By Stacey Kusterbeck
Standardized, evidence-based clinical pathways are an effective approach to combat stigma toward individuals with mental illness in the ED setting, reports Nasuh Malas, MD, MPH, division director and service chief of Child and Adolescent Psychiatry at University of Michigan Health System.
“It is important for EDs to combat this stigma,” stresses Malas. “Everyone inherently has stigma and bias. Our job is not necessarily to eradicate stigma and bias, but to recognize it, and minimize its impact on care.”
Evidence-based clinical pathways reduce variability in practice that can allow stigma and bias to negatively influence care, says Malas. Clinical pathways for the assessment and management of aggressive behavior are one important example, in light of evidence of racial and ethnic disparities in ED restraint use.1,2 “It is also important to consider engaging those with lived experience in developing these pathways to provide unique insights into language use and care delivery,” adds Malas.
Once the ED has clinical pathways in place, along with associated order sets, workflows, and electronic medical record tools, “it mitigates the risk of deviation from best practice,” Malas explains. Emphasis on de-escalation strategies in clinical pathways can reduce inappropriate use of restraints, for example.
Clinical pathways allow ED providers to demonstrate that their decision-making for a psychiatric patient was rooted in evidence-based standards. ED providers also can document the rationale for deviating from the pathway. For example, if a child has a history of good response to a specific medication for agitation, use of that medication may be preferable instead of a medication that the child has never been exposed to before. Alternatively, a medication that is standard of care in a pathway may be contraindicated in a child because of a past allergy, past negative response, or another comorbidity that does not allow for the use of a PRN medication. “The pathway may guide most cases but needs to be supported by clinical judgment to identify those few cases where an alternative to the pathway is warranted, while still following the principles that underpin the pathway,” Malas explains.
By using clinical pathways, “one can minimize how stigma and bias can filter into care delivery. It allows one to be more objective and consistent in how care is provided,” says Malas. Clinical pathways allow the ED to answer these questions:
• Are we completing the necessary steps in care that we believe are standard for a given condition?
• Are we improving the clinical care for individuals by providing this care?
“By creating greater transparency, consistency, and accountability, the risk of significant deviations from standard practice based on stigma and bias can be significantly minimized,” says Malas.
An ED’s overall culture should be welcoming and supportive of individuals with mental illness. “It is important to consider built environment and how that may impact care delivery,” suggests Malas. Fluorescent lights or loud sounds can be overly stimulating or distressing to patients with sensory sensitivities or autism spectrum disorder. It may be possible to mitigate exposure to create a more therapeutic environment for ED patients.
EDs can convey a supportive culture for individuals with mental health issues by displaying posters with resources listed (such as the national 988 Suicide & Crisis Lifeline, or other crisis services in the area). ED staff also can disseminate brochures to educate patients and families about the importance of suicide screening. “Partnering with patients and families in the design of these materials can ensure the messaging is engaging, comforting, and helpful to the populations served in the ED,” offers Malas.
Overall, combatting stigma requires a change in mindset for all ED providers. “Think about how steps in the care process are structured in a way to make patients and families at ease when they are presenting in crisis or in a mental health emergency,” recommends Malas.
REFERENCES
- Carreras Tartak JA, Brisbon N, Wilkie S, et al. Racial and ethnic disparities in emergency department restraint use: A multicenter retrospective analysis. Acad Emerg Med 2021;28:957-965.
- Smith CM, Turner NA, Thielman NM, et al. Association of Black race with physical and chemical restraint use among patients undergoing emergency psychiatric evaluation. Psychiatr Serv 2022;73:730-736.
