Environments: Acute Care/Inpatient Psych

Question 1

Acute Care

Answer 1

• generalist
• fast paced, short length of stay
• – limited opportunity to get to know patient
• understanding medical conditions is important
• safety is important
• skilled observation over standardized assessment

Question 2

Acute Care: Intervention Methods

Answer 2

• Preparatory methods
• Rehabilitative/restorative approaches
• Compensatory approaches
• Use of activities, education, training – occupation can be a challenge

Question 3

Acute Care: Patient Navigator for ASD

Answer 3

• Collaborate with multi-disciplinary team
• Educate staff
• Coordination in continuity of care (acute –> inpatient –> outpatient)
• Examine and streamline current hospital processes

Question 4

Inpatient Psychiatry: Goals for Patient

Answer 4

• Safety
• Clarify diagnosis
• Symptom management
• Coordination of outpatient treatment

Question 5

Inpatient Psychiatry: OT Assesses for

Answer 5

• Cognitive impairments that affect function
• Coping skills (stressors, symptoms, coping strategies, values, routines)
• Sensory processing challenges that affect function
• Social and communication skills
• Patient’s goals for hospitalization
• Use the COPM

Question 6

Inpatient Psychiatry: Groups vs 1:1

Answer 6

• need to maximize use of time, cannot see everyone one on one
  Prioritize people for 1:1 sessions:
• Identified as high risk for seclusion or restraint
• Actively experiencing distressing symptoms such as urges to self-injure, PTSD symptoms such as flashbacks, hallucinations, agitation, suicidal thoughts, panic attacks
• Assessment of home safety indicated

Question 7

Inpatient Psychiatry: OT Assessment and Intervention

Answer 7

1. Home Safety Evaluation: MET, EFPT, skilled observation of ADLs
2. Sensory Modulation: educate on strategies to use in and out of the hospital
3. Health and Wellness: coping, communication, reconnect with meaningful occupations, organize and establish routines, wellness recovery action plan/crisis management plan

Question 8

Client Process Through Mental Health System

Answer 8

1. Emergency dept, urgent care center
2. acute inpatient psychiatric unit, crisis stabilization unit
3. residential program, state hospital
4. partial hospitalization program, intensive outpatient program, psychiatric vna, homeless shelter, supportive housing
   - group homes: supervised, partially supervised
   - outpatient supports: psychiatrist, therapist, psychologist, CBFS worker, rehabilitation
   - peer supports: clubhouse, support groups, recovery learning community

Question 9

CBFS workers

Answer 9

• community based flexible support

- i think this is a massachusetts thing

Question 10

Legal Status

Answer 10

• Conditional Voluntary Admission
• Involuntary Admission
• Commitment

Question 11

Being Committed means…

Answer 11

• assisted outpatient treatment
• – lots of support services given outside of the hospital
• home, supported housing to transition between residences, shelter
• does not always mean going to a state hospital

Question 12

Case Study: Sue is a 32 y/o young woman with acquired brain injury & h/o depression, admitted from MGH neurology service for ongoing electroconvulsive therapy to treat catatonia. She presents with cognitive impairments (attention, memory, problem solving, sequencing/organization) , self injurious behaviors (biting self, scratching self with objects) and suicidal thoughts (stating she wants to die).
Interests: Sue has a BS in elementary education and previously enjoyed working as a teacher in a preschool. She enjoys volunteering in her community, crafts (crochet, artwork), and spending time with her nephews (ages 3 & 5) and family.

Answer 12

• IDK

Question 13

Case Study: Sally is a 65 y/o woman with schizoaffective disorder and multiple prior admissions who was brought in by staff at the shelter where she resides on a section 12 due to symptoms of decompensation, including being verbally aggressive/threatening, dressing provocatively, using racial slurs, and making false accusations about staff. She was offered a conditional voluntary, but refused to sign. She reports a history of PTSD due to trauma. She presents with aggressive behaviors including yelling, spitting, and throwing objects, resulting in her being restrained.
Interests: Sally previously worked as a hairdresser, and is interested in fashion and makeup. She loves listening to music (KISS 108, Musicals) and dreams of traveling. She has a granddaughter whom she loves dearly.

