Treating Patients with Mental Health Issues in Emergency Departments
Mental health issues are among the most common reasons for people to seek emergency care. According to the American College of Emergency Physicians, one in eight emergency department (ED) visits in the U.S. is related to a mental disorder and/or substance use issue, and these visits increased by more than 44% between 2006 and 2014 . However, many EDs are not well-equipped to provide adequate and timely care for patients with mental health needs, resulting in long waits, poor outcomes, and dissatisfaction for both patients and staff.
In this blog post, we will discuss some of the challenges and solutions for treating patients with mental health issues in EDs, based on the latest evidence and best practices from various sources. We will cover the following topics:
– How to triage and assess patients with mental health issues in EDs
– How to create a suitable environment and staff education for mental health care in EDs
– How to collaborate with liaison psychiatry services and other multidisciplinary services for mental health care in EDs
– How to manage frequent attenders and care plan management for mental health care in EDs
– How to evaluate and involve service users in mental health care in EDs
Triage and Assessment
The first step in treating patients with mental health issues in EDs is to identify them and assess their level of risk, urgency, and need for care. This can be done by using a standardized mental health triage tool, such as the Emergency Triage Education Kit (ETEK) , which assigns patients to one of five categories based on their presenting problem, behavior, and vital signs. The categories are:
– Category 1: Immediately life-threatening
– Category 2: Imminently life-threatening or important time-critical treatment
– Category 3: Potentially life-threatening or situational urgency or severe discomfort or distress
– Category 4: Potentially serious or situational urgency or significant complexity or severity
– Category 5: Less urgent or situational urgency or uncomplicated
The triage category determines the maximum waiting time for the patient to be seen by a clinician, as well as the appropriate location and level of observation for the patient. For example, category 1 patients should be seen immediately in a resuscitation area with continuous observation, while category 5 patients can wait up to two hours in a waiting area with intermittent observation.
The triage process should also include a brief screening for mental health issues, such as suicidal ideation, psychosis, substance use, or cognitive impairment. This can be done by using simple questions or validated tools, such as the Patient Health Questionnaire (PHQ-9) for depression, the Alcohol Use Disorders Identification Test (AUDIT) for alcohol use, or the Mini-Mental State Examination (MMSE) for cognitive function. The screening results can help identify patients who need further assessment by a mental health professional or referral to a specialized service.
The initial assessment of patients with mental health issues in EDs should be done by a clinician who has adequate training and experience in mental health care, such as an emergency physician, a psychiatric nurse practitioner, or a psychiatric social worker. The assessment should include a comprehensive history of the presenting problem, past psychiatric history, medical history, medication history, substance use history, family history, social history, risk assessment, mental status examination, physical examination, and laboratory tests if indicated. The assessment should also consider the patient’s cultural background, preferences, strengths, and goals. The assessment should aim to establish a provisional diagnosis, determine the level of care needed (e.g., admission, discharge, referral), and develop a management plan in collaboration with the patient and their family or carers.
Environment and Education
The environment and education of staff are crucial factors for providing quality mental health care in EDs. The environment should be safe, comfortable, and respectful for patients with mental health issues, as well as conducive to effective communication and collaboration among staff. Some of the environmental features that can enhance mental health care in EDs are:
– A designated area for mental health assessment and observation that is separate from the general ED area, preferably with natural light, soundproofing,
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The Importance of a Separate Mental Health Area in Emergency Departments
Emergency departments (EDs) are often the first point of contact for people experiencing mental health crises. However, EDs are not designed to provide optimal care for these patients, who may face long waits, overcrowding, stigma, and inadequate resources. A possible solution is to create a designated area for mental health assessment and observation that is separate from the general ED area, preferably with natural light, soundproofing, and trained staff.
Benefits of a Separate Mental Health Area
A separate mental health area in EDs can offer several benefits for patients, staff, and the health system. Some of these benefits are:
– Improved patient outcomes: A separate mental health area can provide a more comfortable, safe, and therapeutic environment for patients, which can reduce agitation, anxiety, and distress. A study by Forster et al. (2018) found that patients who were admitted to a separate mental health area in an ED had lower rates of restraint use, seclusion, and medication administration than those who were admitted to the general ED area.
– Enhanced staff satisfaction: A separate mental health area can also improve the working conditions and morale of ED staff, who may otherwise feel overwhelmed, frustrated, and burned out by caring for patients with complex mental health needs. A survey by O’Connor et al. (2019) found that ED staff who worked in a separate mental health area reported higher levels of job satisfaction, confidence, and teamwork than those who worked in the general ED area.
– Reduced costs and resource utilization: A separate mental health area can also help to reduce the costs and resource utilization associated with ED visits for mental health reasons. A separate mental health area can facilitate faster triage, assessment, and referral of patients to appropriate services, which can reduce length of stay, admission rates, and readmission rates. A study by Zeller et al. (2017) found that EDs that implemented a separate mental health area saved an average of $2.16 million per year in direct costs compared to EDs that did not.
Challenges and Recommendations
Despite the potential benefits of a separate mental health area in EDs, there are also some challenges and barriers to implementing this model of care. Some of these challenges are:
– Lack of space and funding: EDs may not have enough physical space or financial resources to create a separate mental health area that meets the standards and requirements for patient safety and comfort. To overcome this challenge, EDs may need to seek external funding sources, such as grants, donations, or partnerships with other organizations, to support the construction or renovation of a separate mental health area.
– Lack of staff and training: EDs may not have enough staff or staff with adequate training and expertise to provide quality care for patients with mental health issues. To overcome this challenge, EDs may need to recruit and retain more staff with mental health qualifications or experience, or provide ongoing education and training for existing staff on topics such as mental health assessment, crisis intervention, de-escalation techniques, and referral pathways.
– Lack of integration and collaboration: EDs may not have effective integration and collaboration with other services and agencies that are involved in the care of patients with mental health issues. To overcome this challenge, EDs may need to establish clear protocols and communication channels with other services and agencies, such as primary care providers, community mental health teams, social workers, police officers, and ambulance personnel, to ensure coordinated and seamless care for patients.
Conclusion
A separate mental health area in EDs is a promising model of care that can improve the outcomes and experiences of patients with mental health issues who present to EDs. However, there are also some challenges and barriers that need to be addressed before this model can be widely adopted and implemented. EDs that are interested in creating a separate mental health area should consider the benefits, challenges, and recommendations discussed in this blog post.
References
: Forster C., Finnerty M., Callaly T., O’Reilly H., O’Neill H., & Kennedy H.G. (2018). Impact on patient outcomes of a psychiatric emergency service within an emergency department: The Irish experience. International Journal of Psychiatry in Clinical Practice 22(4), 281–287.
: O’Connor N., Warburton J., Currey J., & Castle D. (2019). The impact on emergency department staff satisfaction when caring for people with mental illness assignment help – write my nursing thesis: A qualitative study. Australasian Emergency Care 22(2), 83–88.
: Zeller S.L., Calma N., & Stone A. (2017). Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments. Western Journal of Emergency Medicine 18(1), 86–92.
