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Changing Mental Health Care in the Emergency Department

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Hospital emergency departments are treating more and more patients with mental health and substance-use related issues. It is one of the fastest growing patient populations in U.S. emergency departments, and it’s creating a crisis for some facilities.

With limited access to behavioral health specialists to perform mental health evaluations or readily available psychiatric beds for admission, these patients may hold or “board” in the emergency department for hours, days and even longer, often without receiving the specialized psychiatric care they need. During their wait, these patients are subjected to the noise and chaos of the ED – potentially exacerbating their condition – while occupying beds that might otherwise accommodate patients with physical medical conditions.

Many factors led to these circumstances — from the closure of state mental health facilities, to the rise in opioid prescriptions to the shortage of mental health professionals. While hospitals may not be able to change all the trends driving the influx of behavioral health patients to the ED, what they can do is change the way they think about and treat this patient population.

Adopt a new mindset

Consider how ED clinicians treat behavioral health patients compared to those with physical conditions. A patient with pneumonia, for instance, would not be made to wait for an inpatient bed before receiving antibiotics, breathing treatments or other necessary care. In the same way, many behavioral health patients can benefit from receiving medication (beyond sedatives for de-escalation) immediately.

If hospitals approach behavioral health patients the same way as those with physical conditions – moving with urgency to secure an evaluation and/or begin active care – with the goal of discharging patients home, they can potentially:

  • Help patients get well, faster
  • Expedite discharges, improving patient flow
  • Reduce wait times, length of stay and left without treatment rates
  • Improve all patients’ experience of care in the ED
  • Reduce demand for patient sitters, security, etc.

Embrace technology

Telepsychiatry is an increasingly attractive option for hospitals struggling to get timely mental health evaluations in the ED. These programs use telecommunications technology to make psychiatrists available “on-demand” to provide patient evaluations, risk factor assessments, disposition and treatment plan discussions and psychotropic medication recommendations. It can also alleviate patient boarding by helping ED clinicians more quickly determine which patients are safe to discharge. And when inpatient care is required, telepsychiatry can provide support to the emergency clinician in determining appropriate medications for treatment while the patient awaits placement.

Start medication

Whether telepsychiatry is available or not, there are things ED clinicians can do to provide better quality care to behavioral health patients. Foremost, starting medication is often the best strategy to manage illness and keep the patient stable while waiting for a consultation or placement.

The vast majority of behavioral health patients can benefit from medication. Patients with psychosis can rapidly improve with antipsychotic medication. At times, patients with depression can improve with a single dose of an anxiolytic to allow them to sleep and can be discharged the next morning. The sooner the patient begins treatment, the better.

To change practice patterns in this way, EDs may need to offer additional education on behavioral health conditions – beyond usual emergency care – and the appropriate medications to start in the ED for longer-term management. (Because the clinical effect of these medications extends beyond the duration of the traditional ED visit, emergency clinicians may have considered these drugs outside their scope of practice.) Extra training may help clinicians feel more confident in beginning treatment for patients who present with depression, suicidal thoughts, agitation, psychosis, etc. And this can go a long way to helping patients get better faster and potentially be discharged more quickly.

Change the environment

To help alleviate, or at least not exacerbate symptoms, EDs should aim to create a calm environment that treats behavioral health patients with dignity and respect. That means avoiding isolation and restraint when possible, providing human interaction, ensuring bathroom privileges, etc. For individuals who may be a threat to themselves or others, ED leaders should ensure patient rooms are safe and provide a 1:1 sitter relationship when necessary.

To that end, one TeamHealth client hospital in Pennsylvania created a five-bed behavioral health suite within the ED. It helped reduce restraint use among the approximately 135 behavioral health patients it treats each month by creating a calmer environment, free from the loud sounds of monitors. It’s staffed with a dedicated, specially-trained nursing team, and clinicians start medications when appropriate and round on patients each shift. A psychiatrist from the hospital’s affiliated psychiatric facility is available when necessary. The improved environment and enhanced focus on these patients have been well-received by patients and staff.

Create continuity

After providing treatment, clinicians should re-evaluate behavioral health patients who remain in the ED. Regular rounding allows clinicians to better monitor symptoms, evaluate the effects of medications and assess improvement. Following treatment, many patients can be discharged with a referral for outpatient services.

Connecting patients to outpatient follow-up in a very short time is particularly critical when prescribing medication. Side effects that most often appear days after starting a medication are a leading reason for suicide attempts.

It’s time

Industry trends indicate hospital EDs will continue to see a high volume of behavioral health patients. Instead of providing expectant care while patients board in the ED, it’s time for hospitals to take a more active approach to caring for these patients – moving with urgency to secure an evaluation, providing meaningful treatment and re-evaluation with the goal of helping patients get better faster. This shift in thinking can help EDs deliver better care, improve the patient experience, and improve patient flow while

James Horst, DO, FACN, is the national medical director of behavioral health and post-acute care for TeamHealth.