The lifesaver bridge

How advanced practice nurses at Massachusetts General Hospital help psychiatric patients go from crisis to finding stability and care

By Linda Wessling
On Call Magazine Correspondent / March 6, 2009
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Say lifesavers and what comes to mind? Perhaps you think of candy or the story you heard on the news about the little boy who saved his mom by calling 911. Or maybe you think of firefighters and paramedics on call 24/7 to handle life threatening emergencies. The term can also be applied to the advanced practice nurses in the urgent and emergent care departments of the Massachusetts General Hospital (MGH) in Boston. These nurses are part of a team of medical staff striving to move psychiatric patients from a state of crisis to one of stability and ongoing medical care.

A collaborative effort

Gail Leslie, APRN, is one of those MGH "lifesavers." Leslie works in the urgent care outpatient psychiatry clinic located in the Wang building of the MGH campus. She sees a wide range of patients who come to the clinic from any number of departments throughout the MGH health system. She works with adults who don't need emergency room care but who can't wait weeks to be seen by someone who can evaluate them and perhaps write them a prescription.

"There are a lot of reasons why people can't wait for an appointment," Leslie says. "Sometimes it's that they're running out of their medicine and that would not be good. Sometimes it's that people really are unstable." She says that because her job goes beyond tending to a patient's immediate needs to helping that patient get into a program of ongoing care, what she and others do is provide a bridge that traverses the gap between urgent care needs and longer-term care.

As an advanced practice nurse, Leslie collaborates with the psychiatrists and psychologists in both urgent and emergent care. She says that collaboration is a critical component of being able to provide high quality treatment. "I learn from [physicians]," she says, "and they learn from me. We are a collaborative team, and that lets us provide better care for people who are often seriously ill."

The urgent care psychiatric clinic gets two kinds of referrals from the acute psychiatry service department (APS) of the MGH emergency department. One is same-day referrals. "That would involve a patient who presents to the emergency room and is triaged. Then, if the patient can safely leave the emergency room, the patient is sent up to the clinic that same day for evaluation and care." The other kind of patient that comes to the clinic from the emergency room is one who has been evaluated in the emergency room but has no immediate follow-up in place. When that patient needs to be seen before a follow-up can be arranged, the referral is made to the clinic. In addition to the patients that come from the emergency room the psychiatric staff in the clinic also see patients referred by primary care physicians who feel they need care sooner than they would get it through the normal referral process.

Another way patients are referred to the urgent care department is through the MGH inpatient psychiatric unit. Physicians in the inpatient unit will sometimes ask urgent care staff "to bridge patients," according to Leslie. "For example, suppose somebody comes in, is admitted, but then when they are discharged, they are not able to get an outpatient psychiatry appointment for a month, even though they really need to be seen within two weeks of being discharged." Leslie says, in that case, the urgent care staff will see the patient.

Deborah Clark, CS, NP, is another MGH lifesaver. Clark works in acute psychiatric services in the ER, rather than in urgent care. Like Leslie, Clark evaluates patients prescribes medication if necessary, and makes referrals for ongoing care. According to Clark, the MGH psychiatric ER department sees more than 250 psychiatric patients a month. Sometimes the patients identify themselves as needing psychiatric assessment, and sometimes they are identified by hospital staff.

"I work out of a department that is staffed by attending psychiatrists, psychiatric residents, psychology interns, resource specialists -- who help us find placement and other resources – and me," Clark says. Clark is commonly involved in triaging a patient who comes in needing psychiatric help. "I go in and do my initial psychiatric assessment," she says. "I order the lab work and I order and needed medication. Sometimes, then, I'll refer them to Gail Leslie and maybe bridge them with a medication to tide them over until they can see her."

Seeing a full spectrum of psychiatric patients

Clark may see several patients in a day. Or, on some days, she may "get wrapped up in one very complicated case." The fact that she works Monday through Friday, Clark says, makes her job easier in some respects. "Because I'm here Monday through Friday," she says, "I get to know a lot of the patients that we see frequently. The residents rotate every three months. So they don't necessarily know [some of the repeat patients] in the way I know them."

