Coping with a Non-medical Emergency in a Medical Setting using the FOCUS and PDCA Models

Abstract

This paper will explore how the FOCUS model and PDCA cycle can be used to improve a hypothetical non-medical emergency in a medical setting. The scenario that will be analyzed involves the erratic and inappropriately treated episodes of a possible seizure victim and IV drug user called Mr. X. By examining the problems that led to the issues in this situation, this paper will show how these two models could be used to improve the effectiveness of medical staff in order to deal with a possible psychiatric emergency in a medical setting.

Coping with a Non-medical Emergency in a Medical Setting using the FOCUS and PDCA Models 

A psychiatric emergency in a non-psychiatric environment can be complicated to deal with for staff and physicians in a medical setting. In this hypothetical psychiatric emergency, medical staff is faced with the indecipherable outbursts of a possible seizure victim and IV drug user named Mr. X. The frantic behavior of this patient caused several episodes that were dealt with by an unresponsive and inappropriately behaved group of physicians and medical staff. In order to analyze and improve a situation like this from actually occurring, I will be using the FOCUS model and PDCA cycle to see how a psychiatric emergency can be dealt with in a non-psychiatric setting in a more effective manner.

There were many issues pertaining to the scenario with Mr. X that could have easily been avoided or improved upon. In order to properly improve the given situation in accordance with the first step of the FOCUS model, it is first necessary to designate the problems that needed to be corrected. The most all-encompassing issue in this situation is the neglect and negative attitude that all of the staff displayed in dealing with the patient’s issues. Mr. X is described as having been left in nothing more than “ill-fitting boxers and no shirt” prior to the incident. This was the wrong decision in an ethical dilemma on the part of the staff and physician’s and it could have been very disconcerting for the patient. Mr. X may have felt neglected and being dressed in no more than his boxers could have fed the anxiety that led to the episodes that later ensued. At the very least, proper medical scrubs should have been provided for him right after he was checked in. Mr. X is also described before the incident as having possibly had a seizure before the incident in the hospital. Considering that the patient also tested positive for drugs, he should have had a CT or MRI test to better confirm whether or not he actually had a seizure. This inattentiveness may have directly led to the complications that ensued later on and may have also been a result of his not being administered as a drug user (as opposed to simply being administered as a seizure victim). 

From the moment that Rapid Response was initially called, all of the staff on hand were also both extremely unresponsive and unsympathetic to the frantic and possibly dangerous behavior of the patient. This proved unacceptable in dealing with the situation. Respiratory staff, physicians, physician’s assistants, an ICU nurse, and unit staff all stood around “paralyzed” as Mr. X continued screaming on all fours. It is not clear whether it was necessary for all of the staff who were on hand to be present at that point in the situation. It is also unclear how and in what order each member of the staff should have reacted. Before the patient was hooked up to a cardiac monitor and he was administered oxygen, no efforts were made to calm him down or make him feel more at ease. This only helped escalate the complications that would happen later in the situation. 

When Mr. X suddenly jolts up in a daze, the attitude of the staff was negative and nobody displayed any incentive to help calm Mr. X down. It was inappropriate for the respiratory therapist to respond by expressing disdain towards his job and it was also counter-productive for the nurse to treat the patient with a harsh tone. None of the nurses present added anything positive to the situation by staring at Mr. X and the ICU nurse seemed to assume that his EKG was normal in spite of his behavior and the fact that he had ripped off the EKG monitor from his chest. It was also inappropriate for the physician not to know more about the patient and his condition before the situation took place. When Mr. X finally escaped into an elevator, nobody took the incentive to stop him. He was treated with as much disdain and indifference when he returned to the hospital which only helped to perpetuate the patient's discomfort. Finally, nothing was done to confirm why his chest and head hurt in lieu of his previous visit and medical staff avoided any interactions with Mr. X even more than before.

In accordance with the last steps of the FOCUS model, an appropriate team must be organized to better address the situation and a better plan of action should be constructed by clarifying current knowledge of the process.  First off, there do not have to be as many nurses on hand as there were in this emergency situation, especially if they are not going to contribute in any constructive way. The ICU nurse should have initially responded by being more sympathetic to the patient by making an effort to calm him down and sit in a proper position. This should be done before any of the other staff begin administering any tests. The nurses, in some ways, should be the leaders of the situation by mediating the behavior of the patient while also helping to better understand what needs to be done to control his condition (ie: checking his EKG, etc.). The patient should also be informed about what is being done to him to decrease his anxiety when, for instance, EKG leads are being attached to his chest. 

