Emergency departments have rapidly become the primary care providers for persons with behavioral health or substance abuse disorders. The 2011 Healthcare Cost and Utilization Project (HCUP) Nationwide Emergency Department Sample (NEDS), recently published by the Agency for Healthcare Research & Quality, reports that 5.5 million or 4 percent, of all emergency room visits were for a behavioral health/substance abuse diagnosis (1). Even more significant, there were 43 million or 33 percent of patients that presented with either a primary or secondary behavioral health/substance abuse diagnosis. This indicates that one in three emergency department visits involve a patient with a significant behavioral health condition. Because of dwindling community resources and fewer inpatient treatment settings, emergency departments have become the “de facto” care provider for the mentally ill.
Caring for behavioral health patients often affects timely throughput of all patients in the ED and it presents many other risks in the emergency care setting. The future of rapid improvement in access to appropriate treatment settings and care providers is uncertain. Therefore, organizations must identify and implement strategies to mitigate risk and improve patient safety. The major high-risk conditions for emergency departments caring for behavioral health patients include suicidality, aggression and elopement. Adverse outcomes involving behavioral conditions has led to legal claims with the most frequent allegations including inadequate risk assessments, lack of a safe treatment environment and lack of staff competencies. These deficiencies can lead to a variety of exposures such as regulatory risk, healthcare professional liability risk and reputation risk from adverse media attention – none of which fare well for organizations.
It is not an impossible challenge for EDs to provide safe care to the behavioral patient population. The first step in identifying risk is to conduct an assessment of the treatment setting. Once completed, this assessment can yield valuable information to set priorities for improvements and develop strategies to improve safe care and prevent adverse events.
The following are three common risk assessment findings that are high liability areas ripe for risk mitigation strategies.
- Insufficient initial and routine assessment for patients that demonstrate high risk behaviors.
The lack of screening, assessment, reassessment and documentation of such opens the door to liability for the facility.
Risk management strategies
- Identify patients “at risk” during the initial triage assessment to be followed by a comprehensive assessment by a behavioral health clinician. The identification of individual risk factors and protective factors is an important part of the assessment (2).
- Implement frequent assessment (every one to two hours) and document patient contact by care providers. Note: anxiety and agitation are usually the first signs of increasing risk. Regular contact with staff helps to minimize these symptoms.
- Perform reassessment at critical junctures and transitions in care: change in level of functioning, change in observation level, and at discharge.
- Assign the appropriate level of observation to the patient based on the risk assessment. Staff providing the monitoring should have documented competencies to provide this monitoring.
- Based on the risk assessment, medication management should be instituted promptly to manage symptoms. The Substance Abuse and Behavioral health Services Administration has developed the Suicide Assessment Five Step Evaluation and Triage – “SAFE-T” assessment tool. This could be used by professionals with limited competencies in suicide risk assessment (3). There are also many tools that are widely used to both screen and assess behavioral patients. While these can be helpful, it must be remembered that it is not possible to predict suicide.
- The lack of a safe treatment setting.
Given the high rate of behavioral health patients presenting to emergency departments, it is essential that there are safely designed treatment areas to minimize the risk of suicide, aggression, and elopement. Agencies and accreditation bodies have provided recommendations for safe treatment environments such as The Joint Commission Sentinel Event Alert Issue 56 which provides recommendations for the assessment and management of behavioral health patients in non-behavioral health settings and is a useful reference (4).
Risk management strategies
- Staff should escort patients presenting with a behavioral health complaint directly into the ED or other safe location where they can be observed. High risk patients should not be left in the waiting room as this can increase anxiety which can lead to agitation and/or elopement.
- Conduct an initial search of the patient for any items of potential harm. These items should be secured in a locked cabinet in the room or another safe location.
- Establish “safe” rooms close to the central nursing station and not near doors that provide for easy egress (ambulance bay, exit doors, etc…). These rooms can be a permanent design or able to be converted for use in a medical situation. The Facilities Guideline Institute can be accessed to obtain the “Behavioral Health Design Guide” which is currently considered the standard in the industry for a safe environment of care (5).
- Design a large room for two or more patients and provide recliners instead of beds for patient comfort. This can optimize staff resources for observation of patients as well.
- Provide diversions such as a television, magazines, music, and food/fluids. By doing so, we decrease the anxiety of the patient; decreasing risk.
- Conduct routine surveillance and searches of the designated treatment area for potentially dangerous items (plastic bags, sharps, ropes, strings, etc.).
- Ensure that the bathroom used by patients is safely designed or provides for constant supervision of high-risk patients. Patients that are high risk should be constantly monitored even when using the rest room.
- Consider the use of a different color gown, scrubs or footies for easy identification of behavioral health patients or those at risk for elopement.
- Insufficient staff competencies.
Considering that the emergency room is often the first stop for patients having a behavioral health crisis, it is imperative that the staff treating them have competencies in managing their behaviors and symptoms in a safe, therapeutic manner.
Risk management strategies
- Provide education/training in assessment, de-escalation, and non-violent management of aggressive behaviors. Minimally, the staff that should be trained include: Security personnel, ED nursing staff, behavioral health staff, and nurse supervisors.
- Ensure that all staff that is involved in restraint and seclusion procedures has firm knowledge of the federal guidelines surrounding the use of these restrictive interventions.
- Provide adequate behavioral health professional support to allow for timely and comprehensive assessment. Crisis counselors, social workers, or advance practice nurses are invaluable to assist in assessment and discharge planning. Psychiatrist consultation should also be available for evaluation if necessary.
- Hire trained behavioral health technicians to provide routine monitoring and management of behavioral patients in the ED or on units were there is a significant number of patients at any time. These staff members can be cross-trained to function as ED technicians or assistants should the volume of behavioral health patients diminish.
- Provide patient companions or “sitters” that function as observers. These staff should have documented competencies to be in this role. The use of safety companions is widespread in acute care settings. While it is considered to be the highest level of monitoring for a at risk behavioral patient, there is no evidence to suggest that they prevent adverse events.
- Tele-psychiatry can be useful in providing timely assessment and disposition of patients. At the present time, there are barriers that exist for the widespread use of tele-psychiatry and include: reimbursement, clinician licensing, and credentialing.
To conclude, safer care for behavioral health patients in the emergency department is possible. While there are many additional risk mitigation strategies that have proved to be beneficial, an organizational focus on these three high risk areas in the management of this population can greatly assist in reducing organizational risk and improving patient safety.
(1) Agency for Healthcare Research & Quality (AHRQ), retrieved from https://www.hcup-us.ahrq.gov/nedsoverview.jsp.
(2) Editors Jayaram, Geetha, M.D., M.B.A. and Herzog, Alfred, M.D., (2008, June).SAFE-MD: Practical Applications and Approaches to Safe Psychiatric Practice Committee on Patient Safety.
(3) Retrieved from: http://www.integration.samhsa.gov/images/res/SAFE_T.pdf.
(4) The Joint Commission, Sentinel Event Alert Issue 56, retrieved from https://www.jointcommission.org/sentinel_event_alert_issue_46_a_follow-up_report_on_preventing_suicide_focus_on_medicalsurgical_units_and_the_emergency_department/
(5) Hunt, James and Sine, David. (2017, April). Behavioral Health Design Guide, 7.2 edition. Retrieved from http://www.fgiguidelines.org/resource/design-guide-builtenvironment-behavioral-health-facilities/
Monica Cooke BSN, MA, RNC, CPHQ, CPHRM, FASHRM, is the founder and CEO of Quality Plus Solutions LLC.