Magazine article American Nurse Today

Managing Mental Health Emergencies in the ED: Safety and Continuity Are Key to Successful Care

Magazine article American Nurse Today

Managing Mental Health Emergencies in the ED: Safety and Continuity Are Key to Successful Care

Article excerpt

WITH NEARLY ONE in five Americans (approximately 10 million people) suffering from a mental illness, emergency departments (EDs) are facing an unprecedented challenge. Psychiatric admissions are at an all-time high, and inpatient beds for patients with psychiatric disorders are in high demand. Delivering optimal care to those with mental health emergencies is a complex challenge that requires evidence-based, streamlined protocols and policies. Staff also should be provided with the education and resources they need to feel empowered to care for these patients.

Standardized plans of care that prioritize safety, continuity, and quality should be the focus of mental health care in the ED, whether you're in a 10-bed ED or a 100-bed trauma center.

Where to begin--Triage and medical clearance

Psychiatric emergency care begins with accurate, timely triage using the emergency severity index, an algorithm that stratifies patients into groups, from 1 (most urgent) to 5 (least urgent). During this process, the ED nurse combines both clinical judgment and emotional connections to assess the patient's situation to identify possible mental health issues. Hospitals should have policies in place for patients who have psychiatric signs and symptoms. Policies include continuous monitoring, risk assessments for domestic violence and suicide, and precautions to prevent elopement--wandering away from the facility.

Know that many medical conditions, including encephalopathy, infections, and medications, can cause reversible psychiatric symptoms. To rule out medical causes, proper clinical assessments, physical exams, and pertinent laboratory work should be completed. However, these evaluations take time, so you should be familiar with your hospital's policies on medical holds. Typically, physicians can place patients on a medical hold to prevent them from leaving the hospital until medical tests have been completed to rule out organic causes of their symptoms. This differs from an application for emergency admission, referred to in some states as a "pink slip." This legal hold can be placed by physicians or law-enforcement officers if the patient is believed to be at substantial risk of physically harming him- or herself. It's legally binding and can be overturned only by a physician or judge.

Safety first

Patients may feel a loss of control when they come into the ED, which can lead to agitation, so make them a part of their care plan whenever possible. The Emergency Nurses Association (ENA) recommends treating patient agitation as if it's "the chest pain of behavioral emergencies." Promptly share your assessment of rapidly escalating situations or increasing agitation with the treatment team.

Take agitated patients out of public spaces and to a secure room with trained emergency staff. The room should provide a safe environment for the patient to help de-escalate the situation, with nothing that might be used as a weapon or increase the patient's agitation. A collaborative approach to de-escalation that includes the patient is recommended. For example, when possible, give patients choices so they have a sense of security and control. Respect personal space and speak calmly.

The ED team should try every measure available to avoid resorting to physical restraints. However, if restraints are required to ensure patient and staff safety, follow your organization's guidelines, including timeframes for reassessment and specific nursing documentation.

Behavioral health emergencies can be frightening and overwhelming for both patients and staff. Developing a standard for safety protects everyone. (See Steps to safety.)

Barriers to providing care

Fear, lack of resources, and inadequate training are all reasons ED staff give for their apprehension about caring for patients with psychiatric conditions. For example, some staff report being abused by patients, even to the point of physical injury, which makes them wary in future encounters. …

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