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Emergency  Hospitalization Hold Emergency  Hospitalization Hold

Emergency Hospitalization Hold - PowerPoint Presentation

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Uploaded On 2019-12-21

Emergency Hospitalization Hold - PPT Presentation

Emergency Hospitalization Hold 72 hour hold Shamsah Rehmatullah RN APRN CNS Niki Gjere RN APRN CNS Jason Helling MHA PT Objectives Review current organizational situation Provide knowledge of ID: 771090

hold patient time hour patient hold hour time provider case emergency hospital order health commitment leave document physician progress

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Emergency Hospitalization Hold(72 hour hold) Shamsah Rehmatullah, RN, APRN, CNS Niki Gjere, RN, APRN, CNS Jason Helling, MHA, PT

Objectives Review current organizational situation Provide knowledge of applicable statutes of current law and our own organizational policies with regard to placement of 72 hour holds. Review required documentation and patient rights. Review resources available for providers.

Current Situation T here are significant errors occurring in the placement of 72 hour holds across M Health.

Background Recent audits, patient complaints and staff feedback indicate widespread misunderstanding of the requirements needed to initiate and complete a 72 hour hold. Regulatory focus on patient rights is increasing.

72 Hour Hold: Purpose Patient is identified as being an imminent threat to self or others and is unwilling to remain in the hospital voluntarily for further evaluation and/or treatment. To evaluate the patient for commitment to a mental health institution. University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.

How is this Legal?Authority for placement is in Minnesota Statutes Chapter 253B Civil Commitment https://www.revisor.mn.gov/statutes/?id=253B&format=pdf

When to Place72 Hour Hold Emergency Hospitalization allows the hospital to hold a patient for up to 72 hours (exclusive of weekends or legal holidays), only because he or she: is in imminent danger to self or others AND i s mentally ill, has an intellectual and developmental disability, or is chemically dependent; AND an order of the court cannot be obtained in time to prevent the anticipated injury . http://intranet.fairview.org/Policies/Category/PatientCareClinicalGuidelines/PatientRights/S_100220

What a 72 hour is NOT:For patients who have decisional capability, a 72 hour hold is NOT to : Delay discharge. Threaten. Hold patients who disagree with their care plan.

Qualified Examiners Who May Order a 72 Hour Hold Any licensed physician L icensed psychologist who has a doctoral degree in psychology or who became a licensed consulting psychologist before July 2, 1975 Advanced practice registered nurse certified in mental health Licensed physician assistant

EvaluationAllows the clinical team the ability to evaluate the patient for potential commitment as either mentally ill or chemically dependent . Examiners must be: knowledgeable , trained, and practicing in the diagnosis and assessment or in the treatment of the alleged impairment.

Evaluation (for Commitment) Starts as soon as the hold is placed. Plan must be documented in the progress notes. If proceeding with commitment, see commitment evaluation policy. http://intranet.fairview.org/Policies/Category/PatientCareClinicalGuidelines/PatientRights/S_100240

Examiner ResponsibilitiesMust complete and sign the Examiner’s Statement in Support of Emergency Admission form Must have examined the patient within 15 calendar days of the date the hold is placed. Must complete the form documenting the patient’s imminent danger to self or others in behavioral terms with sufficient specificity to provide an adequate record for review. Form must include the date and time the hold is initiated

Documentation: OrderInclude begin date / time to match the time of Examiner’s statement Include end date / time The order is in addition to the 72 hour hold form that mus t be completed

Must include clear behavioral criteria indicating imminent danger to self or others. Must include date and time, Epic order item must match

Copy is given to patient; RN documents in progress notes. Copy is scanned into Epic (media section)

Enter date and time hold was initiated Enter date and time hold expires Give patient a copy; RN documents in progress notes Copy is scanned into Epic (media section)

Documentation P atient’s clinical status needs to communicated and documented by the provider in the progress notes. DO document that if a patient asks to leave, the patient should be evaluated for safety. Do not document in the notes “ if patient asks to leave, initiate a hold” as the patient needs to be evaluated for safety at the time they request to leave vs. preemptively and because this is like starting a hold with no time limitations which is not allowed.

If Deciding NOT to Pursue Commitment The 72 hour hold should be discontinued. The patient would then be a voluntary patient and could: choose to stay be discharged choose to leave AMA Patients do not need to stay the entire 72 hours if commitment is not pursued. Holds do not have to go the length of the initial 72 hours or “expire.”

If the patient wants to leave… …and the provider feels there could be imminent danger to self or others due to mental illness or chemical dependency: the provider (or covering) should assess the patient. After that assessment… the disposition is determined: willing to stay (voluntary)discharge discharge AMA 72 hour hold Choose the least restrictive option available for the patient in the moment and document accordingly.

