Purpose: Behavioral health (BH) complaints are a component in one out of every eight emergency department visits.  With the closing of many inpatient psychiatric beds, emergency departments are the primary source care for many individuals experiencing a behavioral health crisis. Often assessment and care for BH patients is delayed to provide care to medical patients who are perceived to be more acutely ill.  Emergency nurses are frequent recipients of aggression and violence from this population.   Research findings demonstrate that most acts of aggression and violence occur within one hour of arrival in ED.  Therefore delays in care may exacerbate the risk for aggression or violence.  Expediting care for behavioral health and other patients experiencing emotional crises is essential in the emergency department to prevent increasing agitation and/or aggression.  This project developed by a multi-disciplinary team used a standardized protocol to provide definitive care, including medications, before being seen by the physician.

Design: This quality improvement project was instituted In response to increasing numbers of BH patients presenting to a busy emergency department.  Its goal was to reduce risk of  agression and violence through prompt initiation of definitive care.

Setting: Community hospital in Southern California.

Participants/Subjects: All ED staff have been trained and participate in this project.

Methods: A team composed of staff nurses, ED leadership, and physician examined issues and proposed solutions to improve timeliness of care for the BH population with a secondary goal of reducing acts of aggression and restraint use.  As allowed by California Board of Registered Nursing, a standardized procedure (STP) allowing ED nurses to assess and order medication for anxiety or aggression was developed.  Subsequent to approval by multiple hospital, physician, and interdisciplinary practice committees the procedure was instituted.  Emergency staff nurses received extensive education, both in groups and one-on-one to train them in the use of the procedure.  Competency was documented prior to the nurse being able to institute the STP.

Results/Outcomes: Time to medication for anxiety and agitation has decreased from 43 minutes to an average of 19 minutes. The implementation of the STP has also resulted in a 50% decline in the number of restraint episodes.  For those in restraints, time in restraints has significantly decreased.   The number of code grays has demonstrated overall reduction.

Implications: Use of a STP is an effective method for the nurse to autonomously assess and immediately begin treatment of patients with signs of anxiety and aggression, and thus reduce risk for violence.  An additional benefit is earlier initiation of therapeutic BH care and reduced time to disposition.  This process can be replicated in other emergency departments through the use of a standardized procedure or protocol based on state regulations.