1 The Difference One Nurse Can Make A dedicated Withdrawal management (WDM) nurse on an adult inpatient mental health unit

2 Withdrawal management program Central LHIN Medically supervised withdrawal management 4 beds Inpatient mental health unit

3 Withdrawal Management Program Elective service Planned admissions Treatment planning group once weekly prior to admission Daily contact with team and WDM psychiatrist

4 The Challenges Multiple inpatient nurses for withdrawal management patients Inconsistent care Varying levels of comfort level/knowledge base re: addiction issues and addiction population Expectations were inconsistently reinforced Frequent “staff splitting” Poor coordination of care High level of conflict between staff and WDM patients Discharges AMA

5 Goals Improve care coordination Reduce AMA discharges Increase patient satisfaction Increase staff satisfaction Increase knowledge regarding withdrawal management and addiction issues in nursing staff Improve relationship between program staff

6 The Intervention One dedicated WDM nurse during the day shift (0730h – 1530h) Monday to Friday Rotate through a period of 6 weeks Manage all WDM admissions and discharges Provide nursing care for all WDM patients

7 The Effects Consistency, predictability Nurse with high level of interest in addiction population Nurse with high and/or increasing level of knowledge base re: addiction issues/WDM protocols Expectations consistently reinforced Daily meetings between team and patient = minimize staff splitting Quality of coordination improved – one “go-to” person on inpatient floor Stronger, more consistent advocacy for WDM patients.

8 Effects on discharges AMA? Pre-implementation period (12 months) 19 discharges AMA Post implementation period (12 months) 14 discharges AMA

9 AMA discharges… 14 discharges during 12 month post implementation period Discharges during evening shift: 5 Discharges during weekend shift: 5 A total of 10 patients out of % of all unplanned discharges occurred when the designated WDM nurse was NOT on duty!

10 Implications Need for dedicated WDM nurse during each shift? Need for dedicated WDM nurse during weekends?

11 Results of Staff Survey: “The quality of care for WDM patients improved since implementing the WDM role on day shift.” 83% of staff agreed “There is less conflict between WDM patients and staff with the implementation of the WDM role.” 83% of staff agreed “It was better when the WDM patients were divided among all staff.” 74% of staff disagreed

12 Comments from staff “There should be a WDM nurse on all shifts” “It should be D/E/N for consistency. It defeats the purpose when (the WDM patients) are split up after 3:30 pm.” “Drug addicts should not be placed with vulnerable elderly patients.”

13 Results from Patient Survey “I like having the same nurse take care of me Mon-Fri during the day.” 93% agreed “I feel more comfortable talking to the withdrawal management nurse about my problems than the regular nurses.” 86% agreed “I am less likely to leave before my treatment is complete if I am under the care of the withdrawal management nurse.” 93% agreed

14 Patient comments “My daytime nurse Liz worked well with Dr. Styrsky. I can’t say the same for evening and weekend staff.” “I feel the withdrawal management was very helpful and helped me a lot.” “On several occasions I didn’t know who my evening nurse was and while sick in bed, I would have to go looking for them.” “While inquiring politely at the nurses station you are usually met with indifference…there seems to be an attitude of “I’m not your nurse.”

15 Concepts and Issues Stigma against addiction/WDM patients Knowledge base re: addiction

16 Review: Implementation of dedicated WDM nurse: an effective solution! Improved quality of care for detox patients Increased patient and staff satisfaction Reduction in AMA discharges

17 Questions

18 The Difference One Nurse Can Make Effects on rates of discharges AMA post implementation of a dedicated Withdrawal Management (WDM) inpatient nurse