If the patients wants to stay… The patient is considered voluntary and the hold is: discontinued never initiated

Patient Rights: Emergency Hold Patients placed on an emergency hold: must receive a written copy of the emergency h old must be given a copy of the Notice of Patient Rights, 253B.03 and the Notice to Patient of Rights under Emergency Hospitalization, 253B.05, subd.5. RN must document the patient’s receipt of the forms in the progress note.

Patient RightsThere isn’t a legal “medical hold.” Choosing not to follow a treatment plan or medication regime post discharge is a patient right and does not warrant placing the patient on a 72 hour hold. The patient has the right to disagree with the provider and team without being placed on a 72 hour hold.

ResourcesNursing Unit manager Administrative Nursing Supervisor (ANS) Social worker APNL / CNS Risk Management Ethics Consultation Service

Process for RN/SWIf there is disagreement about a 72-hour hold order:RN/SW should immediately contact Physician Administrator of the Day (PAD) for review of the case. PAD reviewing the case will contact the professional who placed patient on 72-hour hold for further discussion if clarification is needed.

RecommendationsPhysician leadership determines the education modality best for that group – content of the LMS / PowerPoint is important. Though it may be delivered in a different format to be determined by physician leadership . For example: Key physicians engage and teach their colleagues – either partner training / education or teach alone. Physician champions needed! Consider an outside legal consultant for education. The Ombudsman may also be helpful in the education efforts. LMS could be used for staff education (social workers and RNs).

Case Studies

Case Study 1An 80 year old female is admitted with pneumonia. She has a diagnosis of dementia. It is midnight. She is getting agitated, hitting out, and wants to go home. She is walking to the elevator. Do you need a 72 hour hold? No . The patient needs to stay on the unit for her safety. Utilize nursing interventions appropriate to the patient clinical situation – distraction, environmental changes, redirection, sitter, etc . Contact the patient’s family member/authorized surrogate decision-maker.

Case Study 227 year old male patient with endocarditis caused by IV drug use. The patient is in a 6 week course of IV antibiotic therapy. There have been attempts to place the patient for long term IV antibiotic therapy, but he has been declined by all such providers. In week 3, the patient decides he wants to leave the hospital and does not want to continue his antibiotic therapy. He has decisional capacity, though he makes unwise decisions, such as this one. The provider has explained to the patient the risks of his decision to stop antibiotic therapy – including the risk of death. Do you place a 72 hour hold ? NO The patient should be discharged AMA with appropriate discharge orders. Document the discussion of risks, including the risk of death. Document encouragement of the patient to return to the ED if he decides to seek further care. Remove the IV access if that can be accomplished without force.

Case Study 3Patient presents to the E.D. with a suicide attempt (overdose). He is admitted to the inpatient med-surg unit for medical stabilization with a 72 hour hold in place. A day after admission, the patient says he knows he needs to be in the hospital. He will go to psych when he is stable, which is expected in a few days. The provider assesses that the patient intends to accept treatment. What do you do with the hold? Patient is willing to be voluntary. The provider must discontinue the 72 hour hold. Document in the progress notes the discussion with the patient. Patient remains on a 1:1 with attendant and other suicide precautions due to suicidality.

Case Study 4 Progress Note vs. Orders Patient has come into the hospital with alcohol withdrawal and has been receiving oral diazepam. The provider enters a note that states, “The patient is at high risk for alcohol withdrawal seizure, if he tries to leave, place a hold.” This represents a future plan. As with all changes in clinical condition, the patient needs to be assessed. From that point the decision is made about next steps . What do you do? Inform the provider that this is an incorrect note, which could result in concerns related to failure to protect patients rights.

Case Study 5Patient is an admission to the hospital with a pressure ulcer requiring a wound vac. Patient is on antibiotics and needs two more days of IV antibiotics before switching to oral. The patient has a history of frequent admissions and non-adherence to medical therapies. Patient is very concerned about finances and would like to leave the hospital today. Provider would like the patient to stay 2 more days in the hospital to finish the IV antibiotic treatment course. What do you do? Social worker seek assistance from Fairview financial counselor to see if there is a way to allay financial concerns. Assist with arranging home cares (teaching, home care services, etc.) Discuss with the patient and document in the medical record.

Case Study 6 Patient has active TB or is strongly suspected to have TB. The physician orders isolation. The patient intends to leave AMA. The physician orders an Emergency 72-hour Hold. Is the order proper? No The county health department social worker requests that the patient be place on a 72-hour hold. May we hold the patient? No Only the Commissioner of Public Health or an authorized community health board with express delegated authority may issue a hold order for TB patient or request an Apprehend and Hold order from the court. Tuberculosis Health Threat Act (MN Stat. 144.4801 – 144.49)

Thank you