2021 Annual Conference

CNS as Project Manager

Title

Integrating Psychiatric Technicians into a Medical Emergency Department: A CNS led project

Significance & Background

It is well known that the United States is experiencing a mental health crisis. Between 2006 and 2013, there was a 55.5% increase in emergency department (ED) visits for depression, anxiety, and stress reactions (Weiss, et al., 2016). This creates a strain on the mental health system and the local emergency departments who are providing care in an acute mental health crisis. While all nursing students receive basic education on caring for a patient with a mental health disorder or in an acute crisis, emergency department nurses were placed in the unique situation of caring for this population for a prolonged length of time. A review of visits to a community hospital revealed an increase in patients presenting for a mental health evaluation, length of stay for this population, and instances of workplace violence. The leadership was ready to implement changes to keep the teammates safe and improve the care for the mental health population.

In 2018, we experienced 85 workplace violence instances in the ED, or an average of 7 per month. The leadership of the healthcare system was looking for a way to decrease the number of instances of violence toward the teammates. Additionally, we were seeking a way to provide better care to our increasing mental health population. An interdisciplinary team was formed to review a potential new position: a psychiatric technician. We hypothesized that adding an experienced psychiatric technician to the ED team could decrease the length of stay and increase the percentage of patients we could discharge to home because of earlier therapeutic interventions. We additionally hypothesized that the psychiatric technician could decrease the amount of time a violent patient would need to remain in restrictive interventions because of their unique training with therapeutic communication.

In August 2019, hospital leadership approved for the Emergency Department to hire 5 full time psychiatric technicians to cover the shifts 24/7. We borrowed an experienced psychiatric technician from a psychiatric hospital within our healthcare system and utilized their nursing educator to assist with and onboarding plan. The Clinical Nurse Specialist (CNS) for the Emergency Department worked to outline the project timeline, create an onboarding strategy, and develop metrics to monitor for program success.

Evaluation Methods

The team gathered and reviewed 10 potential metrics to monitor. After the CNS gathered baseline data, determined a secure locate to retrieve the data, and presented potential goals to the interdisciplinary group, five final metrics were identified.

1. Decrease workplace violence
2. Increase teammate perception of safety in the Emergency Department
3. Increase/Maintain non-BH patient perception of safety while seeking care in the ED
4. Increase percentage of BH patients discharged to “home”
5. Decrease average time in violent restraints

Teammates were surveyed on feelings of safety and security, pre-implementation and monthly for 3 months during the pilot. Length of stay, disposition, and restraint data were gathered from a review of relevant electronic medical records. Workplace violence data was gathered from the hospital security team who reports these on a monthly basis.

Outcomes

During the three-month pilot project, there was a decrease in workplace violence instances and length of stay. The teammate perception of safety, patient perception of safety, and average time in restrictive interventions were not affected.

The most impressive outcome from the pilot was the decrease in workplace violence. We experienced a 9.4% decrease in reported instances in 2019 compared to 2018. During the pilot period alone (Q4 2019), there was 28.5% reduction in in reported instances in Q42019 compared to Q42018.

Due to the decrease in workplace violence and the positive feedback from the teammates (both nursing and psychiatric technician), an additional emergency department within the healthcare system adopted the program and has begun integrating psychiatric technicians into their teammate mix.

Implications

Integrating psychiatric technicians into a medical emergency department can help decrease violence in the department, alleviate some of the stressors associated with caring for a difficult patient population, and decrease the LOS by starting therapies early. The mental health population needs a different type of intervention compared to the traditional ED patient. Adding psychiatric technicians to your ED teammate mix can help provide population specific care.

Reference:
Weiss, A.J., Barrett, M.L., Heslin, K.C., & Stocks, C. (2016, December). Trends in Emergency Department Visits Involving Metal and Substance Use Disorders, 2006-2013. Healthcare Cost and Utilization Project. https://hcup-us.ahrq.gov/reports/statbriefs/sb216-Mental-Substance-Use-Disorder-ED-Visit-Trends.pdf