Educating ED staff to care for psych patients
TJC issues sentinel event on suicide in EDs
In its latest sentinel event alert, issued Nov. 17, The Joint Commission calls attentions to preventing suicide risks in the emergency department and medical/surgical unit and recommends educating clinicians, noting that many of these suicides are committed by patients who had no prior psychiatric history.
Hospital Peer Review spoke with two experts about treating psychiatric patients in the ED setting: Lauren Ball, MSW, LCSW, BCD, administrative director, youth services and social services at Loma Linda University Behavioral Medicine Center; and Michelle Buckman, RN, MSN, psychiatric clinical nurse specialist working as a consultant to Loma Linda's emergency department.
Ball sees movement in the regulatory arena on standardizing and educating hospital staff about dealing with patients who have psychiatric disorders. The industry continues to "see that suicides in hospitals are still one of the top sentinel events," Ball says. "As long as those statistics are there, then we are going to be expected, as an industry, to do better, and we need to do better."
The Joint Commission's National Patient Safety Goal 15.01.01 requires hospitals caring for patients with emotional/behavioral disorders to identify those at risk of suicide. (See the alert for EPs related to the goal: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_46.htm.)
Both Buckman and Ball note that the industry is moving away from using what was once the traditional form of de-escalation restraints and seclusion and using assessments and patient preferences to find better ways for stabilization; it's something they both agree with. Restraints are a "plain out physical risk for the patient, never mind the re-traumatizing of someone who is already scared," Ball says. Ultimately, she adds, you have to try everything and chart everything, with a "whole tool box of things" to de-escalate before using restraints and the rules surrounding them.
"I see a lot of indifference to psych patients" in the ED, Buckman says in part, because staff are scared or think, "'Oh brother, here comes Joe again. He's going to act out...' They don't understand mental illness. They think he is acting out on purpose to make your day bad. " And in an ED where multiple complex situations demand priority, the thought may be to keep Joe quiet and out of the way in order to treat patients who seem more urgent, such as a car crash victim. A patient in an aggressive stance puts staff on the defensive and gets them riled up, she adds.
"I've had to do a lot of education," she says. "I think it has helped them to learn mental illness is really a disease. Joe coming in and acting out is really a symptom of all the problems that are going on or the abuse that he's had or the voices in his head." Or staff may see a kid, who may look like a gangster, in an aggressive stance and think, "We're going to have to tie this kid down," when, as Buckman says, if you sit and talk with him for a minute and validate his feelings, it can de-escalate the entire situation.
"It's very difficult, no matter your level of skill, to manage the patient in a way that's safe for them or other patients," Ball adds. For instance, with a patient who has not taken his medications and is hearing voices and thinks you are part of the CIA and trying to kill him, you may not be able to reason with him in that state. Those are challenging situations, she says.
Buckman says the priority for nurses in the ED is simply to stabilize the patient and not try to treat or gather a comprehensive history. Often, she'll tell nurses, "You just help me with vital signs and getting the patient in the bed.
"Sometimes they could do a lot better job, though, if they had some better understanding of the psych patient. There are some days that they really don't have to ignore the patients the way they do or they don't have to get out restraints as quickly as they do... [Their role] is pure stabilization and not really any treatment or any attempt to help the patient discover their own triggers or their own coping skills."
Buckman and Ball admit they are lucky to have a psychiatrist who visits patients in the ED and note that many smaller or rural hospitals might not have the same resources internally, or the closest psychiatric unit may be 150 miles away for possible transport. Buckman says one hospital she's familiar with is training its paramedics in mental health and certifying them so they can complete mental health screening exams in patients' homes. Ball says some hospitals are thinking about tele-psychiatry or working with their state's mental health department or private psychologists in the area who can be on call if needed in the ED. Some hospitals are doing "really creative things," Buckman says.
As community resources for psychiatric patients become backlogged and financially tied, more of these patients search out the ED for help, Ball says. Sometimes, Buckman says to her ER nurse, "Who will die faster? Your patient having a heart attack or your patient who shoots himself in the head with a gun? You know, if they are going to be dead in a few seconds, either way you look at it, both of them need emergency care really, really fast. Dead is dead." And Ball concurs. She says staff must understand that patients with behavioral or mental issues in the ED are in crisis, too. "[T]hey are not something that is getting in the way of your business; that is your business," she says.
In its latest sentinel event alert, issued Nov. 17, The Joint Commission calls attentions to preventing suicide risks in the emergency department and medical/surgical unit and recommends educating clinicians, noting that many of these suicides are committed by patients who had no prior psychiatric history.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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