This Nurse Leader Cut LOS by 40% in the Emergency Department

Adding an NP with a background in psychiatric nursing was just one tactic a Chicago nursing director used to dramatically improve care among unfunded behavioral health patients in the ED.

Around 2012, Ajimol Lukose, DNP, RN-BC, nursing director at Swedish Covenant Hospital in Chicago, noticed a trend—more patients with behavioral health issues were seeking treatment in the emergency department. This development came on the heels of the state cutting $113.7 million in general funds from its mental health budget, and Chicago closing of six of its 12 city-run mental health clinics.

"There was a reduction in mental health clinics, so the follow-up or outpatient programs were limited. That resulted in patients showing up in the emergency department," Lukose told me.

On any given day, there could be as many as six or seven behavioral health patients in the ED.

"Our emergency department was struggling with patients with mental health issues staying there for three and four days and waiting for state transfer, especially unfunded patients," she said.

At the same time, Lukose needed to implement a project for the doctorate of nursing practice degree she was working toward. She has a background in psychiatric nursing and thought she could help address some of the issues around caring for this patient population by developing a safe care delivery model to improve care quality and reduce length of stay in the ED.

Her results were even better than expected.

The Best-Laid Plan
Lukose developed a number of goals for the project. Short-term, she wanted the initial behavioral health assessment in the ED to occur within one hour of its order time and to have behavioral health interventions initiated within two hours of the consultation order time.

Long-term, she wanted to decrease behavioral health patients' ED length of stay, the use of sitters and behavioral restraints, elopement events, and labor costs.

Through a literature review, she identified three best practices to support these goals:

• Place a psychiatric liaison in the ED
• Designate a dedicated area in the ED for behavioral health patients, separate from the general patient population
• Create guidelines, protocols, and policies to direct ED staff on how to care for behavioral health patients

Lukose hired a family nurse practitioner with a background in psychiatric nursing as the psychiatric liaison. The NP worked eight-hour shifts, Monday through Friday. She rounded on behavioral health patients in the ED, completed the psychiatric evaluation, initiated appropriate interventions, and coordinated discharge planning.

"The interesting thing that we found was many of them did not need to be in an inpatient psych unit," says Lukose. "Because the ED physicians were not comfortable, they would keep them" until the patients could be transferred to a psych unit.

The NP also facilitated a 30-day medication supply program for underinsured patients and established a "bridge" program for patients who needed temporary support until they connected with a behavioral health follow-up provider.

"If they get discharged from the ED, they don't always get an appointment for follow-up right away. It might take a month or three weeks," Lukose says. "She provided three follow-up visits while [a patient] was waiting for the post-discharge follow-up with the mental health provider. They could walk into her small program, which is a room in the ED."

Location, Location, Location
Creating a dedicated space in the ED for behavioral health patients may sound costly, but Lukose says it wasn't not the project highest ticket item. The largest expense in the entire project was hiring the NP.

"Doing the facility enhancement is not a costly program," she says. "We weren't buying equipment. We just removed items to make the room simple."

Working with the ED director, they were able to identify a section of the ED where five beds could be dedicated to behavioral health patients. The crisis department, which had previously been located outside the ED, was moved inside the department to help improve collaboration.

"There was a big disconnect between the crisis staff and the ED staff so we moved their office to this particular area so they are available constantly," she says.

Clustering the behavioral health beds in one area also facilitated a decrease in sitter use.

"We had them in the general ED, but here and there, we had to provide a sitter for each patient," Lukose says. "In reality, they don't always need one-to-one care. Because we have this one separate area, you can have one sitter for three patients."

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."

Impressive Outcomes
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."