Tips on managing psychiatric patients

Because psychiatric patients are more likely to become hostile or violent than the general patient population, it’s important to take a proactive approach. Here are some specific suggestions to manage these patients and minimize risks:

• Have a policy in place before a problem occurs. To ensure the safety of ED staff, training in assaultive behavior management should be held regularly. Staff should be able to clearly recognize precombative behavior, with a clear protocol in place in the event an incident occurs.

"It’s also important to have regular drills, so the protocol becomes second nature. Assaultive behavioral management is the CPR of mental conditions," says Ronald Rae, MD, RPh, DAPN, FACEP, medical director at San Diego County Psychiatric Hospital’s ED, the largest psychiatric ED in the country."It’s a cognitive and behavioral skill you should drill staff on regularly, just like CPR."

Quarterly drills are ideal for EDs, he says. "I don’t think enough time is spent training staff in this," he adds. "A big mistake is when there is a code [announced indicating a potentially violent patient], but no one assumes leadership. Then, when something [violent] does happen, everybody is trying to intervene." Increasing the frequency of drills decreased staff injuries at San Diego County by 10%, he says.

A decision should be made about whether hospital security should be armed. Often, deaths can occur from patients grabbing the weapon off the security guard, he adds. "We don’t allow weapons in our facility, so police have to keep their weapons in the car."

• Educate staff. For EDs without substantial security at their disposal, frequent drills are crucial to train staff to handle a potentially violent patient. Training could be done by a nurse educator, suggests Rae. Another avenue might be to hire ED nursing staff with backgrounds in psychiatry or substance abuse, as well as emergency medicine, he adds. People trained in both areas would be a valuable asset to any ED.

• Recognize liability risks. Psychiatric patients are more likely than others to refuse treatment. In that scenario, a mental status exam needs to be given to assess the patient’s mental capacity. (See the related article on standardizing the mental status exam, p. 30.) "If you have a patient who is combative or intoxicated, they may not have the capacity to make an informed refusal of care," says Rae. "The tendency is to say, ‘Go ahead and leave,’ but realize that the patient can come back later with a claim."

• Be prepared to restrain a patient if necessary. The ED’s policy should address how restraint will be handled when the time comes. "You need to have an organized show of support and a code system," says Rae. San Diego County’s ED uses a code green if a staff member senses that a patient is becoming violent. The person who calls the code usually continues to run it, and four other people arrive to restrain the patient’s limbs.

"Sometimes the person calms down and can be redirected, but other times they escalate. In that case, we set firm limits, such as ‘Sit down and take your medication,’" says Rae. "If they don’t, a signal is called to restrain the patient. Often, staff do get injured from the trauma of pinning someone down, even if it’s just a minor bump or bruise. Last year, there were 30 such injuries reported, but as a psychiatric facility, the ED sees code greens every day. Regular training keeps such incidents to a minimum," he says.

It’s important to have adequate restraints on hand. "You need firm leather restraints, but some EDs use soft terry cloth restraints, which aren’t as durable," says Rae. "They’re used to medical restraints. The problem is, a person can tug and get out of them and can actually hurt themselves more because the band is narrower and puts more pressure on the skin."

• Consider directing psychiatric patients to a designated ED. It’s impractical to suggest that a low-volume, rural ED should designate space specifically for psychiatric patients. However, when an incident occurs, a restraining area might be needed. Therefore, some EDs might consider having a similar arrangement for psychiatric patients as with severe trauma patients, who are directed to a regional trauma center, suggests Rae.

"It might make sense to have a designated ED, which is better able to handle psychiatric emergencies," he adds. "It’s ideal to have a couple of semi-soundproof rooms for seclusion and restraint, with a bolted-down bed. That way, you could wheel a gurney into it with the patient tied to the gurney, and, if they de- escalate more, you can take them from the gurney and just leave them in the room in locked seclusion."

Every state has different requirements, but most require 15-minute checks for patients in restraint or seclusion, regular rotation of limbs if a patient is in restraint, and documentation of bathroom privileges.

"It’s pretty labor-intensive, so you can see why EDs haven’t jumped to doing this," says Rae. "If you build it, they'll come, and often these people are indigent, so it’s left back to the counties to provide it. Now, with cutbacks, they’re talking about eventually closing us down and dumping the patients back into the community EDs, which might force directors to develop a better plan."

• Recognize warning signs. It’s important to respond quickly to any signs of impending violence. The biggest mistake non-psychiatric EDs make is not being aggressive enough in identifying a potentially assaultive patient, says Rae.

"Look at the patient in the waiting room and see if he is agitated, pacing, or yelling. If I saw that, I would realize there is potential for violence, so I’d take at least one other person with me to the waiting room," says Rae. "I stand eight feet away from the patient and ask how I can help them. If they clench their fists or make any threats, I’ll probably call a code green. On the other hand, the patient may de-escalate, sit back in the chair, and converse with you."

If law enforcement officials bring a patient into the ED who is behaving in a hostile manner, it is important to restrain the patient before the police leave. "If they’ve been combative out in the field in transport and arrive handcuffed and resisting, yelling, or making verbal threats, they’re an automatic Level 3, which means we’d have the police put them down on a gurney and in restraints," says Rae.

• Keep abreast of trends in drug abuse in your region. Violent or disoriented behavior is often linked to drug use. Cocaine or crack use tends to cause an acute panic disorder, presenting with chest pain or hyperventilation, while other drugs cause different symptoms.

"This area is inundated with methamphetamine, which is a more behaviorally dangerous drug than cocaine because it lasts so long in the body," says Rae. "People come in quite delusional and combative, with sleep deprivation and intense paranoia. They’ll respond to a caregiver as somebody who will harm them."

The drug accounts for fully 25% of the ED’s arrivals, he adds. It’s cheaper than cocaine because it has a longer life, and users get more mileage out of it. Also, there has been a crackdown on international cocaine markets, and methamphetamine can be made in bathtubs or toilets, says Rae. "It’s a real epidemic here, and I think it will be increasing across the nation."

• Link with local organizations. St. Joseph’s Regional Health Center in Bryan, TX, works closely with a state organization to provide placement for patients who are having psychiatric emergencies. Trained mental health staff at Mental Health/Mental Retardation (MHMR) Services assist with both voluntary or involuntary commitments.

"That keeps the physicians and nursing staff from having to spend hours on the phone, dealing with all the paperwork, and getting the notary signatures," says Sheila Hejl, RN, assistant director of nurses for the hospital’s ED. "The arrangement decreases the amount of time the patient is in the ED. In our area, we didn’t have a psychiatric call schedule, so we had to call psychiatrists and ask them to come in, and sometimes it would take a very long time," she explains.

MHMR staff are now used as consultants on-call. "They help us with the disposition, and they also know the resources that we can utilize to help patients after they are discharged from the ED," says Hejl. They help us deal with the various entities that provide care for mental health patients, from day care outpatient facilities, to counseling, to group therapy, to state inpatient facilities.

The arrangement is helpful to ED staff who don’t see psychiatric patients regularly. "This is one of the most difficult types of patients to deal with because we don’t routinely see them," says Robert Patton, MD, FACEP, medical director of the ED at St. Joseph’s. "Collaboration with the mental health experts who work daily in this environment gives us a heads up on dealing with this patient and getting them the proper treatment."