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Treating, not boarding, mental health patients in emergency departments

Emergency departments across the nation have been challenged by rising volumes. ED crowding is exacerbated by the increase in the number of patients with mental disorders, substance abuse problems or both, who present with acute problems. Besides the mental health conditions such as schizophrenia, mood disorders, anxiety disorders, alcohol and drug disorders and intent to self-harm, these patients often have other medical problems including diabetes, liver disease and various infections.

Our experience in EDs has found some consistent issues that affect patient care and throughput. While the balance of these issues varies in different hospitals and localities, they are fairly consistent issues. These can include (1) lack of standardization of care relative to mental health patients; (2) lack of resources during peak times; (3) concerns related to maintaining a safe environment; (4) lack of space tailored to the needs of this population; (5) discharge planning issues; and, (6) staff frustration and concerns about their safety. In addition, mental health patients have expressed their concerns about how they are treated. They want to be able to talk with providers about their problems without stigma and without being "written off as a psych patient." They want their right to give input on their care to be acknowledged, especially when they are competent to make decisions.

How to address these problems may depend upon the size of the ED and the number of mental health patients who present, as well as the post-ED mental health resources that are available in the community.

Building a set of solutions
Often, these issues get discussed without a clear direction, plan or commitment to fixing the problem. While we agree that the problem as a whole can be overwhelming, breaking the problem into components, each of which contribute to fixing a component of the situation, provides a framework for improving the overall situation. Incremental change is more appropriate to addressing the reality than hoping for transformative change.

Because no one observes the problem more often than those involved, it is useful to meet with the ED staff to listen to their concerns and observations. The staff should appreciate the sentiment of "we want to hear your concerns" from hospital leadership. After staff members are allowed to vent, they need to be involved in sorting out the issues. The focus and challenge will be to use data to validate staff's observations and understand the factors that contribute to the overall problem. Data such as staff turnover, patient satisfaction, throughput times and safety data specific to ED visits should be gathered to build an objective picture of the status quo.

Gaining support for change will require that there is a sense of urgency in developing a plan. The project team will need expertise in the care of mental health patients — this may be a challenge for hospitals that do not provide inpatient or outpatient mental health services. When possible, this group should include stakeholders from the community that provide mental health services. The project team needs to have clear expectations about building a solution set, rather than looking for one silver bullet and about the importance of initiating some changes quickly. Like most change initiatives, finding some quick wins builds momentum and confidence that real improvement can be achieved.

The importance of a well-prepared ED
The care needs of these patients should be the driving focus of the initiative. An ED that is well prepared for managing mental health patients can address the needs of these patients with less stress. For example, learning to use tools, such as suicide risk assessment, reduces staff uncertainty by enabling nurses to consistently evaluate the degree of suicide risk in a way that can be linked to standardized plans of care.

Once staff members know how to use the tools available to them most effectively, the next component of preparedness is to ensure that the staff is trained to work specifically with this population of patients. Staff members must be aware that while these patients may differ from other ED patients in their behavioral responses and decision-making, some of these patients are able to participate in their care. Training caregivers to assess patients' adaptive abilities so they can interact effectively and safely goes a long way toward reducing potentially disruptive and unsafe behaviors.

Improving care and safety
De-escalating dangerous behaviors by decreasing unnecessary stimulation can be an important opportunity for improving care and safety. While EDs often have protocols for managing patients with strokes, trauma and heart attacks, few EDs plan how they will care for patients who present with mental health issues. Perhaps the absence of life-threatening symptoms drives the difference, but quickly assessing patients and providing them with appropriate treatment can better address the needs of the patient and improve patient safety. Developing guidelines such as triage standards specific for mental health patients and medical clearance expectations that are consistent in assessing and treating patients will help staff to feel competent in their ability to provide good care to patients with mental health issues.

Additionally, carving out space for a small, contained area connected to the ED can provide a quieter setting. After patients are medically cleared, they can be placed in the special area. Because these are ED patients, an ED physician is still responsible for these patients. However, these patients can and should be treated while in this area, not just housed there. We recommend that the staff for the area include a psychiatric RN, mental health staff (behavioral health techs), and a social worker; security may also be required on an as-needed basis. The staff's primary goals should be to assess the patients, consult with the on-call psychiatrist for treatment modalities, support the patient and family, and maintain a safe and therapeutic environment. Furthermore, the social worker will also work on disposition issues.

Assessment and disposition are common delays in ED care. When hospitals use staff who are part of the local community-based system, hospitals may be able to expedite disposition by having an ED case manager work on finding a post-ED care location while the assessment staff work on documentation and coordination with a psychiatrist. In some areas, to ease the burden of providing screeners, government agencies contract for screeners. The problem with this approach for the hospital is the loss of control over the timing of the care process. Depending on a number of factors, some hospitals might consider weighing the benefits of relieving the problems with the cost of hiring behavioral health staff members that are licensed to assess patients in a timely manner. These staff can consult with a psychiatrist to make decisions about placement and treatment modalities for all patients. Some hospitals have mental health staff on duty in the ED during peak times, while others may have staff on call. This allows the ED staff to focus on providing care in collaboration and support of a trained mental health professional.

Due to delays such as waiting for bed space in hospitals, placement in the community and the need for transportation, hospitals need to begin treating patients while they are in the ED. That means beginning an initial treatment plan before the patient leaves the ED. We don't delay treating patients when they are being transferred to medical facilities, so mental healthcare should not be different. In addition, starting treatment can reduce risks to both the patient and staff. To do this safely, the hospital will need to develop protocols with treatment facilities to begin appropriate treatments as soon as a sufficient assessment is completed.

Commit to a plan to achieve positive changes
Positive changes in the treatment of mental health patients in the emergency department cannot occur until the hospital's leadership commits to fixing the problems at hand. The plan for improving patient care should involve including staff in the process, creating a safer environment, providing resources to standardize care, collaborating with other stakeholders and meeting regulatory expectations. Use data to direct the organization in the development of the plan, and divide the problem into components that can be addressed individually, which allows for faster implementation, a more timely realization of benefits and a more efficient use of resources. These quick wins build momentum to keep the staff motivated. The development and implementation of a plan will demonstrate to staff, patients and families that the organization is committed to improving care for every patient in the ED and creating an environment that is safe for all.

Issach Abraham, MSN, RN, is a senior consultant with Compass Clinical Consulting. Prior to joining Compass, Mr. Abraham worked as a director of behavioral health at a nonprofit hospital. He has co-authored a publication on organizational changes in psychiatric hospitals and has been an invited speaker at numerous conferences, where he presented on topics of patient care in the field of behavioral health. A registered nurse, he holds a Master of Science in Nursing from the University of Virginia and a Bachelor of Science from Virginia Commonwealth University.

Dr. Cary Gutbezahl, president and CEO of Compass Clinical Consulting, has a diverse background in hospital, medical group and managed care settings, as well as the strong knowledge base and skill set to redesign work to create safer, more reliable care. In addition to consulting work, he has worked as interim CMO for several hospitals and health systems, where he led major change initiatives in case management, leading to reductions in length of stay and introducing a culture of safety and professional accountability. He has also served as a physician mock surveyor to prepare hospitals for regulatory surveys. While Dr. Gutbezahl was on active duty in the U.S. Navy, he was Head of the Quality Assurance Department of the Navy Medical Command, National Capital Region, in Bethesda, Md. He is board certified and completed a laboratory medicine residency and an immunohematology fellowship at Washington University in St. Louis.

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