New policies developed by nursing leaders at three Chicago-area hospitals guide hospital staff in caring for behavioral health patients and keeping them safe.
Caring for behavioral health patients is a major challenge for nurse leaders. When it escalates to elopement—the unauthorized departure of a patient from a hospital—patient safety becomes an immediate concern.
Patients with behavioral health needs often present to hospital emergency departments or, because of medical co-morbidities, are admitted to a medical-surgical unit where staff may not know how to care for this patient population.
But nurse leaders at Weiss and three other Tenet Health Chicago-market hospitals have worked together to develop standardized polices regarding patient elopement.
Creating policies to guide staff in caring for behavioral health patients can improve both quality and safety of care, says Mary Shehan, DNP, RN, NEA-BC, chief nursing officer at Louis A. Weiss Memorial Hospital in Chicago, part of Tenet Health.
Shehan spoke at the recent HealthLeaders Media Chief Nursing Officer Exchange at the Bacara Resort & Spa in Santa Barbara, CA.
Patient elopement is a very real problem that most organizations have experienced at one time or another, but it is rarely discussed. About 20% of adults in the U.S. experience mental illness in a given year. About 4% experience a serious mental illness that interferes with life activities, according to the National Alliance on Mental Illness.
"Preventing patient elopement is a concern we all face, especially for those patients who are at risk for harming themselves or others," Shehan says.
Patients elope in a number of ways. Some will leave the building if they do not have constant supervision when they are sent to a have a test or procedure done, or while using the bathroom. They may also exit out an open door after another person leaves, which Shehan calls "tailgating."
No matter how elopement occurs, there are consistent, proactive ways to better prepare an organization and its staff to better deal with the issue.
Shehan recommends identifying patients at risk for elopement—including those with severe psychosis, dementia, or drug and alcohol withdrawal—and reviewing current practices as well as best practices in the literature.
She also suggests performing a gap analysis and getting answers to these questions:
- Where are the opportunities to reduce the risk of elopement?
- Once patients leave, how do you take them back?
- If they leave and are not found, how is that handled?
- Is there a "safe room" in the emergency department?
- Is there enough staff to have a constant patient observer or are patient care technicians being pulled out of care to act as sitters?
It is also important for nursing supervisors to know how many patients are in restraints hospitalwide and how many are in need of constant observation.
Shehan says the biggest innovation that has come out of this work is the creation of a psychiatric program director position at Weiss.
When she came to the organization over a year ago, there was a half-time manager/half-time staff position open for the 11-bed psychiatric unit. The two openings were combined to create the full-time psychiatric program director position.
"With an 11-bed unit, the average daily census is about nine, but I have a greater average daily census [of behavioral health patients] when one factors in the rest of the house—in my emergency department and on my med/surg floors—where patients are being medically cleared to go to the next level of care," she says.
Instead of being responsible for just the 11-bed unit, the psychiatric program director has responsibility for the continuum of behavioral healthcare across the organization. The director oversees behavioral health nursing care in the ED, on the med/surg units, as well as in the psychiatric unit.
The director conducts daily rounds on all patients with behavioral health concerns, including those with restraints and those who need a constant observer. In addition, he does on-the-spot education with nursing staff.
"He's got the full picture," Shehan says. "We now have consistency in how we care for our patients throughout the organization."
Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.