TL5-11 Minutes– Emergency Department, Behavioral Health & In-Patient Collaborative group

Location: ACR 1

Date: Thursday, April 14, 2011 Time: 12 – 1300p.m.

TeleconferenceBridge: 8004,776-8004or 866-382-0408, Access Code 7765507#

Members:Don Walker, Charlene Coffin, Kate McCord, Dr. Oram Smith, Pam Assid, April Buxa, Melissa Williamson, Rosanna Parmelee, Brian Sarpy, Bob Trefethen, Julie Sanford, Rebecca Kahl, Tamara Renzelman.

Time / Content / Follow Up/Actions/Status
1300 / Welcome & Reflection
* Kate has that we hold weekly meetings at least until the Psych Survey takes place
  1. ED M1 Hold Elopement Points of information
  2. Pt still had under wear on
  3. Delay in M1 implementation
  4. Prior hx of elopement
  5. Doors did not slow down patient
  • Pt. clothing MUST be removed, and pt put into a yellow gown
  • The pt that eloped on April 12th from PH, is now in the Centura system as EDTP – so will show in Medi Tech
  • Psych POD doors at PH will lock once a system override key has been created. If there is a system failure, exit from POD is possible but not entrance (override key will allow entrance during system failure)…however, please be aware of pts attempting to escape when doors are opened
  • A “run risk” sign will be put on each door into the Psych POD (PH)
  • A panic button/alarm will be installed in the Psych POD (PH)
  • Will also be installing two computers in the Psych POD (PH), monitor, key board and CPU will be attached to walls in such a way so that they cannot be used as a potential weapon by a pt.
  • Need to be sure that hall is as cleared out as possible
  • We have asked EMS to come into the ED through the ambulance bay, not the front doors
  • To do a proper pt eval in the hall is tough…
  • McCrea needs to follow up on progress of moving Visitor lockers from 3 East to PH ED. Tell psych visitors that they need to leave belongings in their vehicles, if they do not have a vehicle, they may use the lockers provided…Security will not be able to monitor the lockers, they are already stretched thin
  • Need to decide how many visitors will be allowed at a time for psych pts
/ a. Re-Education of ED & psych staff re undressing at risk.
b. Work with docs in pre-filling out forms for signature, M1 now attached to Benchmark.
c. EDTP completed related to SI and elopement risk.
d. Working to activate doors to psych pod
  1. State of Colorado 27-10 Psych certification review for Penrose St. Francis.
  2. Data to be gathered and available
  3. M1 holds
  4. EC – Aidad
  5. Transfers
  6. Restraints – these need to be logged as well! Hospital wide, not just in ED
  7. Chemical restraints
  8. Policies in Place as Needed?
  9. In Patient issues
  10. Greater than 24 hours in ED
  11. In patient orders to be implemented
  12. Home meds to be ordered and given
  13. Other needs?
  14. Staffing Certifications
  15. Chart Review, deficiencies?
  16. Other Issues
M-1 Holds: Kelli e-mailed the State accepted format to gather the information
  • does the state want PH and SFMC broken out?? Technically we hold different state licenses…so we need to find out the correct way to log the M-1 Holds
  • We also need to do a daily “real time” report because we are concerned that not all M-1 Holds are shown in the data already collected
  • PH ED is creating a new sheet to use for daily tracking that will accept the pt sticker, binder with tracking sheets will be put into the Psych POD
  • We are responsible for data from January 1, 2011 to current (SFMC already has this data collected for M-1 Holds and ECs. April and Pam pull this information every couple of days)
  • Some M-1 holds are pulled from the PETT tracking and then cross references with the floors.
  • We need to create a system to be sure that the loop is closed for M-1 Holds (if hold expired or was removed by a physician). If PETT removes the hold, then that will close the loop
  • Send the completed data forms to Kelli Saucerman
  • Security has already been on 196 watches in the PH ED this year!
  • When to start an M-1 Hold is a case by case decision, if the hold can be delayed (and the safety of the pt and staff is not compromised), then do it so that hold can potentially be effective longer once the pt is transferred to another facility
