Emergency nurses who are confident in their ability to take vitals and start an IV can feel less sure of themselves when it comes to treating the needs of behavioral health patients. Yet it’s important to learn how to manage mental health emergencies, as this patient population has been steadily increasing. Mark Goldstein, MSN, RN, EMT-P I/C, FAEN, who works at Denver Health, recounted his experiences and presented suggestions during yesterday’s session “Caring for Mental Health Patients in the ED: A Quality Improvement Project.”
Mark Goldstein shared the specific strategies and tactics one ED used to transform its mental health patient experience.
In 2018, mental health emergencies were responsible for roughly 18 percent of all ED visits — but that was before the COVID-19 pandemic intensified demand. Hospitals nationwide are dealing with an increase in mental health visits, with varying degrees of success depending on the quality and design of their infrastructure, education, leadership and supplies. “We’re all in the same boat,” Goldstein noted. “Some have yachts, some have dinghies, some have rowboats.”
In a former job, Goldstein felt he and his ED colleagues weren’t providing optimal care to mental health patients. Some of these patients eloped (left against medical advice) or had hospital staff misplace their belongings. The environment also wasn’t safe for patients or staff: Two colleagues had experienced workplace violence at the hands of a behavioral health patient.
The ED put together a team to analyze the gaps in care and implement process improvements. Members included not only emergency nurses, ED techs and risk managers but also chaplains, security guards, plumbers and electricians. Working with ED and hospital leadership, these employees undertook a deep dive into their protocols to scan for deficits.
One glaring shortcoming was the way in which ED staff determined who was at risk for self-harm. “We didn’t have a valid suicide assessment tool,” Goldstein stated. Rather than just asking questions of the patient, the team knew they needed a reliable method to decide the level of patient risk. They chose to use the Columbia Suicide Severity Rating Scale, now considered the gold standard of suicidal ideation assessment.
The team invested in training using Crisis Prevention Institute materials, which taught them how to communicate in order to de-escalate behavior. They made changes to the ED’s physical layout, including using piano door hinges and ligature-safe doorknobs, installing floor-mounted beds that could not be overturned, and setting up security cameras with low-level lighting to replace harsh overhead fixtures. Secure flat-screen TVs were placed in rooms for entertainment, along with wall-mounted clocks. Nurses put patients’ belongings into individual lockers, transcribing the information into their notes.
Mark Goldstein exchanged ideas about behavioral health care with Wendy Warren, BSN, RN, of Henderson Hospital in Henderson, Nevada.
One area not outfitted with cameras was the patient showers. They were enclosed by abbreviated doors, so feet and heads remained visible while the rest of the patient was hidden. Goldstein labeled this a “humanistic approach” to ensuring privacy while allowing staff members to monitor for safety.
The results of the team’s efforts were significant. One year after starting the process improvements, elopements had decreased from 0.58 percent of patients to 0.02 percent, workplace violence had declined by 93 percent, and no patient belongings went missing.
Goldstein closed the session by telling attendees they now had concrete suggestions to take back to their ED leadership and encouraged them to speak up for change. “What you do as a staff member makes a huge difference,” he said.