Pediatric ED opens behavioral health area
Improved security for agitated patients
Behavioral health issues present an ongoing challenge for ED managers in pediatric as well as adult facilities. To address these challenges, the ED leadership at Akron (OH) Children's Hospital has built a separate area within the department to treat patients with such issues.
'We have seen mental health and behavioral health issues escalating in the ED, and we did not feel we could safely care for these patients in a regular setting,' says Helen Raub, BSN, MBA, RN, the ED nursing director. For example, Raub points out, 'there were many things they could harm themselves on -- monitors and other equipment -- and there was the risk of flight for children in crisis.'
In addition, she says, patients in crisis might be yelling and screaming next door to a 2-year-old being treated for an earache, and there had been instances when teenagers had attacked staff. Security officers and nurses had been injured.
Timothy Lee, MD, medical director of the facility's main campus, says, 'We wanted to create a space where, for example, there were no wires hanging from the ceilings. And like any peds ED, we see some pervasive developmental disorders like autism and Asperger's syndrome. Even just the bright lights of the ED and noise levels can escalate agitation.' (Tours of other facilities helped the ED team with the design of the unit. See the story, below.)
Fortunately, Lee says, there were generous donors in the community who were willing to underwrite the $500,000 unit, which is located within the ED.
Raub says, 'It is a secure five-bed unit that is locked and monitored with security cameras. It is designed to be safe. There is no heavy equipment, and there are no medical gasses.' (Raub says Lean principles were used in the planning of the unit. See the Management Tip, below.)
Each room has a cot, a couple of chairs, a TV behind a clear acrylic wall, locked cupboards, no sharp corners, and dimmer lights.
'The doors on the rooms swing outward, which means that patients cannot barricade themselves in,' Raub adds. 'There is a large interview room where nurses and social workers can talk to the family, as well as a family waiting room.' Sometimes the family is in as much crisis as the child, she notes, and they need a quiet, safe area where they can collect themselves.
After patients present, the triage nurse determines if they require treatment in the behavioral health unit -- for example, if they are threatening suicide or are otherwise agitated. 'If the nurse determines there are exclusively mental health issues involved, they take them straight back where they are seen by a nurse, a mental health worker, a social worker, and an ED physician who will make sure that there is nothing medically wrong with them,' says Raub.
If the patient is relatively calm, the parents can walk them over to the unit themselves, where they press a button to gain entry. The nurses can see them through a security camera.
If they are not cooperative, the nurse will go over with them or, if necessary, they will call security.
The unit is working well, says Lee. 'We had one patient in particular who was agitated, but all it really took was to allow them to walk the hall [in the separate unit], and they de-escalated,' he recalls. 'That sort of thing would never have been feasible in our other space.'
Raub says, 'It's going great. On our first day we saw seven patients in the unit. The parents really appreciate it, and it's absolutely done what we expected in terms of safety.'
Facility tours help with unit design
To plan the design of a behavioral health unit within its ED, leaders at Akron (OH) Children's Hospital toured several other facilities that already had such units.
'We belong to the National Association of Children's Hospital's ED focus group,' says Timothy Lee, MD, medical director of the facility's main campus. 'All of its members travel to different hospitals and observe operations.'
One of the facilities was Kosair Children's Hospital in Louisville, KY, which had a separate behavioral health unit. 'The staff they utilized was a lot more psychologically focused. Mental health techs and psych nurses seemed to make a big difference,' Lee notes.
Helen Raub, BSN, MBA, RN, the ED nursing director, says, 'I see things totally different than how a parent would see them. Another thing we did well was to involve families with children who could potentially be in the ED and find out what they would need.'
Initially, she says, she consulted with a parent who is also on a countywide advisory board and advocates for children. 'She met with the multi-disciplined hospital planning committee,' she shares. 'We talked about key design issues and met with her several times.'
Then, prior to the opening, she invited a group of about six people from the Family Center Care Council, a hospital council that includes parents, and asked them if they had any concerns. 'We wanted to know that they would feel comfortable with the unit, its design, and the security equipment, if they brought their child in,' Raub explains. 'We also asked them how we should present ourselves to the community; after all, we did not want to let people think there would be a psychologist here 24/7.'
All of this preparation was valuable, says Raub. 'We've found it really helpful since we were going with a brand new site, facility, staff, and processes,' Raub says. 'We put on that 'green belt' and looked at it from a Lean perspective, focusing on the patient's needs.'
Use Lean techniques when planning unit
Whenever you're planning a new unit or a physical change to your department, you should employ Lean Six Sigma techniques, advises Helen Raub, BSN, MBA, RN, the nursing director of the ED at Akron (OH) Children's Hospital, which recently added a separate unit for behavioral health patients.
'We've found it really helpful since we were going with a brand new site, facility, staff, and processes,' Raub says. 'We put on that 'green belt' and looked at it from a Lean perspective, focusing on the patient's needs.'
During such an initiative, you have to get away from a 'we've always done it this way' attitude and examine those approaches that best utilize your available resources, she says.
So, for example, the staffing mix was changed. 'Instead of all RNs, as we have in the ED, we added mental health technicians, which was getting away from how we did things in the past,' says Raub. In addition, she notes, in the past when children came into the ED in crisis and out of control the first thing the staff did was medicate. 'Now, we first use de-escalation techniques to get the child under control and only go to medication or restraints as a last resort,' Raub says.
