The Treatment of Psych Patients in the ED: What You Need to Know – Part 1

Isaac Abraham, MSN, RN, has worked with us at Compass Clinical Consulting for many years. He’s one of the most truly authentic, compassionate, skilled, gifted and exceptional leaders (and teachers) in healthcare consulting. Isaac specializes in the treatment of Mental Health Patients in the Emergency Department (ED). A tireless advocate for psychiatric patients, Isaac shares with us some of his hard-earned insights and illuminating lessons he’s learned throughout his career.

Behavioral Health Patients are “Our Patients”

I went to the University of Virginia and earned my Master’s Degree in Psychiatric Nursing I wanted to learn as much as I could in the field, and teach other healthcare professionals.  Soon, my overarching goal became apparent. I wanted medical professionals to understand that mental illness truly is a sickness. That’s the point that I try to drive home to every healthcare professional that treats mental/behavioral/psychiatric patients.

As the years passed, I noticed we began to have fewer and fewer resources in the communities.  In some areas I traveled, they didn’t even have enough beds to take care of the psychiatric patients, especially smaller rural areas. That’s what got me interested in caring for psychiatric patients. One of the things I experienced early on was that when I’d go to the emergency room to assess psych patients, some nurses would refer to them as “your patient.” I’d try to get them to understand that “they’re our patient.”

Unfair Double Standard

In my mind, the experience of how the psychiatric mental health patients were treated versus the people who came in for medical reasons became an unfair double standard. This sparked me to become an advocate for the treatment of mental health patients in the ED. I’ve always been a strong advocate for the mental health population, but this increased my motivation to want to do something to make their patient experience in the emergency department as comfortable and efficacious as possible.

It became apparent to me that it was happening all across the country – and still is. The treatment of psych patients in the ED caught the attention of government leaders and action was taken. The Joint Commission and the Centers for Medicaid and Medicare Services (CMS) got involved with regulatory rules, standards, and procedures. Because of this, I started traveling the country doing mock surveys (assessments) of the treatment of psychiatric patients in the ED.

In performing these mock surveys, I realized it was a serious problem. Why? Because psychiatric patients will stay in the emergency room for not only hours at a time, but for days and days!  When we first started surveying, there were people who were staying in the emergency room for up to 7 to 14 days!

We identified several important elements in the treatment process that had to be in place or improved.

Leadership Commitment

Leadership has to make the commitment to fix the problem to improve treatment and care. The first step in the process to fix the problem is to understand the problem. How do you do that?

Common Treatment Issues

If you don’t do an assessment of your ED, you can’t begin to realize what some of the actual problems are. And, you have to involve not only the CEO suite in the process, but also nurses,  staff, transportation personnel, and anyone who comes in contact with the patient process.

We’ve (Compass ED Psychiatric Patient Treatment teams)  discovered, from doing hundreds of ED assessments, that:

  • Maintaining a safe environment is difficult for most Emergency Departments. To correct this means getting security and additional staff involved.
  • There is often a lack of sterilization when working with mental health patients.
  • ED staff resources are limited, especially during peak times.
  • ED staff training with psychiatric and behavioral health patients needs to be improved, especially in areas of de-escalation and agitation.

One hospital I recently assisted had enormous ED peak times. They’ve addressed this by putting a system in place that enables ED personnel to call for resources and help from the psychiatric/behavioral health department. Personnel from the unit go to the ED and work together as a team with ED staff. That system made things much better. EDs need to have access to more behavioral resources and people to work with during peak times.

Staff Training

One of the things we do is collaborate with the staff that treats people with mental health issues. You have to be trained on how to work with psych patients because as a clinician, a physician, or whatever position you’re in, you can cause them to become agitated and out of control. I teach them the signs and symptoms of when psychiatric patients are about to have a behavioral outburst. The most important part of this training is to educate the staff on how to de-escalate these behaviors before they get out of control.

Explosive Signs and Symptoms

Pacing: A lot of times, psych patients will pace, which is often a precursor to becoming agitated.

Loud:  Patients become extremely loud. Look at their affect.

Anger: Often when a psych patient arrives at the hospital, especially the emergency department, hospital staff thinks that the patient’s anger is directed at them. It’s usually not. That anger is because someone brought them to the hospital. More often than not, it’s a reaction due to a family member, or from an unfortunate encounter with a police officer.

The staff has to realize that it is not them that the patients are angry at. They need to be responsively therapeutic, kind, and quiet, and watch their tone or voice, to make sure the patient doesn’t think they’re being challenged. This is one of the biggest areas that we have issues with if a psychiatric patient is being loud sometimes and saying things that you don’t want to hear.  I’ve seen professionals, unfortunately, challenge them and become as loud as the psychiatric patient. This is a big area of concern. If a psychiatric patient is being loud and saying things that the staff doesn’t want to hear, the staff has to show restraint.

Avoiding Negative Intervention

If a psych patient begins to act out, the staff need to do the opposite. They need to be calm. Sometimes you can tell them:

“Well, right now, I want you to settle yourself down, and I’ll get back with you later.”

The best course of action is not to impose on the patient or force the patient to do things they don’t want to do at that moment. All staff has deadlines, and they want and need to get things done, but sometimes it’s better to take a minute to be safe than to end up with thirty minutes or an hour of negative intervention.

I like to involve the staff in treatment education by encouraging them to be open and honest about their experiences. You have to remember that ED personnel pride themselves on saving lives, treating gunshot, fixing broken limbs, etc. Treating psych patients is typically not a practice they envision when going into the ED. I’ve heard staff say,

“Isaac when they go on cursing, it really makes me angry.”

In cases like that, l talk to them about trying to understand, and to perceive, the psych patient in a different light. I might  say to them,

“If I’m a diabetic and my blood sugar goes up to 600, would you get angry at me?”

They say, ‘No, no way.’

“When people have a mental illness, especially those who are agitated,  cursing at you is a symptom of their illness.  Same as a 600 blood sugar count. Mental illness is something that these patients cannot help and did not choose. Be empathetic, caring, and have compassion for not only the medical patients you treat, but for all patients, especially psychiatric patients who come to your emergency department. Helping and healing is why you chose your profession, isn’t it?”

End of Part 1 of Issac Abraham Insights on the treatment of psychiatric patients in the ED.

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