This team is comprised of 59 employees including USCs, PTCAs, RNs, and a nurse manager. This nomination is in regard to the care of a specific patient who spent 91 days at Lancaster General.
IICU is quite skilled at caring for multiple types of patients including traumatically injured, critically ill, and co-occurring disorders such as drug and alcohol withdrawal and psychiatric emergencies. It takes true talent and energy to adapt the nursing plan of care and respond to each patient with an individualized approach in a fast-paced critical care setting.
In November 2019, a 28-year-old female patient spent 10 days in the ED awaiting an acute psychiatric inpatient placement. The patient was demonstrating repeated self-injurious behaviors and expressing suicidal ideations. The patient had a well-known serious borderline personality disorder complicating her ability to rationalize and contract for her safety. While in the ED, she broke a plastic spork and used the sharp edge to lacerate her forearm requiring sutures. After initial repair, the patient repeatedly attempted to worsen the wound to prevent healing. these self-harming behaviors were beyond her control, indicating the highest level of suicide risk this team had ever encountered. After denial by 22 facilities for transfer and demonstrating continued escalating behavior of self-harm attempts while in the ED; it was determined that the patient required a different, more calming environment while continuing a bed search for placement.
Upon admission to the IICU, the patient was out of control requiring placement in 4 point violent restraints, vest restraints, and hand mitts to prevent further self-harm or harm to the staff. Initially, she received all medications IV due to refusal to take oral medications. She also refused to eat anything for her first full day of admission. This was unlike anything the nursing staff had ever encountered. Our goal as an organization is to utilize the least restrictive means possible to maintain safety. However, this patient's strength and irrationality were making it very difficult. the team, with advice from BIT team, security, and nursing leadership, determined a plan for the patient's safety as well as their own. A 2:1 staff-to-patient assignment was implemented. This had never been done in the IICU, due to fixed staffing rations. The patient was assigned both a PTCA and RN to remain within arms' length of the patient while restraint types were removed limb by limb. The patient compulsively would thrash free limbs or she would bang her head against the bed rail. Padding had to be placed for further protection. The RN and PTCA were often holding limbs to prevent self-harm, as verbal de-escalation was not effective. The need for 2:1 continued for about a month. Eventually, after rapport was established and medication plan effective, the team was able to decrease resources dedicating a team-specific 1:1 sitter and resuming normal RN-to-patient ratios on the unit. She was only permitted to eat finger-foods to avoid the risk of utensils being weaponized again. For the duration of her hospitalization, only this team provided care to avoid introducing unfamiliar faces to the patient which had the potential to escalate behaviors.
The patient's non-compliance made wound care particularly difficult. Aside from not sitting still, the patient would have an escalation in behaviors upon seeing her wound itself. The site of the wound ignited a desire by the patient to want to scratch at/further harm herself through the existing wound. This team reached out to wound specialists for advice on how to quickly heal her wound and determine a creative would dressing plan. The team learned to shield the patient's view of the wound during assessments and dressing changes. Within a month the wound healed entirely.
Due to manipulative behaviors by the patient, a "treatment team" formed to address her demands, answer her requests for rewards, or make changes to her care plan. The treatment team, consisting of a psychiatrist, BIT member, primary nurse, and unit nurse manager, rounded the same time each day. Ground rules were established to promote consistency and avoid the patient's attempt at manipulation. No off-shift changes to her plan of care occurred. This rigid approach helped the patient avoid impulsivity, comply with her plan of care, and support the team members assigned to care for her.
Frequent and ongoing education of PTCAs and RNs specific to severe borderline personality disorder was provided to empower the staff to feel confident in interactions. The team had to quickly learn a new approach to caring for a high-risk psychiatric patient in a critical care setting. The team had been accustomed to patients requiring hemodynamic stabilization and brief lengths of stays, but this patient required psychiatric expertise beyond their experience with no discharge plan.
The physical and emotional energy required to work with her for 91 days took its toll. To promote safety, patient interactions were limited to only the IICU. Sitters had to truly watch the patient's movements every second of the shift because the patient was always looking for opportunities to self-harm. For instance, one night, the patient asked for toileting. While the sitter was walking alongside the patient, she spontaneously ripped a piece of particle board off her belongings closet and attempted to slit her own throat. Because of the training of the sitter, she was able to immediately call for help, press her panic button to alert security, and physically restrain the patient preventing harm. Another time, the patient tried to head-butt an employee in an attempt to elope. The patient was not successful and the employee was not harmed.
