Psychiatric emergencies in medical settings may be particularly challenging since the staff does not encounter them frequently and may not have experience dealing with behavioral crisis intervention. The purpose of this exercise is to help staff improve understanding and coping with nonmedical emergencies that occur in medical settings using the PDCA cycle.
Mr. X is a 41-year-old male admitted to a medical unit with a diagnosis of possible stroke. The patient is ambulatory, 5’10’’, and 350 lbs. Mr. X presented to the emergency department the day before after apparently losing consciousness at home. The initial CAT scan of his head was negative. It is suspected that Mr. X may be an IV drug user since his urine toxicology screening came back positive for opiates. The medical staff thinks that Mr. X had a seizure prior to admission, but he has shown no abnormal signs or symptoms within the last 24 hours. Mr. X was moved to an acute care unit where he sits in bed wearing only a pair of ill-fitting boxer shorts and no shirt. He is able to communicate without any signs of aphasia. The medical staff is still not sure what is wrong with Mr. X.
As the nurse administrator of the day, you hear a Rapid Response called overhead for this patient. As you enter the room, you see Mr. X screaming and on all fours in his bed. He is saying “Help, help” and “I don’t know” repeatedly. Respiratory staff, physicians, physician’s assistants, an ICU nurse, and unit staff are all standing there watching Mr. X scream for help. They all seem paralyzed. Finally, one of the staff nurses asks Mr. X to turn over so that respiratory staff can administer oxygen via a facial mask. He complies and at that time the ICU nurse hooks him up to the cardiac monitor as per protocol in a Rapid Response.
Mr. X remains quiet and still for about 60 seconds and then proceeds to rip off the oxygen mask and the EKG leads attached to his chest. He climbs over the side rails and stands there in a daze, saying “I don’t know, I don’t know.”
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The staff reacts negatively to Mr. X’s behavior in front of him. The respiratory therapist says, “If you think I’m going in to get an ABG from him, you’re crazy.” Speaking to Mr. X, the ICU nurse repeats over and over in a stern impatient voice, “What don’t you know?” Mr. X seems overwhelmed and can’t answer. The physician looks through the chart and asks the nurses questions about the patient. The other nurses stand there staring at Mr. X. The ICU nurse leaves a few minutes later stating that the patient’s EKG is normal.
All at once, Mr. X bolts from the room towards the elevator, which has just opened, and gets on. One of the nurses calls a security code, but it is too late; Mr. X has disappeared. The county police are called and hours later they find Mr. X at his nearby home. They try to encourage him to return to the hospital, but since he has not been deemed a danger to himself or others, they have no choice but to leave him alone.
The next morning Mr. X returns to the Emergency Department with “severe chest discomfort and a headache” and is admitted back to the same unit. When the staff see him, they are apprehensive and somewhat angry that he is back. After about three hours on the unit, Mr. X starts yelling that his stomach is hurting. His nurse calls the physician about his symptoms but she and the rest of the staff avoid extended contact with him because of what happened the day before.
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Task:
Write an essay (suggested length of 5–10 pages) in which you develop a plan to help this staff become proficient in handling behavioral emergencies on a non-psychiatric unit by doing the following:
A. Analyze the situation using the FOCUS and PDCA models by doing the following:
1. Use the FOCUS model to identify possible causes of the staff’s problem.
a. Find a Process to Improve (What needs to be improved based on the incident in the scenario?)
b. Organize a Team That Knows the Process (Who is the leader, the facilitator, the recorder, the time keeper, team member? Do you need all these people? Do you need others?)
c. Clarify Current Knowledge of the Process (What is being done now that might have added to or allowed the incident?)
d. Understand Causes of Process Variation (Use cause-effect diagrams, concept maps or other diagrams to show how you would understand the cause)
e. Select the Process Improvement (What would you do to improve the situation so that you decrease the risk of it occurring again?)
2. Develop an improvement plan that will ensure appropriate response times and appropriate clinical interventions in this situation, using a modified version of the PDCA model (PDC).
a. Plan (develop a plan to address the situation and possible risk in the future)
b. Do (You are not expected to actually do the plan but tell how it would be done)
c. Check (How would you check if the plan worked?)
d. Act (Note: Act has been omitted in the modified version since you are not expected to carry out this plan so you cannot periodically review the change to ensure that it is successful.
B. Write a unit protocol containing at least five directives for staff to follow in case of a behavioral emergency in a non-psychiatric setting.
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