Safety is a critical issue — for both patients and nurses. “These patients are not getting the intervention they need,” says Stephanie Cota, RN, BSN, CEN, clinical director for the emergency department at St. Mary’s Medical Center in Long Beach, Calif.

“The issue is not being able to provide the attention. I’ve left at night and come back the next day and they’ll still be here. We give emergency medicines to keep them sedated, but there’s no social intervention, no conversation. It’s just like we can’t keep an ICU patient down here. We can get them stable, and we keep them as safe as we can, but we’re not skilled in managing these patients for more than a few hours. And we’re expected to take care of new patients coming through the door.”

Keeping mental health patients in the ED also creates a potentially dangerous work environment, Cota says.

“A man came in and we tried to restrain him, but no one could get near him,” Cota says, describing an incident last year at her former job in an emergency department in Northern California. “Then he got combative and tore the room apart. He jumped up on the gurney, tore the ceiling tile and rebar from the ceiling, and started hitting at people.”

Before anyone was hurt, one of the staff nurses managed to get the patient’s attention and “talk him down,” Cota says, adding that similar incidents happen several times a month. “Patients who have behavioral issues are difficult to read. It’s the unpredictability of it that most nurses say gives them the most anxiety.”

JoAnn Lujan, LCSW, director of the WestCare Community Triage Center in Las Vegas, agrees — and adds that it’s also a safety issue for other patients in the emergency department.

“Not only are you dealing with an individual with severe mental illness that’s going untreated, but they’re angry that they are sitting in the emergency room without treatment,” Lujan says.

Wrong place at the wrong time

“Picture yourself as a person waiting to be treated for a fracture, listening to somebody screaming and yelling, paranoid, not using the best language about what’s happening to them as they are handcuffed to a gurney. You hear this person yelling, ‘I’m going to get you!’ Think about how that affects their care. Our emergency rooms were not meant to be psychiatric wards.

“These nurses didn’t choose to go into psychiatric nursing, yet that’s exactly what we’re expecting them to be,” Lujan says. “They’ve been bit, hit. How do you provide mental health treatment in an emergency room, where you don’t have walls but curtains?”

Recently, Brackenridge Hospital in Austin, Texas, instituted an innovative program to cope with the increase in the number of psychiatric patients coming into the ED: hiring psychiatric patient “sitters.” These nonprofessionals simply keep watch and alert nurses, security, techs, the police department, or social workers if patients need help or look like they might flee the emergency room, says Laurie Toth, RN, BSN, director of the Brackenridge children’s emergency department.

“We don’t want to restrain people chemically or physically,” says Toth, who was director of both children’s and adult emergency services for five years. “We’d like the least restrictive method of dealing with them, and also keep them from eloping from the ER. It’s really hard to keep an eye on everyone.

The 28-bed ED also has social workers available 24/7. “ERs that don’t have social work support, it can be difficult for the nurses. The social workers make a big difference. They are knowledgeable,” Toth says.

In addition to doing evaluations and facilitating transfers for patients who have been medically cleared, social workers offer advice, helping nurses work with unpredictable and potentially violent patients.

“It’s basic kinds of tips, like don’t turn your back on [psychiatric patients], make sure your back is to the door, don’t touch a psychotic patient,” Toth says.

Separate spheres of care

Hospitals that are fortunate enough — and well-funded enough — to have a separate psychiatric emergency department or an inpatient psychiatric unit have an advantage over those that must treat mental health patients in a sole emergency room.

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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Smooth Talkers

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