The beauty of a New Years Eve duty at A&E

4. january 2016 at 7:00 | Veronika Valdova, ARETE-ZOE |  Risk Management

A while ago I was invited to comment on training procedures pertaining to triage of patients with mental health issues at a major UK hospital. This particular case study involves a nursing assistant who in his or her limited capacity has to decide how to handle each specific case many times a night.

The hospital asked its staff a simple question:

"In your capacity do you feel you have enough training and coping mechanisms in place to safeguard yourself and a patient experiencing mental- ill health?"

After considerable time spent interviewing staff over their knowledge and understanding of existing laws, regulations and procedures, the simple and short answer is "No".

This particular A&E admits about 320-400 new patients a day, of whom about 20 are patients with some kind of mental health problem. This figure does not include patients with dementia. Some of these patients are violent as a result of alcohol or drug abuse. The hospital also has to handle patients with long-term previously diagnosed psychiatric conditions, new onset psychiatric conditions, including drug-induced psychoses, erratic behavior and seizures resulting from trauma, poisoning, adverse drug reactions or metabolic conditions or other underlying disease, and distressed victims of crime such as domestic violence or sexual abuse, and victims of human trafficking.

Clear and understandable instructions for staff are necessary to comply with all applicable laws, regulations, instructions, and with hospital policy.

The following intriguing questions for handling these cases shall be promptly resolved by management of the hospital, and appropriate procedures including training shall be circulated to people on wards to minimize any liability caused by improvisation and human error.
  • What is the standard procedure for obtaining informed consent from patients who are conscious and able (but unwilling) to give consent with admission for examination and treatment?
  • What is the standard procedure for obtaining informed consent in situations when the patient is unconscious, incapacitated, disoriented but conscious, incapable of giving consent and non-aggressive, aggressive and uncooperative?
  • What are the symptoms a nursing assistant need to watch out for before he/she shall escalate the matter and ask someone to decide?
  • What are the roles and responsibilities for making decisions on such cases?
  • Who is the correct person to go to if the initial assessment indicates that the patient is a mental health case?
  • When a nursing assistant is allowed to use force, and what are the appropriate techniques? Do they need to record in patient chart that force had to be used, and what technique was applied? What if the patient becomes injured during the procedure?
  • How does a nursing assistant know who is the patient's next of kin? How does the hospital determine who is the most appropriate person to talk about the patient's health, especially if his/her family status is less than straightforward? The hospital already experienced cases of family feud and honor killing. The city is also a major human trafficking hub.
  • How does staff communicate with other persons who came in with the patient (police, neighbors, family members, coworkers)?
  • Who is responsible for accepting restraining orders, warrants, and similar measures, and how does a nursing assistant find out? Is this listed in the patient documentation, or is this communicated during a handover brief? Does the note on file refer to applicable internal procedure?
  • Does the hospital separate appropriately guarded ward for patients who can endanger themselves, other patients and staff?
  • How does the hospital ensure that distressed victims of crime, especially domestic violence and rape, are not held together with potentially dangerous individuals in the same "mental health" ward?
  • What is the protocol for the treatment of victims of rape to make sure forensic evidence is not destroyed in the process?
  • If drug abuse is suspected, especially substances such as bath salts, what is the correct procedure for obtaining and handling samples? Does the hospital use LC/GC detection equipment where the samples can be examined quickly?
  • What if poisoning or drug-induced psychosis is suspected, including adverse drug reactions to Rx drugs and Rx drug interactions?
  • Who is responsible for triage of these patients?
This list is by no means exhaustive. It is, however, illustrative of some of the challenges first line staff faces on busy nights.

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