  • If the patient is 1) a threat to themselves or someone else AND 2) has the capability to leave of his/her own power, then start an M-1
  • Some Physicians, even with a PETT eval, are not comfortable releasing an M-1 Hold.
Transfers:
  • Psych transfers are becoming a state-wide issue
  • Rosanna in one day has sent pt info up to Greeley and down to Pueblo
  • Littleton Adventist has been getting quite a few of our pts, but they are not set up for high acuity psych pts.
Policies in Place:
  • PH ED has changed their policy about lights in pt rooms remaining on. In Psych POD, it is now permitted to turn off the lights if that helps to soothe the pt
  • At SFMC, their lights must stay on, but they can dim the lights for their psych pts
  • The M-1 Hold Policy needs to be reviewed closely, and ASAP, the final Policy will be released on Monday
  • The PH ED Psych Policy also needs to be reviewed and amended as needed ASAP. Don will need to add what is missing or revise areas, then submit the changes to the ED Leadership Team
Greater than 24hrs in ED:
  • If pt is in ED longer than 24hrs they need to be treated as an in-patient
  • Daily and home meds need to be available and given as prescribed…it is detrimental to pt and staff to not give prescribed meds if pt has been in ED for a long period of time (over 24hrs.)
  • Benzos need to be started on Detox pts ASAP
  • Don started to open communication with the ED Manager at Memorial to ask how they handle meds for psych pts that have 24hr+ ED dwell times
  • If pt is in ED over 24hrs they also deserve to have a shower. How will we handle that at PH? Our Decon shower is very large and would take two staff members to be able to ensure the safety of a pt during his/her shower
  • Diabetic pts is an issue that needs to be addressed through out the ED
  • For diabetic pts please remember that the cafeteria closes at night, so plan ahead to have food for diabetic pts
Staffing Certifications:
  • EAM, psych ad PETT certifications must all be up to date
  • This was a big deal for the HSS Security Survey
  • Since HSS will be assisting with psych watches/sits ask Manuela where their staff files will be kept. Since HSS is contracted are their files kept off site? Can we get a copy to have on site?
Chart Audits:
  • At 3 East RNs did chart audits every night
  • We should start doing them at both PH and SFMC so that we can catch any problem areas and work on them before the survey
  • Look for M-1 Hold info (is it the original), PETT Eval, documentation of all staff actions (room safety, etc.)
  • Also let the floors know what we are looking for in the audits, so that they can help us catch areas that need to be focused on
Other Issues:
  • Communication seems to be an issue in the PH ED Psych POD
  • For pts who are on an M-1 Hold or EC, can we have color coded charts so that it is easier to distinguish? If we do that are the chart can’t be seen from where the staff is, it won’t mean anything
  • What about getting another color coded bracelet for M-1 Holds and ECs? Maybe orange and black diagonal lines ( like “caution” tape)
  • At PH, the 3am Psych shift needs to hand pts off to the Black POD nurse and let him/her have as much information about Psych pts as possible…Psych Tech reports seem to be much better than the psych RN reports
  • ED Physicians need to improve their handoffs too
  • There have been M-1 hold pts in the psych POD without Security…that can not happen
  • Staff needs to be careful about referring to pts by the room numbers. Pts rooms can be changed, and then potentially will not be discussing the correct pt information
  • Psych staff seems unsure of what their roles/responsibilities are. That needs to be addressed and corrected
  • Can we talk to Nutrition Services and come up with some finger food options for the psych pts.
  • Also can we get paper or foam trays, the hard plastic trays are not the best option
  • Too often knives and forks are on the trays and no one notices or removes them. We used to have vinyl flatware for psych pts to use, is that still an option?

