An increasing number of psychiatric and mental health patients are being admitted to Emergency Departments (ED) in nearly every hospital in the U. S. It’s an ongoing surge, and is heavily taxing EDs and community hospital resources.  

How to deal with a growing influx of psych patients in the ED when you have limited resources?

Part 2 of “Treatment of Psychiatric Patients in the E.D.: What You Need to Know,” by Isaac Abraham, MSN, RN.  

Essential Training

One way to help cope with the increase of psychiatric patients is to get your medical staff involved and cross-trained. Train your staff on the basics of treatment of psychiatric patients in the ED. They won’t be psychiatric nurses, doctors, mental health workers or CNAs, but they will be able to understand how to de-escalate patients, when to back off and not put themselves in dangerous positions.

Many hospitals I’ve worked with are beginning to see the value of this cross-training concept. The last hospital I worked with had all the staff in the ED take the same training, the de-escalation techniques that the staff on the mental health units undergo; if they had an issue in the emergency department, the psychiatric staff would come down and help the ED personnel and vice versa. Everybody worked together to ensure the safety of the patients – even if it wasn’t their department.

Plan of Care

There used to be an old mindset that advised;

Just give them their medication, put them to sleep and then you don’t have to deal with them.

That’s a recipe for disaster. One of the biggest issues we run across while treating psych patients in the ED is patients either not taking their medication or in noncompliance with their medication regimen. The first step needed upon arrival of a psychiatric or mental health patient in the ED is to do a complete health assessment.  Many times patients do need medications, because noncompliance is a significant issue with psych patients. And, when they come in, and they haven’t been taking their medication, the physicians in the ED need to do some intervention at that point, and this is important, but that’s not all they need. They also need a correct plan of care.

Regulators like The Joint Commission (TJC) and CMS have standards that demand staff takes care of the whole patient while they are in the ED.  You just don’t medicate, restrain, or seclude them.  These patients have to be taken care of like any other patient.  Many times psych patients have medical issues unrelated to their mental behavior. Care for them like they are your family.

The Use of Restraints

The improper use of restraints on psych patients can be a serious issue with deadly outcomes for all involved. Patients have died in restraints. Hospitals have closed because of the improper use of restraints.

The biggest cause for complaints and medical issues with restraints is a simple one. Lack of monitoring the patient. This is an easy fix. Monitor the patients in a prescribed and timely manner.

Five-point restraints are also a cause for alarm;

A five-point restraint is when you use a leather strap and tie down the five points of both legs, both arms, and the chest.  The strap goes across the chest and you then tie the patient to a bed so they can’t get out.  But, they struggle mightily trying to get out. 

Imagine yourself tied down in a five-point restraint.  

How would you feel?

I was involved in several cases where patients that were restrained had heart attacks. Why? The patients had medical problems that weren’t fully assessed during intake – and the struggle to get out of restraints can be fierce.  Incidents like this can lead to regulators determining that the organization is an unsafe one to treat patients. Regulators can then order the hospital closed.

I don’t use the five-point restraint myself because I don’t believe in tying patients down at the chest. The reason I don’t is borne of my experiences. At one time, I was called into turning around an organization that had used the five-point restraint method, and several people had died because of it. It’s sobering.

The theory of five-point restraints is one thing. The real-life application is another.

Chemical Restraints

Chemical restraints can be, and are, effective. But sometimes they are over-used. I hate to keep repeating this, but the very first step in the treatment of a psychiatric patient in the ED is the complete health assessment. How would/could the chemical restraint react with the patient in his current health status?

In one turn-around situation I was involved with, they were using such heavy doses of chemical restraint that it became problematic. The patients were not acting out once they got the chemical restraint, but they were still strapped to the bed in five-point restraints. Chemical restraints and five-point leather straps can be a lethal combination, especially if someone has cardiac problems or respiratory problems.

Sit and Stay, Soon Restraints Go Away

My rule about restraints is simple and effective. If a patient is restrained to a bed, a nurse has to sit with the patient during the entire time they were restrained. Once I implemented that rule, restraints went down to almost nothing.  The easy way is to restrain. The best way, the safest and most effective, is to treat the patients like they are a member of your family.

End of Part 2

Read Part 1,Treatment of Mental Health Patients in the Emergency Department.”

Read Part 3:Important Steps to a Well-Prepared ED for the Treatment of Mental Health Patients





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