HCE600 - Week 7

Case StudyTurn the page...

Page 1

In 2023, Sam Smith brought his 13-year-old son, Charlie, to the emergency department of Longmont Hospital at approximately 3:30 in the afternoon. At the time of admission, Charlie was in the midst of a severe mental health crisis. He was aggressive and combative, and his only form of verbal communication was screaming. After numerous other interventions failed to calm him, ED staff were forced to physically restrain him to allow the administration of sedating medications. Once Charlie was behaviorally stable, the ED physician learned from Mr. Smith that, at an early age, Charlie was diagnosed with a severe form of autism spectrum disorder. His condition was so severe that he required substantial support, even when not in an escalated behavioral state.

Page 2

Mr. Smith was cooperative and compassionate throughout Charlie’s initial admission, and he provided the ED physician with a plastic bag containing all of Charlie’s medications. He also gave the nurses a small bag of Charlie’s clothes, and explained to them that Charlie is frequently incontinent and would likely need at least one change of clothes during his stay. He shared with the doctor that Charlie’s mother was unable to handle her son’s behavior and medical needs. Neither he nor Charlie had seen or heard from her for more than three years. Mr. Smith also told ED staff that he was Charlie’s sole caregiver. No other family members were able to handle the complexity of his son’s conditions and, over the years, friends had all but disappeared from their lives.In addition, over the past three months, Mr. Smith had missed long periods of work due to Charlie’s escalating behavior. He frequently has had to leave work early to pick-up his son from his day-treatment when his behavior was out of control. Mr. Smith shared with Charlie’s nurse that he had been fired from his job last Tuesday due to his absences and early departures from work.

Page 3

By 7:45 p.m., Charlie was calm and settled enough to watch his favorite TV show on Mr. Smith’s cell phone. Mr. Smith requested food for Charlie and helped to ensure that his son consumed the full meal. He asked Charlie’s nurse if they could help him place Charlie in an inpatient mental health facility so that his son could receive the necessary care and treatment. Mr. Smith then left Charlie’s hospital room to use the restroom.At 8:25 p.m. Charlie walked out of his patient room and began to wander through the ED, looking into other patient rooms and opening doors as he passed them. He then walked into the back area of the nurse’s station and positioned himself with his back against a wall. Rocking side-to-side, wide-eyed and breathing heavily, it was evident to a nearby nurse that Charlie’s behavior was likely to escalate quickly.

Page 4

The nurse was successful in getting Charlie back to his room. She stayed with Charlie while other nurses and ED techs looked for his father. Two hours later, Mr. Smith still had not returned to Charlie’s room. The ED charge nurse asked security to look in the cafeteria and other waiting areas for Mr. Smith, and she asked the communications manager to page him overhead. Phone calls placed to Mr. Smith’s phone went straight to voice mail.

Page 5

By the next morning, while still prone to behavioral escalations, Charlie was considered medically stable and deemed appropriate for discharge to home. The ED case manager had prepared a list of referrals to other facilities for Mr. Smith to explore as options for Charlie upon his discharge. A member of the hospital staff had been assigned to sit with Charlie in his room until Mr. Smith could be reached. As of lunchtime, Mr. Smith still had not returned to the hospital and he had not called the ED despite numerous voice mail messages asking him to do so. With no next of kin listed on Charlie’s medical record, hospital staff were left with an unclear discharge plan.

Page 6

Approximately 46 hours after his admission to the ED, a local county human services case worker agreed to take custody of Charlie. However, when she arrived at the hospital, he was in another episode of severe behavioral escalation which required another round of physical and chemical restraint. Given his behavior, the case worker refused to take him with her saying that he was currently safe in the ED. She said she has three other children currently living in the county welfare offices and that Charlie would pose serious risk to them given his combative behavior. Three more days passed, and the case worker told ED staff that it would likely be weeks before Charlie would be placed in an appropriate facility as residential treatment options were limited for children with complex behavior health needs. Nearly two months later, Charlie was still living in the ED awaiting transfer to an appropriate pediatric mental health facility.

Page 7

This case study identifies several interconnected issues: • ED staff are equipped to deal with even the most severe medical issues quickly and efficiently. They are not trained to manage several mental health issues extending beyond the initial stabilization. The quality of care is compromised in the absence of appropriate resources to meet patient mental or behavioral health needs. • At a time when nursing staffing is very limited, patients such as Charlie consume a significant amount of nursing time, the consequences of which is further depleting already stretched nursing resources needed to care for patients with medical emergencies. • When patients such as Charlie occupy a bed in the ED, patients who require medical stabilization are forced to sit in the waiting room until another bed becomes available. This extends wait times and significantly decreases patient satisfaction. • Reimbursement for caring for patients such as Charlie does not cover the actual costs of care. Furthermore, it has become more common for family members to leave their relatives (of any age) in the ED when the physical demands of care become too great. • Without an adequate mental or behavioral health infrastructure, hospital leaders have few options but to provide care for such patients. This further stretches limited healthcare resources and places serious physical and emotional stress on ED staff.

Page 8

Now that you’ve read through the case study, visit our Yellowdig Learning Community to discuss this case. • As a future healthcare leader, what would you do in this situation? • What are the values, principles and logistics involved in the care of patients like Charlie or others who need mental or behavioral health services? • What else are you thinking about after having read this case?

Federal and state-level family medical leave statutes are relevant here. Federal FMLA laws require employers to offer job-protected leave from work for family and medical reasons. Mr. Smith's employer may have offered leave as an option given the circumstances. However, FMLA does not protect workers from termination for repeated, incremental absences from work. Question to ponder:

1. What ethical obligations exist for Mr. Smith's employer in supporting him to care for his son who has complex mental health issues?
2. In way ways do these ethical obligations create competition with the company's ability to operate a well-functioning business?
3. If you were a healthcare leader in this situation, how might you resolve this conflict of values?

Hospitals across the United States are faced with the same or similar issues. Here is another news story detailing the scope and magnitude of this problem: https://boulderweekly.com/news/the-ones-we-leave-behind/

In this case study, Charlie is subjected to both physical and chemical restraints. Relevant regulations include: Colorado Code of Regulations Department of Public Health and Environment 6 CCR 1011. Health Facilities and Emergency Medical Services Division Chapter 2. General Licensure Standards Part 8. Protection of Clients from Involuntary Restraint or Seclusionhttps://www.sos.state.co.us/CCR/GenerateRulePdf.do?ruleVersionId=10855&fileName=6%20CCR%201011-1%20Chapter%2002