Managing behavioral health risks in the emergency department

Solveig Dittmann, Senior Risk Specialist, Coverys - Print  | 

Few work environments are as hectic, complex, and rapidly evolving as a hospital emergency department (ED). When you add behavioral health issues into the mix, that environment becomes exponentially more challenging – at times, even chaotic and violent.

The healthcare industry still focuses most of its time and resources on improving treatments for physical health issues. Meanwhile, psychiatric admissions in EDs have reached an all-time high as the number of beds available for psychiatric inpatient services has dwindled due to changes in reimbursement for these services and other funding cutbacks. According to the Healthcare Cost and Utilization Project (HCUP), about 1 in 8 ED visits in the U.S. are for treatment of mental health or substance use disorders. The opioid abuse crisis has exacerbated the situation.

Unfortunately, most EDs are not fully prepared to manage behavioral health patients.

Most simply don’t have the training, the staff, or the space, and many lack accurate, timely triage protocols for patients with psychiatric issues. These deficiencies can lead to inaccurate assessments, inadequate care, and as a result, deterioration of the patient’s symptoms and behavior escalation.

Maintaining a safe environment while treating behavioral health patients is an uphill battle for EDs not properly equipped. Exacerbating the issue is that many organizations have not standardized medical screening exams for psychiatric conditions. These risks are further compounded by the lack of available inpatient psych beds to transfer patients. As a result, psychiatric patients are often boarded in EDs for several days while awaiting placement. This leads to overcrowding, which leads to more noise and chaos, which can lead to behavior escalation – and an increased risk of someone getting hurt.

How can EDs maximize safety and minimize exposures?

First, ED providers need more staff training on how to manage behavioral health patients and psychiatric emergencies. This should start early, with greater emphasis on behavioral health treatment in emergency medicine residency training, more questions on the emergency medicine board exam, and more continuing medical education (CME) courses focusing on intervention in psychiatric emergencies.

Ideally, all EDs and community EMS personnel should use a common triage protocol. Then EMS personnel could screen patients in route to the ED and give ED personnel the patient’s BARS rating prior to arrival. This common language would allow the ED to prepare for the patient according to his/her symptoms.

But those are ideal circumstances and are not current realities. Maintaining safety and minimizing your exposures is the real world, right now. So, what can you do? Here are five key steps:

1. Chart a clear course. Get the hospital administration and ED staff together to craft a clear, step-by-step plan of action for handling behavioral health emergencies from time of admission. Develop a predetermined code that is announced over the communications systems to let staff know when there’s an event that requires assistance.

2. Train and educate. All ED staff (including security) should be trained in crisis intervention and de-escalation techniques. The Crisis Prevention Institute provides gold standard training, and the American Psychiatric Association and the National Association of Mental Health have several resources for evidence-based suicide risk assessments.

3. Become proficient in mental health assessment. A complete physical and emotional assessment of the behavioral health patient is a must because there may be other underlying physical issues to be treated. Be an excellent listener. A few minutes of communication can keep an event from spiraling out of control. Train your team to perform a Suicide Risk Assessment early on. If a patient is suicidal, one-on-one care is needed. Staff this with a trained mental health nurse or technician if possible. You must also reconcile the patient’s medications because behavior will deteriorate if the patient’s routine psychiatric medicines are missed.

4. Create a safe environment. If possible, remove agitated patients from the chaos of the ER and take them to an environmentally safe, secure room or suite with trained emergency staff to de-escalate the situation.

5. Foster self-awareness. When dealing with an agitated or aggressive patient, there should be only one agitated person in the room. Train staff to always remain calm, maintain professional composure, and use de-escalation techniques. Use restraints only as a last resort, and follow guidelines from your organization and from the Centers for Medicare and Medicaid Services (CMS). Many untrained staff members may have resentful attitudes toward these patients. Remind staff members that for many of these patients, the ED is the only way they can access care. Strive to overcome mental health stigmas with training.

Failing to develop a solid strategy for managing behavioral health and psychiatric emergencies in your ED is a prescription for disaster. It can also expose you to medical professional liability claims, and that’s an emotional and costly complication you don’t need.

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