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Improving the Care and Management of Behavioral Health Patients in the Emergency Department

Laura M. Cascella, MA

Improving the Care and Management of Behavioral Health Patients in the Emergency Department

Behavioral health issues have escalated in recent years and pose serious public health and patient safety concerns. Nearly 1 in 5 adults in the United States has a behavioral health condition; more than 1 in 10 adolescents report having a major depressive disorder in the last year; and only half of people who have mental illnesses receive treatment.1

One issue in particular has emerged as a top concern for healthcare organizations, providers, and staff members — managing behavioral health patients in the emergency department (ED). The convergence of multiple factors has exacerbated this problem, including the opioid crisis, an uptick in suicide attempts, mental health workforce shortages, and dwindling behavioral health services.2

As a result, EDs are becoming a safety net for many individuals who experience mental health or substance abuse episodes or crises, which has cascaded into problems associated with overcrowding, lack of appropriate treatment, and potential violence. Further, as an article in Health Affairs explains in relation to behavioral health patients, “EDs remain poorly equipped to address these individuals’ needs because of a variety of issues, including regulations, policies, training, culture, stigma, and the lack of integration and connectivity to other settings in the community.”3

Various strategies have been proposed to improve the care and management of behavioral health patients in EDs. Although no single set of strategies offers a perfect solution for all facilities, various recommendations — such as the following — should be considered:4

  • Thoroughly evaluate current protocols for managing behavioral health patients to determine how well they are working and where opportunities for improvement exist. Solicit feedback from healthcare providers, staff members, patients, and family members.
  • Provide clinicians and staff members with ongoing education about behavioral health conditions to raise awareness of the situations they might encounter and their seriousness. The aforementioned Health Affairs article explains that “When behavioral health needs are viewed as ‘other’ and ‘not my job,’ the quality of care and the patient and family experience of care suffer.”5
  • Foster an ED environment that supports the principles of a trauma-informed culture, a concept of the Substance Abuse and Mental Health Services Administration. Examples of these principles include safety, transparency, and collaboration.
  • Educate healthcare providers and staff about available mental health and substance abuse services in the community, and forge collaborative relationships with these resources to improve care and streamline referral processes for behavioral health patients.
  • Use evidence-based guidelines to develop standardized protocols for managing different types of behavioral health conditions and crises. Develop policies related to triage, patient assessment, screening, monitoring, diagnosis, medication and other treatments, referrals, patient and staff safety, etc.
  • Consider the value of using telehealth services (e.g., telepsychiatry) to provide specialty consultation for patients who have complex behavioral health issues for which resources and expertise are not available onsite.
  • When possible, include patients and families in discussions about assessment, diagnosis, care planning, and follow-up. Involving patients and families can help reduce agitation and alleviate feelings of helplessness. The author of an article in American Nurse Today advises “when possible, give patients choices so they have a sense of security and control. Respect personal space and speak calmly.”6
  • Designate a safe observation area for behavioral health patients. Have a trained staff member assess the area for potential environmental risks, such as items that the patient might use as weapons or to inflict self-harm.
  • Determine the feasibility and value of having a separate wing or area of the ED that is designed for behavioral health patients and minimizes visual, auditory, and other sensory stimuli that might agitate patients (e.g., sirens, crowds, and extensive medical equipment).
  • Implement safeguards to prevent elopement from the ED and patient wandering (e.g., door alarms and locks, electronic monitoring, designated gown/sock color for at-risk patients, and diversion activities). Additionally, have protocols in place for quickly responding to missing patients.
  • Train healthcare providers and staff members on strategies for de-escalating aggressive behavior. Consider implementing an emergency response team that can quickly respond if a patient becomes volatile.
  • Conduct drills and simulation trainings to prepare emergency medicine providers and staff members for managing various behavioral health scenarios (e.g., violent patients, suicidal patients, patients who are paranoid or who have hallucinations, patients who have overdosed, etc.)
  • Develop organizational policies related to transferring behavioral health patients to inpatient units, other facilities, or home. Policies should include guidance for coordinating patient care prior to discharge and following up with patients after they are discharged.

Researchers continue to study how to better integrate behavioral health services into the ED and other care settings. Strategies continue to evolve and long-term solutions still need to be identified; yet, healthcare leaders, providers, and staff members can take steps to improve their approaches for managing behavioral health patients. Assessing current protocols to identify improvement opportunities and considering new frameworks and strategies for addressing behavioral health needs can improve quality of care and organizational culture.

Resources

1 Mental Health America. (2019). The state of mental health in America. Retrieved from www.mentalhealthamerica.net/issues/state-mental-health-america#Key; National Institute of Mental Health. (n.d.). Statistics. Retrieved from www.nimh.nih.gov/health/statistics/index.shtml

2 Zeller, S. (2018, July 25). Transforming behavioral healthcare in the emergency department. HealthLeaders Media. Retrieved from www.healthleadersmedia.com/clinical-care/transforming-behavioral-healthcare-emergency-department; Paulus, R. (2017, March 23). Understanding the behavioral health crisis. Hospital & Health Networks. Retrieved from www.hhnmag.com/articles/8149-understanding-the-behavioral-health-crisis

3 Laderman, M., Dasgupta, A., Henderson, R., & Waghray, A. (2018, January 26). Tackling the mental health crisis in emergency departments: Look upstream for solutions. Health Affairs Blog. Retrieved from www.healthaffairs.org/do/10.1377/hblog20180123.22248/full/

4 Zeller, Transforming behavioral healthcare in the emergency department; Paulus, Understanding the behavioral health crisis; Eng, J. (2018, July 26). 3 ways to improve behavioral health in the emergency department. Institute for Healthcare Improvement. Retrieved from www.ihi.org/communities/blogs/3-ways-to-improve-behavioral-health-in-the-emergency-department; Briddon, M. (2018, May 1). To address mental health, EDs should slow down. Institute for Healthcare Improvement. Retrieved from www.ihi.org/communities/blogs/to-address-mental-health-eds-should-slow-down; Dzubak, J. L., (2017, November). Managing mental health emergencies in the ED. American Nurse Today, 12(11). Retrieved from www.americannursetoday.com/managing-mental-health-emergencies-ed/

5 Laderman, Tackling the mental health crisis in emergency departments.

6 Dzubak, Managing mental health emergencies in the ED.

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