The ICU nurse asking the patient what “he was seeing” may have also led to him being more anxious by verifying his delusions. The role of the unit staff should be to ensure that the patient is not a danger to himself or the other people in the room. Due to Mr. X's frantic and unpredictable behavior, Unit Staff should have been ready to prevent Mr. X if he were to suddenly get up and leave the room as he did. The physician should have known more about the patient before the emergency occurred in order to better understand his condition. The physician needs to interact and speak with the patient more to gain a better understanding than simply speaking with the nurse. He should also inform the rest of the personnel what needs to be done in accordance with the patient's symptoms and behavior. This puts the physician in the role of avid observer and primary coordinator. The physician did not display any incentive to take control of the situation and he should be the team member with the most knowledge of the patient's condition and the appropriate course to solve it. Based on these findings, I have constructed a cause-effect diagram to understand the causes of the process.

(Diagram omitted for preview. Available via download)

Using a modified version of the PDCA cycle, I will also develop a model to plan, enact, and check that the emergency situation is dealt with using appropriate response times and clinical interventions. When the situation initially occurred, unit staff should have been on hand to surround the doors and ensure the safety of the patient and medical staff due to the patient’s incendiary behavior. Instead of standing still and then going straight into hooking the patient up with EKG leads, the ICU (and possibly one more nurse) should have made sure Mr. X was sitting in a safe position. Furthermore, efforts should have been made to prevent his frantic outbursts by comforting and calming him down first. The patient should also not have been neglected before this episode and he should already have been dressed in proper medical attire. This is when nurses, respiratory staff, and other necessary staff should begin administering the appropriate tests according to emergency protocol. 

There are several ways to check whether or not a chosen process was effective. The most important way to check is to ensure that the frequency and severity of the patient's symptoms and behavior drastically decrease. If the situation has been dealt with in the appropriate manner, the patient should not display any more frequent outbursts and further issues with the patient should not be a direct result of the improper behavior of medical staff. This means that it should be obvious whether or not a patient's symptoms and behavior are a reoccurring issue if medical staff was able to prevent them (ie: the medical staff’s inattentiveness that led to Mr. X’s reoccurring outbursts and erratic behavior). Another way to check if an emergency response system process has worked is to make sure that the medical staff is aware of their purpose and role during the emergency situation at all times. They should be aware when asked what they should be doing to contribute to the situation and if not, they should not be participating. The patient, in the right state of mind, should also be responsible for saying whether or not he was attended to in the appropriate manner and whether medical staff treated them with attentiveness and care. 

Based on my findings, I will construct a unit protocol to help address another emergency situation like the one involving Mr. X. The first directive for the protocol is to make sure that a patient has been attended to and not neglected (based on their specific needs) before an emergency situation takes place. When an emergency situation does occur, each member of the staff should know their proper roles and be present only if they have a specific function to contribute to the emergency. This also means occupying the appropriate area of the room so as not to get in the way of the roles of other medical personnel who do not require their help. Considering that they are aware of their specific duties in the context of a given emergency situation, staff should always act immediately and never be idle. 

In part, this means ensuring the patient is calm and collected in the appropriate manner before tests are administered. This should be the job of the nurse. The physician should not be too far behind in order for them to address the specific needs of the patient in their current condition. It is also very important for unit staff to be on hand in an unobtrusive manner to make certain that the patient is not a threat to themselves or anybody else. None of the staff should jump to conclusions about the patient's well being until all tests and procedures have been completed properly and the patient has been left in a non-threatening condition. Finally, the patient should be acknowledged after the incident to ensure that their condition is agreeable enough to prevent it from happening again in the future.

Conclusions and Future Study

By analyzing the hypothetical emergency situation involving Mr. X using the PDCA cycle and FOCUS model, I have learned many ways that a similar emergency situation could be avoided in the future. These two models displayed the effectiveness of designating, organizing, and executing a given process to cope with a non-medical emergency in a medical setting. Although it can be hard for medical staff to deal with the psychiatric emergency in the context of a hospital setting, the PDCA and FOCUS models showed that a similar situation to that of Mr. X could have been dealt with much more effectively with the help of a finite plan of action.