Lukose and the ED director developed policies, procedures, and guidelines using the Four S Model, which calls for focus on "safety, support, structure, and symptom management." For example, giving behavioral health patients a different color gown so they can be easily identified if they are trying to elope, placing all patient belongings into a locked cabinet, and ensuring metal objects like soda cans or silverware are not brought into the room.
In addition to training to help boost the staff's comfort and compliance with the new polices, a checklist was created.
"If you give a nurse a three-page or four-page policy, they're not going to sit down and read the policy all the time," she says. "So we made a one-page checklist, which is a summary of the entire policy, so the nurse can make sure everything is done."
After these changes were implemented in April 2013, Lukose collected three months of post-implementation data in October, November, and December of 2013. The results of the project? Behavioral health consultations were completed an hour after being ordered 93% of the time and interventions were initiated two hours after the consultation was ordered 92% of the time. Sitter use decreased by 46% as did sitter costs. Labor costs decreased by 49%.
At first glance, it may seem like length of stay didn't budge much—average length of stay for all behavioral health patients in the ED was 12. 3 hours prior to the project and 8.8 hours after its implementation. But when Lukose looked at insured behavioral health patients' length of stay in the ED compared to uninsured behavioral health patients, there was a definitive improvement for the second group whose pre-project average length of stay was 24.1 hours and post-implementation average was of 16.3 hours.
Lukose took the analysis of length of stay a bit further after her DNP-project was completed. She found that in fiscal year 2014 the average length of stay for all behavioral health patients in the ED decreased to 12.5 hours from 17.9 in fiscal year 2013—a 30% reduction. For all uninsured behavioral health patients in the ED, the length of stay dropped to 29.1 hours in fiscal year 2014 from 48.5 hours in 2013—a 40% reduction.
And, for uninsured patients waiting to be transferred to a different facility, average length of stay was 36.2 hours in fiscal year 2014, down from 74.7 hours in fiscal year 2013.
"That was a great accomplishment for our hospital," she says. "I didn't want to start something and see that the project ended. It shows that the changes that were made have been sustainable and that the project was continuing."
Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.