Answer 13

• IDK

Question 14

Restraint

Answer 14

• is any manual method, physical or mechanical device, or medication that immobilizes or reduces the ability of a person to move his or her arms, legs, body, or head freely.
• Mechanical: using a device
• Physical: holding the person
• Restraints can result psychological and physical harm to staff and patient, re-traumatizing

Question 15

Seclusion

Answer 15

• is the involuntary confinement of a person alone in a room or area from which the person is physically prevented from leaving.

Question 16

Core Strategies to Reduce Restraint and Seclusion

Answer 16

(1) Leadership toward organizational change
(2) Use of data to inform practice
(3) Workforce development
(4) Full including of individuals and their families
(5) Use of seclusion and restraint reduction tools, including environment of care and the use of sensory modulation
(6) Rigorous debriefing after events in which seclusion and restraint might have been used

Question 17

(A) Trauma Informed vs. (B) Non-Trauma Informed Care

1. Recognition
2. Assessment
3. Hospital Culture

Answer 17

1. Recognition: A - high prevalence of trauma. B - ignorance
2. Assessment: A - find out if history of trauma. B- don’t ask
3. Hospital Culture: A - recognize practices that retraumatize people. B- tradition of toughness

Question 18

(A) Trauma Informed vs. (B) Non-Trauma Informed Care

4. Power/Control
5. Role of Staff
6. Blame

Answer 18

4. Power/Control: A - minimized. B - keys, security, staff demeanor and tone of voice
5. Role of Staff: A - caregivers/supporters = collaboration. B - rule enforcers = compliance
6. Blame: A - violence/conflict arise from situational factors. B - patient blaming is the norm

Question 19

(A) Trauma Informed vs. (B) Non-Trauma Informed Care

7. Behavior
8. Language
9. Center of Treatment

Answer 19

7. Behavior: A - all behavior has meaning. B - behavior seen as intentionally provocative
8. Language: A - neutral language. B - labeling language as manipulative, attention-seeking, needy
9. Center: A - consumer, focus on education, self-management. B - lack of self-directed care, over-reliance on medication

Question 20

Trauma Informed Care - Intervention

Answer 20

• Identify Triggers
• Identify Early Warning Signs of Distress
• Identify Calming Strategies
• – Distraction (I.e. puzzle, art)
• – Sensory (I.e. weighted blanket, listen to music, cold)
• – Support (I.e. talk to RN)
• – Environment
• Ensure understanding by all members of treatment team

Question 21

Understanding Episodes of Distress

Answer 21

Trigger –> Warning Signs of Distress –> Crisis Behaviors

Question 22

Universal Triggers

Answer 22

• enforcing a rule

- being told no

Question 23

Understanding Episodes of Distress:

1. Proactive Approach
2. Reactive Approach

Answer 23

1. preventing triggers, or intervening when you see warning signs
   - understanding and recognizing warning signs allows you to intervene early and prevent a crisis
2. intervening after challenging behaviors occur during a crisis

Question 24

Crisis Intervention and Safety Plan

Answer 24

• make a plan of what to do to prevent crisis before it occurs
• staff is prepared with strategies and knows what to do
• individualized

Question 25

Case Study: Gary is a 33 y/o man with Asperger’s Syndrome, OCD, and depression who was brought in by ambulance. He had been discharged from a state hospital ~10 days prior, and had left his group home after becoming upset about rules and restrictions. He had called 9-1-1 in distress because he was stranded in the cold and had no money to return to his group home. He felt EMS was angry and mistreated him, and so he threw himself in front of the ambulance, which resulted in him being restrained on the way to the hospital. He also presents with self injurious behaviors including head banging, aggressive behavior with objects, threatening posture when in distress, and h/o self injury by cutting. He has a h/o of jail time due to aggressive behavior. Interests: Gary identified exercise as his primary leisure (push-ups, sit-ups, basketball). One of his goals and values is to have a romantic relationship and a family.

Answer 25

- Lower adrenaline levels --> sensory modulation, coping strategies --> de-escalate, bring back to a calm state where he can think clearly --> give time for the adrenaline to leave his system - --- use exercise since that is something he enjoys - Work on developing a plan of coping strategies with him - -- help him to identify triggers and warning signs - -- write out what he can do to prevent crisis - Communication - what is a better way to communicate frustration/hurt than throwing yourself in front of the ambulance? - Refer to outpatient services who can provide further assistance on a regular basis since not everything can be hashed out in the hospital and coping strategies plan will need adjusting as life changes