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Prepare for more many more mental health emergencies
A very anxious-looking man told triage nurses At St. Johns Mercy Medical Center in St. Louis, MO, that he had a history of psychiatric disorders. Right away, he was placed in an appropriate room, asked to change into paper scrubs, and all his belongings were placed in a plastic bag.
"Security then came to inspect the belongings of the patient and found a 4-inch switchblade," says Angelique Eichenlaub, RN, one of the ED nurses who cared for the patient. "If this patient was allowed to keep his belongings and stay in his clothing, there could have been a very bad outcome for either the patient or the staff."
You might believe the signs of an individual in distress due to a mental health emergency would be hard to miss. But what if your waiting room was crowded with patients waiting to be seen, and your patient denied any intent to self-harm?
Screening for mental health and substance abuse is now the leading cause of ED visits in the uninsured population, according to the recently released 2007 Nationwide Emergency Department Sample from the Agency for Healthcare Research and Quality. ED visits for this group rose 28% between 2006 and 2007, and they rose between 14% and 17% for insured patients.
"Increased numbers of patients with mental health conditions are indeed being seen," reports Michele Bascom, RN, an ED nurse at The Hospital of Central Connecticut in New Britain. "ED nurses use scripted questions to evaluate suicidality. Positive responses prompt certain actions."
Sandra Menard, RN, MSN, CEN, an ED nurse at Brigham and Women's Hospital in Boston, says, "On a daily basis, we are seeing an increased number of individuals presenting to the ED for both mental health and substance abuse. Some individuals have a dual diagnosis, so you are treating the substance abuse and the mental issue concurrently."
To improve care of these patients, do the following:
Ask the right questions.
Menard says to ask patients this question: "Are you having thoughts of hurting yourself or others?" If the patient answers "yes," always ask, "What is your plan?"
"Knowing the patient's plan is instrumental," says Menard. Also ask about stressors, coping mechanisms such as substance abuse or alcohol, if the patient has a psychiatric history, and if in the last two weeks there have been any changes in sleeping patterns or lack of interest in activities they once enjoyed, she recommends.
Shadow the experts in your ED.
"One simple way to learn how to deal with psychiatric patients is to observe a staff member who always effectively deals with psychiatric patients," says Menard.
Obtain the trust of your patient.
Kelly Powers, RN, an ED nurse ED at Christiana Care Health System in Wilmington, DE, says that you must be truly at ease when assessing a patient with known or new mental health issues. "If the nurse is uncomfortable or nervous, the client may not trust that they are safe or being taken seriously," Powers says.
Eichenlaub recommends these practices: Face the patient, look straight at the patient to let him or her know you are listening, do not interrupt while he or she is telling you what brought them to seek medical attention, keep your arms uncrossed, and keep a neutral facial expression.
Take information you are told by family members seriously.
"The majority of individuals in crisis are brought to the ED by others. One pitfall is not listening to family members who state the individual is not acting appropriately," says Menard.
Your patient might vehemently deny any intent to harm himself, but a family member standing beside them might know otherwise. Powers says, "If the patient arrives with family members or friends, try to find out what has been going on. Ask if there is any history of the same behavior, what treatment they have received in the past or are currently receiving, and what may have exacerbated this episode."
Keep close watch
After you assess a psychiatric patient, might she wait in a crowded ED waiting area unattended?
"One of the most difficult tasks in a busy triage environment is to keep an eye on the patient," says Powers. "Make sure someone is constantly with the patient."
Use mental health aides if possible, or patient care technicians trained in observation, but don't rely on friends or family. "They can be with the patient but should not be responsible for observing them," says Powers.
The Hospital of Central Connecticut's ED has one room visible on camera in the nurses station and in security dispatch, which is used as the psychiatric observation area. "In truth, we can care for any patient in this area, but usually psychiatric patients are placed there," says Bascom. "In addition, a nursing tech observes the patient at the bedside."
Check for this while taking BP
When taking a psychiatric patient's blood pressure, look at the arms for signs of cutting or old wounds, recommends Sandra Menard, RN, MSN, CEN, an ED nurse at Brigham and Women's Hospital in Boston.
"Ask how the injuries occurred. The old story 'My cat scratched me' is often used,'" she says. "Explanations to injuries that do not make sense are a big red flag."