Emergent psychiatry is a time consuming process, according to Clark, further complicated by the fact that psychiatric admissions have to be reviewed with insurance companies. That means some patients may have a long wait before they are seen. "If a patient comes in," Clark says, "if they self present and they have some mild anxiety, they may sit there longer than the patient brought in by ambulance who is catatonic or acutely agitated and needs immediate attention. That's often a bone of contention for people."

While the MGH ambulatory urgent care treats only adult patients, the psychiatric ER team sees both children and adults. The types of cases they deal with range from people who need support and parental education to people who are severely psychotic and catatonic to people who are intoxicated, often with unknown substances.

Bridging to ongoing care

After a patient has received psychiatric treatment and has become medically stable, a level of care assessment is done. Psychiatric options are somewhat limited, Clark says. "People can go outpatient, which involves weekly therapy and psychopharmacology. Sometimes they go to a day program, an option known as partial hospitalization." There are also acute residential programs, a higher level of care, that are usually reserved for kids and adolescents, or patients may become inpatients. "That's kind of what we have to work with," Clark says

After the assessment of what kind of care is "appropriate," resource specialists help the MGH psychiatry team find which option is available. But finding the right options isn't always easy. "In other words, someone might be appropriate for a day program," Clark says. "But if we can't find anything and the patient's not comfortable going home or at too high a risk not to get services, then we see if the patient might agree to a voluntary hospitalization."

The process of getting a patient to the right services is highly collaborative, Clark says, not just within the department but between departments. For instance, urgent ambulatory care and ER staff may check in with each other about issues. In addition, Clark says, "We often refer to Gail if a patient is in need of more urgent psychopharmacology. And then Gail will either start a medication or follow up with what we started and see the patient until the patient's more stable."

For the past seven years, according to Leslie, MGH Urgent Care has offered services to primary care physicians who want their patients to be seen by the psychiatry department. "We bridge them -- as opposed to sending them to the emergency room -- because they can't wait a month for an appointment." At the same time, Urgent Care continues to provide psychiatric services to patients referred from the ER. "I think," Leslie says, "our priority was to try to help with the emergency room because we know how crowded emergency rooms are." However, over the past year, two half-time psychiatrists have been added to the urgent care team. This has made it easier to provide the primary care doctors with timely access for their urgent care patients. "In addition," Leslie says, "the primary care docs are able to call us, both me and the two psychiatrists I work with, for consultations around psychiatric medications."

A wealth of experience

Both Leslie and Clark came to MGH with years of nursing experience in a variety of fields. Clark, who has experience as a research clinician at McLean Hospital in Belmont, Massachusetts, says she "fell" into this field about 15 to 18 years ago when Mass General was doing a pilot program to become part of a community based emergency screening team for Mass Health recipients. "I went out to the community and established a team at North Shore Medical Center very similar to the ER team at MGH Boston," Clark says. "I then came back to Mass General a year and a half ago and resumed doing straight clinical work."

Clark says her experience has been to see psychiatry "on a biological or medical basis and treating the illnesses in that manner versus approaching them with just straight psychodynamic interpretations. So having that biological basis and being interested in psychopharm and doing the emergency stuff I got to combine all three and I feel really lucky because I love what I do."

Leslie has been dong psychiatric nursing for over 25 years. "When I came to the hospital I developed a scope of practice with physician supervisors who review and [sign off on] my work," Leslie says. "There is a credentialing committee within Mass General and then you meet regularly with an MD supervisor. You also are involved with the department of nursing so certainly there is a lot of continuing education," she adds. "There are many good parts of my job. I enjoy the challenge of seeing acutely ill people and trying to help them through the crisis they are in. I enjoy helping people stabilize. I also enjoy the collaborative nature of the practice with the psychiatrists and psychologists and nurses within the system. I think those are probably the things I enjoy most."

Then she adds, "But I also enjoy the challenge of seeing many different kinds of people, many different kinds of diagnostic categories, many different kinds of human situations that people have. And I like being able to help people get through the crisis situation and do better. I have a great sense of satisfaction. It's both challenging and very satisfying."

Linda Wessling is a freelance writer and frequent contributor to On Call.

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