6 Tips for Treating Psych Patients in the Emergency Department

Posted on Tue, Sep 29, 2015
6 Tips for Treating Psych Patients in the Emergency Department

By Megan Medina RN, MSN, ENP
The rate of mental illness emergency department visits has increased 28 percent from 2006 to the most current statistics available from 2010, according to the Agency for Healthcare Research and Quality. There were more than 6 million mental health visits in 2010, and the trend only seems to be rising.
There are many challenges when caring for the mental health population. The following are what I consider to be most important.

  1. De-Escalation: For a significant portion of the time, mental health patients are agitated. These frustrations can be due to being out of medication, substance abuse, lack of resources, or even a physical problem. Regardless, this population should be de-escalated as quickly as possible. Preferably, verbal techniques to de-escalate are recommended first, but should the patient become combative and potentially harm themselves or staff members, chemical or physical restraints might be necessary. Should it come to that as a last resort, please make sure your institution is following the guidelines set by The Joint Commission and Centers for Medicare and Medicaid Services.

  2. Respect and Dignity: Provider and staff attitudes will affect the outcome of mental health patients. Often, there is a sense of hopelessness with these patients, and being rude or ignoring them may lead to agitation or aggression. This population is human, too, and deserves to be treated with respect and dignity. They should be allowed to participate in decision making (when appropriate) and above all, feel like they are in a safe environment. A negative attitude by staff members surely will lead to a negative impact on the care of the mental health patient.

  3. Safety: Staff should never feel threatened, and there should be guidelines in place if the mental health patient is beyond their control. A mental health patient who is expressing harm to himself or others should be kept safe by removing the patient’s clothing and providing paper scrubs or a gown. All belongings, including cell phones, cigarettes, lighters, wallets, etc., should be secured by staff members. It’s our responsibility to keep them from further harming themselves or others.

  4. Medical Clearance: Medical clearance is a term that’s been around for years. It deals with making sure people don’t have a physical or metabolic illness that could be perpetuating a mental illness exacerbation. Any provider knows the routine when a mental health patient comes in: tests are ordered and reviewed, the box is checked that they are medically cleared, and the hunt for a psychiatric facility begins. It’s important to remember that medical clearance means there is no acute problem, but does not ensure that there won’t be physical or metabolic problems at some point. Also, treatment for an acute psychiatric emergency shouldn’t be delayed because laboratory data is not completed. Please refer to the American College of Emergency Physicians for more information.

  5. Overcrowding: Overcrowding is becoming more prevalent as more people are seeking psychiatric care in emergency departments. Lack of primary psychiatric care and the decreasing amount of available inpatient psychiatric beds contribute to the overcrowding problem. This poses many risks not only to patients but to providers and staff. Also important to mention, the longer an emergency department “holds” mental health patients, the more substantial the financial impact. Many facilities are getting creative with mental health patients by providing psychiatric telemedicine and specialized mental health training for providers and staff.

  6. Handoffs: Lastly, as the overcrowding trend continues, patients will be staying longer in our emergency departments, sometimes several days. Providers and staff will rotate in and out. To ensure the continued safety of patients and staff, guidelines must be in place for an appropriate handoff of care. Each staff member involved with the care of the mental health patient should communicate effectively why the patient is there, any medical intervention, risks to self or staff, and plan for the patient. 

It’s important to have an open dialogue with your staff about caring for psychiatric patients to ensure everyone’s safety.

Megan Medina RN, MSN, ENP, is the as the Lead Advanced Practice Provider (APP) for EmCare’s West Division. A board-certified family nurse practitioner, Medina also is Lead APP for emergency medicine and hospital medicine service at the University of Texas’ Medical Branch at Galveston.

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