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What can emergency nurses do to cope with the growing population of mental health patients in the emergency department? First, slow down, says Ken Stanton, RN, PhD, an emergency department nurse at Alta Bates Summit Medical Center in Berkeley, Calif.
"In the ED when there's a crisis, no one wants you to slow down. Most of the time in the emergency room you have to move fast," says Stanton, who brings 30 years' experience as a psychiatric nurse to the emergency department. "The problem is, people who present with a psychiatric emergency need people who can move slowly and speak slowly. They have trouble processing information."
It's worth taking an extra five minutes of time with mental health patients, says Stanton, who will talk about managing psychiatric emergencies in the ED at the annual meeting of the Emergency Nurses Association Oct. 1 in San Diego.
"Ask, 'What's going on with you? Can we rely on you to keep yourself safe while you're here?' I'm not talking about doing counseling or therapy, just interacting to make the rest of it smooth."
The Emergency Nurses Association offers additional advice for nurses in two position statements: "Medical Evaluation of Suspected Intoxicated and Psychiatric Patients" and "Access to Health Care." [www.ena.org, Publications Section]
In addition, "Get educated, be a patient advocate and get political," advises Nancy Bonalumi, RN, MS, CEN, in a March Emergency Nurses Association newsletter article.
Check into standardized programs that provide basic communication, safety, and passive restraint skill training [www.crisisprevention.com]. Many local mental health providers also offer inservice education on common psychiatric disorders and on developing care plans for psychiatric patients.
Assisting patients in maintaining their dignity and privacy is essential in treating behavioral issues. Learn about patients' rights for restraint and seclusion. [For the 2004 Joint Commission on Accreditation of Healthcare Organizations Patient Care and Behavioral Care Standards, visit www.jcaho.org.]
Tell your local, state, and national public officials how treating mental health patients in the emergency department affects the community. Ask for additional funding to support mental health services.
Janet Wells
Janet Wells
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Psychiatry and emergency services “are distinctly different issues,” says Wendy Waddell, RN, MSN, associate director of nursing at Parkland Health & Hospital System in Dallas. Waddell supervises the unit that includes a psychiatric ED, which has eight patient care rooms — four of which are locked seclusion rooms — next door to the 84-bed medicine emergency department. The psych ED treats 800 to 900 patients a month, admitted on both voluntary and involuntary bases. About 20% of the patients are treated in the medicine emergency room as well.
“A patient may be brought in to the medicine ER with an overdose, treated and cleared, and then brought over to the psychiatric emergency room. It leads to having specifically trained and experienced staff members taking care of the patients,” Waddell says.
“I have nursing staff that are experienced in psychiatric care. We do constant monitoring of the patient for safety issues, especially if they are suicidal, a full psychiatric assessment, lots of medication management, interventions with family,” she says.
A 28-bed inpatient psychiatric unit helps St. Anthony’s Central Hospital in Denver treat and manage mental health patients.
“When we are faced with a psychiatric patient after the medical screening, we just call the psych team. They wind up getting admitted upstairs,” says Rick Bailey, RN, BSN, the hospital’s emergency department director. However, at times, the unit is full or the patient doesn’t have adequate insurance and must wait for a bed in one of the public facilities. Often, those patients wait for placement in the emergency room, along with patients seeking medical treatment. “The nurses are adept at managing psychiatric patients,” Bailey says, and a security guard is assigned to any patient who is suicidal or homicidal.
But when mental health patients get backed up in the ED with nowhere to go, “it can have a huge impact on the flow through the ER,” Bailey says.
When that happens, it’s not uncommon for Denver’s Emergency Medical Services system to issue a “psych advisory,” says Vicky Cassabaum, RN, president of the Colorado Emergency Nurses Association. “It means a facility is overwhelmed with psych patients. The ambulances don’t go on divert, but if possible, they should take them to another facility that’s not on advisory.”
With 42 million uninsured and 40 million underinsured people in the United States, combined with severely strained resources in both emergency and mental health services, emergency departments are likely to remain the primary destination and holding tank for psychiatric patients in the near future. In communities like Las Vegas — the fastest-growing city in the country — the situation is likely to get worse before it improves.
In the early 1990s, Nevada — like many states — suffered deep cuts in mental health funding. “We’re still not back to what we had then, and our population has doubled” to 1.6 million in Las Vegas, social worker Lujan says. In 2003 alone, the city gained 60,000 people. That’s 135 new residents a day. Some of those people are bound to need emergency psychiatric care at some point.
“We can’t turn people away,” says Jonna Triggs, EdD, director of Southern Nevada Adult Mental Health Services.
The state Legislature recently allocated $32 million for a new 150-bed psychiatric hospital, and Gov. Guinn made its completion his top capital improvement project. While the government’s level of commitment and funding is laudable, it won’t solve the problem, Triggs says. “When we’re open in 2006, do I think we’ll have 150 patients in those beds the next day? Yes.”
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