A safe environment

Caring for patients with behavioral health issues in the emergency department remains a hot topic in US healthcare. Michelle Foster Earle, president of OmniSure Consulting Group, explores how to reduce the risks to both patients and staff.

One in five Americans is living with a mental health condition. Mental health and/or substance abuse cases accounted for one in eight visits to US Emergency Rooms. Emergency department (ED) visits specifically related to drug use increased 100 percent from 2004 to 2011. Drug-related suicide attempts increased 51 percent. Despite these statistics, hospitals are still struggling to provide compassionate and competent care. In the fall of 2014, the National Alliance for Mental Illness released a survey in which over 1,000 families or individuals who had a psychiatric emergency responded to a request to share their experiences. Two out of five rated their experience as “bad or “very bad”.

What is the risk to healthcare systems that don’t take proactive steps to improve mental and behavioral patient care and safety in the ED? Studies from various sources suggest that approximately 20 percent of claims against hospitals originate in the emergency department. A recent study of hospital professional liability claims by CNA Insurance, for example, puts the number at 19.6 percent with an average total payout at $260,054. The same study indicates that claims against behavior health providers within the hospital, though only 5.8 percent of the total, have a higher average cost, at $300,156.

A complex risk

Patients seeking care for a mental health crisis or an urgent evaluation pose one of the most complex risks in the US healthcare system. Because psychiatric care has become less institutionalized over the past 50 years, and because of widespread budget cuts, there are fewer inpatient beds for psychiatric care, making the local ED the necessary alternative.

The upsurge in psychiatric cases has posed a big concern to many emergency physicians. During his time as the 2014 president-elect of the American College of Emergency Physicians (ACEP), for example, Michael Gerardi, MD, FAAP, FACEP, stated that one of his chief concerns was the inadequate resources of most rural emergency departments to address the needs of psychiatric patients in crisis.

Later in 2014, the ACEP member based Emergency Medicine Practice Committee published a review and summary of resources and best practices to address evaluation, medical clearance of psychiatric patients, boarding of psychiatric patients, medical management, disposition, and community resources. This was a great start towards reducing risk.

One of the chief concerns related to ED boarding, which is primarily due to a lack of appropriate inpatient beds. Just as it would not be acceptablefor an emergency physician to let a medical patient sit in the ED without any treatment until they got a bed in the hospital, so is it unacceptable to let a mental or behavioral health patient sit in the ED waiting for a bed without treatment. It’s imperative that the ED initiate treatment, or if not, clearly document the reasons for delay or omission of initiating treatment. Some suggested practices include having a psychiatrist available to see patients, either in person, or via telemedicine, having treatment protocols if a psychiatrist is unavailable, and creating a separate area in the ED for psychiatry evaluation with a room that offers secured storage, closed circuit observation, and recessed or protected fixtures. The ACEP and other reports also call for the use of mobile crisis intervention teams and other community support resources.

Peer support

Kimberly Allen, MS, LCDC, certified peer support specialist in mental health and peer recovery support specialist in addiction in the state of Texas, and volunteer chair of the Depression and Bipolar Support Alliance (DBSA) Texas Grassroots Organization, recently conducted a survey supported by the Substance Abuse and Mental Health Administration (SAMSHA), a branch of the US Department of Health and Human Services. The survey included how certified behavioral health peers are being introduced into acute care environments in Texas, serving as an integral part of the healthcare delivery team.

Peers are non-clinical support teams: wellness coaches, addiction recovery coaches, youth and family members who are trained, certified, and focused on recovery, and who have lived experiences in mental health and substance use recovery. Peer support services delivered by certified peer support specialists are available in at least 34 states. Some states allow reimbursement by Medicaid for peer support services. Peers help to talk and listen to patients while they are waiting to see clinicians, and connect with individuals about their behavioral health and medical needs in a productive way.

Peer services have been shown to reduce expensive inpatient service use, reduce recurrent psychiatric hospitalizations for patients at risk for readmission, improve individuals’ relationships with their healthcare providers, better engage individuals in care, and significantly increase individuals’ ability to manage their symptoms.

“I have interviewed several large hospital systems who are using peers in emergency departments, helping to support patients remaining in the ER after the decision has been made to admit or transfer them,” says Allen. These hospitals use ‘transition teams’—behavioral health peers in recovery, who work together with clinicians to help provide emotional supports for patients identified as having substance use or mental illness. Peers talk to individuals in crisis and provide recovery support and information on community resources, helping to reduce chaos, reduce crowding, reduce strains on emergency departments and increase patient engagement and satisfaction.”

Allen recommends the resources found on the DBSA website which includes videos, webinars, supplemental materials, free resources and information from the American Association of Emergency Psychiatry. Perhaps the most helpful resource is the Understanding Agitation Kit with de-escalation techniques, posters, and free educational materials.

Mental Health First Aid is another excellent resource. With an initiative to make Mental Health First Aid as common as cardiopulmonary resuscitation (CPR), this organization has 10,000 instructors teaching eight-hour courses that give people the skills to help someone who is developing a mental health problem or experiencing a mental health crisis.

Helpful resources and websites

• American Association for Emergency Psychiatry, a multidisciplinary organization that serves as the voice of emergency mental health professionals—www.emergencypsychiatry.org
• National Alliance on Mental Illness—www.nami.org
• Mental Health First Aid—www.mentalhealthfirstaid.org
• Treatment Advocacy Center, dedicated to eliminating barriers to the treatment of mental illness—http://treatmentadvocacycenter.org/
• The National Council for Behavioral Health, state associations of addiction services—www.thenationalcouncil.org
• Depression and Bipolar Alliance—www.dbsalliance.org
• National Association of State Mental Health Program Directors—www.mnasmhpd.org
• Substance Abuse and Mental Health Services Agency—www.samhsa.gov
• OmniSure’s Suicide Risk Reduction Tip Videos—www.omnisure.com/suicide-risk-reduction-tips

About the author

Michelle Foster Earle is the president of OmniSure Consulting Group, a risk management firm working with some of the nation’s leading medical professional liability insurance companies, medical practices, hospitals, healthcare facilities and providers of healthcare and social services nationwide to help reduce risk, improve performance and avoid lawsuits. She has earned designations in healthcare management, is licensed general lines property and casualty agent in Texas, and is an Associate in Risk Management. She is also a frequent speaker and author for industry associations and publications.