7 ways to improve care of psychiatric patients

By Ilze Sturis, MS, RN, CS
Clinical Nurse Specialist
University of Michigan Health System
Psychiatric Emergency Services, Ann Arbor

Ideally, caring for a patient with a presenting problem that is psychiatric in nature can be a positive, rewarding experience. However, problems with a patient who has a psychiatric condition can become multifaceted.

The origin of some of these problems may be a result of a patient being brought against his or her will to the emergency department (ED). A patient with a prior history of schizophrenia could be acutely agitated and psychotic. The patient could arrive via ambulance or the police department. An employer or a concerned family member may have brought a depressed, suicidal patient to the ED. The patient who is actively psychotic could be misperceiving the environment and behaving in a threatening manner out of fear.

Here are ways to improve care of psychiatric patients in the ED:

1. Don’t overlook the quiet patients.

Quiet, withdrawn patients suffering from depression and suicidal ideation can be overlooked easily. These patients may appear to be adhering to the initial requests for vital signs and not in need of any emergent intervention. Their self-esteem may be so low that they don’t believe that they should be "bothered with"’ and that "others need your help more than I do." Obviously, this type of patient can be as high risk as the one who is actively verbalizing threats toward self and others.

2. Ask why the patient has come to the ED now.

The role of the triage nurse is paramount in the psychiatric patient. It is important to remember that coming to the ED is an unusual event. Attempt to discern from the patient, "Why now?"1 Asking the patients whether they are suicidal is another important triage question.2 Many patients will feel a sense of relief to be able to share this information with a professional. This information also is important to share with the physician if the same patients state that they would like to leave before their evaluations are complete.

If patients state they are suicidal with a plan, ask whether they have the means to act on their suicidal ideation. For example, if a patient states he or she would like to overdose, ask whether he or she has the pills with them. Depending on your hospital policy, you may need to have security present if you have to search the patient’s belongings for any dangerous items. As there are many potentially dangerous objects in the ED itself, including scissors, needles, and oxygen tanks, the patient may be to be placed in a "safe" room that contains minimal potential items that could be used as weapons. This patient would require ongoing monitoring and observation.

3. Use medications appropriately.

Ideally, the patient would be willing to take an oral medication for acute agitation. This should be offered to the patient prior to involuntary medication if possible. There are several new medications available for the treatment of the acutely agitated, psychotic patient. These include a rapidly dissolving tablet form of olanzepine, risperidone (available in a pill or liquid form), and ziprasidone (available both in pill and injectable form.) Refer to the Physician’s Desk Reference (Thomson Healthcare, Montvale, NJ) or package inserts for use and potential contraindications of these newer medications.

At times, the administration of involuntary medication may be administered more safely after a patient has been placed in restraints. At this time, use guidelines from the Joint Commission on Accreditation of Healthcare Organizations for proper monitoring and observation of the patient.

4. Rule out underlying medical causes.

A proper medical evaluation beginning with vital signs and baseline laboratory studies also can be safely commenced in patients that are agitated and out-of-control, once they are restrained. An underlying medical cause for the patient’s psychiatric presentation needs to be ruled out to determine the proper intervention.

5. Enlist family members’ help.

Family members are critical in the evaluation and care of the psychiatric patient. They may possess invaluable information regarding the patient’s medical and psychiatric history. Family members also may be able to identify potential life stressors precipitating the ED visit.

6. Reduce liability risks.

It is important to know state laws and mental health codes as they pertain to involuntarily detainment and hospitalization of patients. In many hospitals, risk managers are available 24 hours a day and can be called upon in this type of emergent situation. This department also may be available to do ongoing inservices as needed.

7. Make the patient comfortable.

In an effort to de-escalate a potentially volatile situation, remember that basic comfort measures can go a long way to develop rapport. Offering the patient coffee, ice water, or a meal tray can work effectively with some less agitated patients. Keeping patients and family updated on estimated wait times also is helpful. Building a therapeutic alliance with the patient and family can be the best intervention for all involved and lead to the best outcomes.

References

1. Fauman B. Commentary on emergency psychiatry. Emergency Psychiatry 2000; 6:127-130.

2. Kaplan HI, Sadock BJ. Pocket Handbook of Emergency Psychiatric Medicine. Baltimore: Williams & Wilkins; 1993.

[Editor’s note: Sturis can be contacted at University of Michigan Health System, Psychiatric Emergency Services, 1500 E. Medical Center Drive, Ann Arbor, MI 48109. Telephone: (734) 936-5900. Fax: (734) 763-7204. E-mail: isturis@umich.edu.]