Other
  1. Breathalyzer(s) at PHED
  2. Computers in psych pod ordered
  3. New Inpatient Psych Sitters
  1. We got a breathalyzer in for the psych POD at PH. It was being kept either in the PETT office or with the BP cuff, where is it now? Don will look for it.
  2. Don is working to get computers put into the Psych POD at PH
  3. We are going to be contracting with HSS for psych pt sitters (M-1 Holds)
  • The hope is that these sitters will be more knowledgeable about de-escalating pts and pt safety
  • If HSS staff is not available when needed, then we will return to the current system that is in place. If policy states that that a sitter will be with a pt, it doesn’t matter where the sitter comes from (HSS or CNAs)
  • HSS can’t do what CNAs can do, but they do have TEAM and CPR
  • Who is the point of contact for the HSS sitters? Manuela M.
  • Per Kate – the HSS sitters (14 of) are designated for PH (and SFMC?)
  • We need to track the use of HSS sitters so that if more are needed, the evidence is available
  • We can not misallocate or abuse the use of the HSS sitters – if an HSS sitter is no longer needed, call them off
  • Tess is no longer on 5th Floor, so she may be a good resource to teach staff how to better handle M-1 pts (Carol Selby could be a good resource too). Give Tess a little time away before calling and asking her to help.
  • SFMC doesn’t have ANY psych staff or a psych pod, so they handle things differently
  • How are bed placements for psych pts determined? Manuela may know
  • Windows are a BIG concern!! Is there any plan to have lexan put in any windows to create a more safe environment? Kate said that this would be revisited
/ Any updates or clarity to EMTALA and our psych transfers?
New breathalyzer obtained
1. Staff and patient Safety, ongoing
  1. Undressing and searching patients. Improved
  2. Staff requests physician support, regarding support of M1 hold placement, and undressing patients. Some physician still saying hold or watch until evaluated. Also directing staff “no need to undress this patient.
  3. Dispo of belongings, now using secure garment bags with more regularity.
  4. Storage on Inpatient units
  1. More staff education and enforcement is still needed for ALL ED staff. Undressing and searching psych pts applies to ALL psych pts, not just those in the Psych POD
c. There has been some improvement with pt belongings due to the use of the locking garment bags. So, storage on Inpatient units is no longer an issue.
  • NO outside food or drink is allowed in Psych POD – we need to put this in the policy
  • Can we create an information sheet for visitors to the Psych POD so that they know the rules and why those rules are in place? They did this at 3 East…do we have access to an electronic copy of what they had at 3 East?
/ New focus on admitted patient belongings being secured
Security issues and updates
  • Right now, our system of security is broken. We need to find a way to fix it.
  • Last Monday – Tuesday from 0800 – 1600 there were no security patrols of PH because all security was on Psych watches (same last Wednesday 0800 – 1400)
  • SFMC has about 90 hours a month of psych watches
  • System-wide Security had 8.78 FTEs for March (5.75 at PH, 3.03 at SFMC)
  • To be able to patrol, security will need one more staff person per shift
  • As of April 14th, security is already at their monthly allowance for FTEs
  • If Psych Techs can sit with M-1s in Psych POD, that may free up security a little bit.
  • There is some concern with that, because in the ED psych pts are not as medicated as they were in 3 East
  • The decision of who sits with a pt needs to be a case by case decision
  • There is a possibility that we will be able to get TVs into the psych rooms, this would help ease many psych pts
  • Our Psych POD is small, and that lack of room can make some pts more agitated, we need to be aware of that
  • Possibly go over Securities policies at the next staff meeting, security is NOT required for ALL M-1 holds.
  • If a psych pt needs to make a phone call that is OK, but the call needs to be monitored and then phone put back in the pt belongings locker
  • Maybe we can start saying NO phone priveledges until AFTER the PETT eval…

Physician related Items
  1. Implementation of increased need for M1 Holds and EC holds on every patient deemed risk to self to others and not allowed to leave.
  2. RNs to obtain and begin the completion of M1 document
  3. Physicians to finish last box and
  4. Encourage ED physicians to order PETT eval for all chronic ETOH patients so we can fast-track them to Detox on an EC
  5. Medical Clearance of MDRO/MRSA patients for transfer base on ED physicians clinical exam and judgment. History of vs. active disease. More accurate than lab cultures in determining clearance.
  6. Medical Clearance of BH patient, chronic vs. acute conditions?
/ Any Progress?
No recent issues related to MDRO patients
Patient representative concerns:Silent/privacy patients, no info available for family to follow up
Frequent Complaints. Solutions?

1