U nderstand process variation and capability
S elect a strategy for continued improvement
Figure 1 - PDCA
Find a Process to Improve
The case involves a potentially mentally unstable individual. This can represent both a problem and an opportunity to increase the health and total…