STRUCTURAL APPROACHES TO PATIENT CENTERED CARE

Contemporary Psychiatric Care in the Emergency Department: Care Options, Treatment Teams, and Documentation Recommendations

Yener Balan and Christopher Lentz Contents

  • 5.1 Introduction......................................................................................................................51
  • 5.2 Operational Processes: Benefits.........................................................................................51
  • 5.2.1 Administrative Benefits..........................................................................................52
  • 5.2.2 Staffing Benefits.....................................................................................................52
  • 5.2.3 Direct Care Staff Benefits......................................................................................52
  • 5.2.4 Patient and Advocate Benefits................................................................................52
  • 5.2.5 Regulatory and Quality Oversight Benefits...........................................................52
  • 5.2.6 Length of Stay Benefits .........................................................................................53
  • 5.3 Appropriate Level of Care.................................................................................................53
  • 5.3.1 Least Restrictive Level of Care: Is the Use of Physical and Chemical

Restraints Necessary? ........................................................................ 54

  • 5.3.1.1 Reduction in Restraint and Seclusion Use ...............................................55
  • 5.4 Emergency Department Workplace Safety Concerns.......................................................56
  • 5.4.1 Improving Workplace Safety.................................................................................56
  • 5.4.1.1 Crisis Response Teams.............................................................................57
  • 5.4.1.2 Safety Committees..................................................................................57
  • 5.4.1.3 Sign-Out Reports........................................................................................58
  • 5.5 Patient and Staff Satisfaction............................................................................................58
  • 5.5.1 Patient Satisfaction Survey.....................................................................................59
  • 5.5.2 Patient Confidentiality...........................................................................................59
  • 5.6 Measuring Success: How Do You Know If the Team Is Making a Difference?.................60
  • 5.7 Interdepartmental Memorandum of Understanding or Service Agreement.......................61
  • 5.7.1 Service Agreement: What Does This Entail?..........................................................61
  • 5.8 Suggested Model for Staffing............................................................................................62
  • 5.8.1 Emergency Department Physician........................................................................62
  • 5.8.2 Emergency Department Nurse.............................................................................63
  • 5.8.3 Emergency Department Social Services and Discharge Planning Team................63
  • 5.8.4 Psychiatrist...........................................................................................................63
  • 5.8.5 Mental Health Therapists.....................................................................................63
  • 5.8.6 The Security Team................................................................................................63
  • 5.9 Recommended Patient Liberties for Attire and Personal Belongings in the ED................63
  • 5.10 Suggestions for Daily Framework......................................................................................65
  • 5.10.1 Morning Rounds...................................................................................................65
  • 5.10.2 Template for ED Psychiatry Pre-Rounding............................................................65
  • 5.10.3 Template for Treatment Update Note ................................................................... 66
  • 5.10.4 Emergency Department Nursing Rounding Note Template ................................. 68
  • 5.10.5 Reviewing the Patient List and Assigning Clinicians ............................................ 69
  • 5.11 Template for Initial ED Psychiatric Consultation Note.................................................... 70
  • 5.11.1 Initial Patient Arrival Information ........................................................................ 70
  • 5.11.2 History of Present Illness ..................................................................................... 71
  • 5.11.3 Psychiatric History ............................................................................................... 71
  • 5.11.4 Past Medical History ............................................................................................ 72
  • 5.11.5 Substance Use History .......................................................................................... 73
  • 5.11.6 Social History ....................................................................................................... 73
  • 5.11.6.1 Living Situation ....................................................................................74
  • 5.11.6.2 Legal History.........................................................................................74
  • 5.11.6.3 Financial History ...................................................................................74
  • 5.11.6.4 Support System ..................................................................................... 75
  • 5.11.7 Mental Status Exam ............................................................................................ 75
  • 5.11.7.1 Appearance ........................................................................................... 75
  • 5.11.7.2 Behavior .............................................................................................. 75
  • 5.11.7.3 Demeanor/Manner ............................................................................... 75
  • 5.11.7.4 Speech ..................................................................................................76
  • 5.11.7.5 Mood....................................................................................................76
  • 5.11.7.6 Affect .....................................................................................................76
  • 5.11.7.7 Perceptual Disturbances .......................................................................76
  • 5.11.7.8 Thought Process.................................................................................... 77
  • 5.11.7.9 Thought Content ................................................................................. 77
  • 5.11.7.10 Orientation .......................................................................................... 77
  • 5.11.7.11 Memory..............................................................................................77
  • 5.1 1 .7.1 2 Concentration ...................................................................................... 78
  • 5.11.7.13 Cognition ........................................................................................... 78
  • 5.11.7.14 Insight.................................................................................................78
  • 5.11.7.15 Judgment.............................................................................................79
  • 5.11.7.16 Impulse Control...................................................................................79
  • 5.11.8 Risk Assessment...................................................................................................79
  • 5.11.8.1 Assessing Suicide Risk..........................................................................80
  • 5.11.8.2 Assessing Homicide Risk......................................................................80
  • 5.11.8.3 Assessing for Grave Disability...............................................................80
  • 5.11.8.4 Risk Level Scaling.................................................................................81
  • 5.11.9 Impression ...........................................................................................................81
  • 5.11.10 Diagnosis.............................................................................................................81
  • 5.11.11 Recommendations and Plan ............................................................................... 82
  • 5.12 Psychiatric Reassessment .................................................................................................82
  • 5.13 To Consult or Not to Consult?: Appropriate Consultations of Psychiatry in the

Emergency Setting ........................................................................................................... 83

5.14 Innovative Care in the Emergency Department: Dedicated Psychiatric Observation

Areas ................................................................................................................................ 84

  • 5.14.1 Recommendations for the Dedicated Psychiatric Observation Area.......................85
  • 5.15 Use of Handouts in the ED.............................................................................................. 86
  • 5.15.1 Welcome Letter..................................................................................................... 86
  • 5.15.2 Diagnostic-Specific Patient Education..................................................................86
  • 5.15.3 Community Resources Information ..................................................................... 86
  • 5.15.4 Therapeutic Handouts..........................................................................................86
  • 5.15.5 Patient Rights and Advocacy Group Information ................................................. 86
  • 5.16 Conclusion ....................................................................................................................... 87

References ................................................................................................................................. 87

Resources .................................................................................................................................. 89

 
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