With the closure of the mental health unit and development of the BIT team, 2019 was a learning curve for all staff at LGH in practicing a new approach to mental health care. Suicide prevention and environmental safety have been hot topics. For this patient, functioning with a heightened sense of awareness and chronic low-level fear was emotionally exhausting for staff in the midst of caring for their other patients. It's challenging to follow our relationship-based model of care and to see someone as a person when the action steps one intuitively wants to take to connect with a person could cause them setbacks to the plan of care. To overcome this barrier, a lot of team building and emotional support occurred. Chaplaincy rounded frequently on staff. The BIT team was this team's sounding board when navigating challenges, exploring ideas, resetting boundaries, and simply listening to staff concerns. Our CNO and director of nursing would check in with staff and thank them for working so hard to care for this patient. Even though it was a challenging 3 months, the team felt well informed and well supported, empowering them to focus their attention on patient care.
The patient's daily attempts at self-harm created compassion fatigue as well. The team was advised to interact with this patient differently because of her borderline personality tendencies. For instance, the team enjoys decorating for the seasons, offering gifts over the holidays, and donating entertainment items to create a sense of home for patients. However, this type of attention tends to lead to negative outcomes for borderline patients. Even staff sharing personal stories about family and life events was discouraged to avoid manipulation of individual staff members. The team is full of creative thinkers. They were able to provide entertainment within the set boundaries. For instance, outside the patient's room, a lighted Christmas tree was placed by the pod-window since it was not permitted to be inside the room. Coloring pages were decorated by the patient and sitters then taped to the wall. The patient enjoyed Shania Twain so CDs were brought in for her to listen to when anxiety flared. Every movie offered on the TV was watched. And on her good days, the patient was permitted to leave her room to walk to the hallway of the nursing unit. These small things created stability and actually meant the world to this patient. Improvements in temperament and behavior became evident in her smiles and compliance. The patient received the true gift of time with a team of compassionate caregivers, able to see her as a person, resulting in zero harm while on our unit.
This team furthered our mission/vision/values with a truly transformative approach to care coordination, high-quality care, and patient safety; resulting in a positive outcome. Over time, the patient truly improved. She was able to remain calm and cooperative and comply with her behavior plans. She continued self-harm attempts daily throughout her entire admission. However, the staff learned her triggers and were able to minimize adverse outcomes. Holding her arms or legs for a few minutes while she thrashed in bed would happen a few times a day. The team would not make a big deal of it, give her time to work through her anxiety and fears, and then resume normal interactions. The patient had a few visitors over her 91-days at LGH. Distracting the patient and helping her maintain hope of better days ahead was a challenge. This team truly worked together to help this patient become mentally stable on her journey towards mental health and wellness.
Discharge planning was complex. The typical admission process for a patient like this would require an emergency evaluation and medical clearance, followed by an admission to an acute psychiatric hospital to start. When no community facility agreed to accept this patient, it became clear this team would need to approach discharge planning differently. Our BIT team completed an exhaustive bed search. Our complex case management team was at a loss for additional PA State options. Nobody quite knew what to do. The IICU started asking questions like "what does this patient need" and "where is the best place for this patient to receive the expert-level of care she needs." The answer kept coming back to a state mental health hospital. However, the process for admission to a state facility requires an acute psychiatric hospital admission first; followed by a long-term admission as pre-requisites. The problem for this patient was that nobody from those types of facilities would accept this patient either. In collaboration with LGH executive leadership and our LBHH partners, we began conversations with Lancaster County Mental Health Services and our local political representatives. The driving question being, "Was it possible this patient could be admitted directly from our hospital to a state hospital?"
After many emails, phone calls, and meetings, the answer was yes! It was possible! However, the patient was placed on a list of individuals from Lancaster County to be admitted, it could take upwards of a year unit she could transfer. Through continued collaboration from all involved, the patient was transferred on her 91st day of admission. Because of her improved mental health, the hours-long transport requiring a paramedic and RN accompanying was uneventful. The patient made no efforts to elope or self-harm. This fact is remarkable given all that she had been through and her compulsory behaviors.