Behavioral Health Center CMC-Randolph Psychiatric Emergency Department staff was recently featured in ADVANCE for Nurses, focusing on the compassionate care provided to patients in one of the only Psychiatric Emergency Rooms in the country.

The Role of the RN in a Psych ED Requires Compassion and Customer Service
Peter, 39, comes to the 24-hour psychiatric ED via the Charlotte-Mecklenburg Police Department (CMPD) on an involuntary petition at 6:30 p.m. Police report he was threatening to jump from a nearby overpass. Peter presents to us disheveled and malodorous, unclothed except for a blanket wrapped around him. He was brought to us in handcuffs. A nurse greets Peter and initiates the triage process. Peter's speech is disorganized and rapid; he is mildly agitated and tells us "the voices" are telling him to jump off a bridge. However, Peter allows the nurse to obtain vital signs. He is given a triage code 1, indicating psychosis, agitation and a need for immediate medication, and taken to the bathroom to don scrubs. The nurse approves the removal of the handcuffs. During this process, a psychiatrist has been observing the patient's behavior and orders medications. Peter has agreed to medication intervention, so the charge nurse prepares the IM injection of the antipsychotic Geodon® (ziprasidone) 20 mg. The triage nurse and a psychiatric technician escort him to an interview room, where he is then medicated by the charge nurse without incident. He is placed on close observation with 15-minute rounds and continuous video monitoring. The lights are dimmed, so Peter can rest in a private room away from any stimulation. Because of his high acuity, the assessment nurse and psychiatrist visit him about 30 minutes later. They review Peter's previous records, make contact with community agencies, obtain admission orders and give report. ED staff and security escort Peter to the inpatient unit at 8:15 p.m.

Specialized ED
Peter has become a patient at North Carolina's primary hospital for psychiatric services — Behavioral Health Center CMC-Randolph, in Charlotte. There are seven psychiatric and substance abuse facilities within the Behavioral Health Center network, which is part of the Carolinas Healthcare System. Services include adult, child and adolescent inpatient and outpatient care, as well as a medication clinic, a behavioral health call center and the system's only psychiatric ED. This specialized ED is one of only a few in the country; others include Jacobi Medical Center, New York; University of Michigan Health System, Ann Arbor, and St. Mary's Hospital, Passaic, NJ. The Behavioral Health Center-CMC's behavioral health call center receives more than 4,000 calls per month and is staffed with master's-prepared clinicians and RNs who answer calls 24/7 from patients, family members and other healthcare professionals. Depending upon the information obtained from these calls, patient referrals can be made to a substance abuse facility, one of our outpatient clinics, other inpatient or outpatient facilities, or the psychiatric ED.

ED Referrals
Forty percent of our callers are referred to the psychiatric ED, which is always open. The department evaluates more than 13,000 patients per year. Patients range in age from 3-90 years. Child and adolescent cases comprise 20 percent of our evaluations. A psychiatrist is present around the clock. The department also serves as the county suicide and crisis hotline. Individuals experiencing a mental health emergency or their caregivers who call the ED are encouraged to come that day for an assessment. Police and ambulance personnel are called when life-threatening emergencies are indicated. Alternatively, concerned individuals may be instructed on how to pursue involuntarily commitment of a patient. The involuntary commitment process assures the patient will receive a psychiatric and/or substance abuse evaluation. Involuntary patients account for 20 percent of the volume in the ED. The ED is staffed with registered nurses, psychiatrists, a nurse practitioner, psychiatric technicians, master's-level clinicians, registration staff and security personnel.

Arrival and Triage
Regardless of how patients come to the ED, they are greeted and triaged by a nurse within 5 minutes of arrival. The triage nurse obtains vital signs and assesses for danger signs (suicidal ideation, homicidal ideation, psychosis, medical emergencies), and assigns a triage code from 1-5, with 1 representing the highest acuity and 5 the lowest. For example, a patient with psychosis and agitation needing immediate medication would be a triage code 1 and seen by the nurse and physician immediately. A patient in need of a medication refill would be assigned triage code 5. The triage nurse's greatest challenge is balancing volume and acuity, ensuring patient/staff safety at all times and maintaining the therapeutic environment of the secure lobby. After triage, the nurse and psychiatric technician use critical decision-making skills to determine whether the patient can wait in the lobby. At any time, our department may have patients who are suicidal, psychotic needing immediate intervention with medications, waiting for EMS because of a medical emergency, and children or adolescents testing behavior limits. The nurse should consider the acuity of the patients in the secure lobby in relation to the new patient's history and whether he might be a danger to himself or others. Patients placed in our secure lobby undergo a contraband and/or physical search to maintain safety.

Assessment
From the lobby, patients are taken back for a comprehensive assessment and evaluation, including review of systems, pain assessment, history of present illness, activities of daily living, substance abuse history, previous treatment, family/social history, a mental status exam and risk assessment. This structured process takes about 30 minutes and the objective is to gather information as it relates to the current psychiatric emergency and obtain the patient's/family's expectations of the visit. Patient and/or family educational needs are assessed and addressed at this time. The existing medical record is reviewed as part of the assessment process. Collateral information from other agencies or family members may be obtained. To maintain patient satisfaction, we inform patients of the staff's efforts to obtain this information. All information obtained is presented to the physician to ensure a thorough assessment. The greatest challenge of assessment is keeping the patient focused on describing their psychiatric emergency so we can gather pertinent clinical information related to this crisis. Timeliness is important because we have a steady flow of patients around the clock. The psychiatrist and nurses work collaboratively to achieve an optimal clinical outcome for each patient.

Disposition and Discharge
After the physician's evaluation, all patients receive a discharge/disposition plan. Eighteen percent of the patients evaluated in the ED are admitted to our inpatient service. Admitting a patient includes telling them all about the admission process, speaking with family, obtaining precertification of insurance, giving report, initiating admission orders and completing legal documentation. While some patients are transferred to inpatient substance abuse or other treatment facilities, the majority are discharged home with appointments for therapy and medication follow-up. Discharge instructions from a nurse include written instructions and educational handouts. Medication teaching and available community resources are the primary emphasis. The discharge nurse is the team leader/charge nurse who is responsible for coordinating the flow of the emergency department and serving as the liaison between the ED and all customers, external and internal. Challenges include maintaining a healthy relationship with the inpatient staff who may be accepting numerous admissions during their shift; prioritizing discharges, transfers and admissions simultaneously; and monitoring the entire department's safety.

Safety & Service Are Key
The two primary goals of the psychiatric ED are patient safety and excellent customer service. The emergency department's personnel participate in a callback system in which most patients receive a courtesy telephone call to follow up on their ER experience. Staff can hear firsthand any customer service issues and receive positive feedback or suggestions for improvement. In the psychiatric emergency department, the environment is unpredictable, potentially volatile, fast-paced and stressful. In turn, we are a flexible, well-organized team. We take our jobs very seriously and are dedicated to our patients. When we treat a patient in the ED and later see them functioning and stabilized in the community, the reward is invaluable.

Jennifer L. Ziccardi, BSN, RN, is director of assessment services, Leslie Atkins, BSN, RN is day shift supervisor, Nicole McMillion, BSN, RN is evening shift supervisor and Angie Martin, BSN, RN is ED charge nurse, all at Behavioral Health Center CMC Randolph, Charlotte, NC. Laura Thomas, group vice president, and Harold Fuller, MD, provided assistance in writing this article.

Issue Date: September 29, 2003
Vol. 5 • Issue 21 • Page 39