Practice Tips

Many behavioral health patients turn to hospital emergency departments when they are in crisis. 

Patients who present to an emergency department in a mental health crisis are evaluated by the emergency department providers in consultation with mental health providers employed or contracted either by the hospital or from community mental health centers. Patients meeting admission criteria may be admitted voluntarily or involuntarily. Involuntary admission orders must follow strict criteria based on state statutes and other regulatory requirements.

How hospitals care for patients awaiting psychiatric admissions, whether the hospital provides psychiatric services or the patient is awaiting transfer to another facility, varies from hospital to hospital. Some organizations keep these patients in secure rooms in the emergency department, while others opt for admitting the patients on observation status to one of their medical/surgical units or the intensive care unit, depending on their level of care. Wherever the hospital holds the patients awaiting placement, there are many factors to consider. 

Develop a Plan

In the American Hospital Association’s publication, Behavioral Health Challenges in the General Hospital,a task force examining these issues recommends that organizations assess the behavioral health needs and resources of their community and use this information to develop a Hospital Behavioral Health Plan. The report goes on to state, “Hospital leaders should work with community agencies and support services with state and local governmental authorities to ensure that all patients are treated in the most appropriate setting so that the hospital’s backstop role is appropriately limited.” 

While hospital leadership works to develop a plan, staff need processes to care for behavioral health patients. Some of the processes hospitals should consider are listed below: 

Staff Competencies

Staff working in hospital emergency departments or medical-surgical units may not have the skills necessary to care for mental health patients. Hospitals have a responsibility to ensure that their staff receives the appropriate training to care for these patients.

Hospitals should:

• Require all personnel who care for behavioral health patients, including volunteers, contractors, and per diem staff, to have education, experience, and training specific to the care they provide to patients.
• Develop an ongoing skills verification process for all personnel caring for behavioral health patients. Maintain written confirmation in their human resources/education file and in the unit to assist with assignments and to identify learning needs.
• Require providers caring for mental health patients to receive ongoing continuing education on the care of these patients.
• Provide education and training on the identification of environmental patient safety factors and mitigation strategies.

Policies and Procedures

Organizations should develop policies and procedures to guide staff in caring for behavioral health patients. The following areas should be covered in these policies:

• Identified Victim: Develop a policy in line with state and federal regulations, which outlines requirements for warning an intended victim of a patient’s threat of danger. Include in the policy written documentation guidelines for staff to follow. Instruct medical staff and counseling staff on the importance of documenting the evaluation of any identified threat to a named victim. Document the time and date that the intended victim or police were notified. If the threat was evaluated and a decision was made not to notify the intended victim, document the rationale for the decision. Monitor compliance with this policy.
• Elopement: Develop policies and procedures for the prevention of elopement. Include:
  • Which patients to prevent from leaving the facility and which patients not to prevent from leaving.
  • Procedure to follow when a patient is in the act of eloping.
  • Procedures that will be followed if a patient is missing.
• Informed Consent: Develop a written informed consent policy that:
  • Identifies the specific care, treatment, or services that require informed consent, following state and federal regulations.
  • Describes circumstances that would allow for exceptions to obtaining informed consent, e.g., situations involving a threat of harm to self or others.
  • Outline when a surrogate decision-maker may give informed consent.
• Involuntary Medication: Develop guidelines for involuntary medication of patients. Periodically evaluate staff compliance and appropriate use of the protocol through observation and chart review.

Management of Behavioral Health Emergencies

Organizations should develop department-specific plans for dealing with behavioral health emergencies. Included in the plan should be a code staff can call when they need assistance. Hospitals should conduct periodic behavioral health emergency drills similar to the drills that are conducted for medical emergencies. 

Staff working with behavioral health patients should receive education on disruptive behavior and violence management. Include in the education:

• How to speak to and treat people with empathy.
• How to respond to alarms.
• Proper code to call.
• Causes of and how to recognize escalating violent behavior.
• How to prevent and diffuse volatile situations.
• How to interact with hostile individuals.
• Multicultural diversity training.
• Safe methods of restraint or escape.
• Identification of patients at risk for acute aggressive or violent behavior and management of such behavior.

Hospitals should carefully consider the role their security staff will play in dealing with behavioral health emergencies. Because many security officers are former military or police officers, they are trained to respond aggressively to life-or-death situations. They are not always trained or comfortable dealing with behavioral health patients in more empathetic ways. Security should follow clinical direction. 

Some hospitals have created teams that respond to behavioral health situations. Staff can call the team when they sense escalating behavior. The team may include nursing staff working on the psychiatric unit, social workers, staff with experience working with behavioral health patients, and security staff. Including security staff on the team allows them to be involved in the situation from the beginning rather than at the point when the situation is out of control and force may be required. Being on the team can also help security staff gain skills in dealing with patients in a more empathic manner. 

Management of Suicidal Behavior

All patients admitted to the hospital should be screened for risk of self-harm. If the screen is positive, an assessment should be performed. The Centers for Medicare and Medicaid Services (CMS) states that “non-psychiatric settings of all hospitals where patients with psychiatric conditions may be cared for must also identify patients at risk for intentional harm to self or others and mitigate environmental safety risks.” The assessment will identify patient-specific characteristics that have the potential to increase or decrease the strength or lethality of the ideation. Assessments should occur upon admission, following marked changes in the patient’s condition, during transitions between units, and before discharge. Hospitals should consider using a nationally recognized suicide assessment tool, such as the Columbia-Suicide Severity Rating Scale (C-SSRS). 

CMS does not differentiate between high or low risk of harm to self or others.

Train staff who care for behavioral health patients on the management of self-harming behavior and require demonstration of competence as part of orientation and annually thereafter.

Patients determined to be at risk for harm to themselves or others who are admitted to a non-behavioral health setting must be protected from harm. Rooms should be assessed for items such as:

• Breakable glass or mirrors.
• Non-ground fault-protected electrical outlets.
• Lighting fixtures are either not accessible or tamper-resistant.
• No plastic trash bag liners.
• Sharps and equipment removed or behind locked doors.
• Alcohol-based hand gel removed.
• Unnecessary equipment removed.
• If medical gases are not required, pressure gauges are removed.
• Chemicals are removed from the room.
• Window coverings with cords.
• Items that may be used as projectiles.

When non-behavioral health facilities are not able to remove all ligature risks, safety measures such as 1:1 monitoring with continuous visual observation and removal of the above-mentioned objects should be implemented.

Observation and sitters:
CMS does not consider 15-minute checks to be an appropriate safety measure for patients at risk of harm to themselves. If patients are determined to be at risk for self-harm and all risks cannot be removed, they must have continuous 1:1 monitoring.

All persons who work as 1:1 observers, whether paid or volunteer, should receive specific training on 1:1 observation, on understanding psychiatric patients and their role in maintaining patient safety. Training should include recognizing early warning signs and how to de-escalate a situation. For 1:1 observation to be effective, staff should be relieved of other duties. 

If volunteers or unlicensed staff members are assigned observation responsibilities, define by policy who is responsible for the observation, the type of care the individual can provide, who provides oversight of the volunteer/staff member, and who assigns the volunteer/staff member to observe the patient.

Contraband search:
Develop a policy for searching suicidal or dangerous patient belongings in the ED, at admission, and periodically during their stay. Develop department-specific policies concerning contraband items that will be taken for the patient. Restricting patient access to items that could be used in a suicide attempt is among the best methods to protect suicidal patients. Because visitors may unknowingly provide patients with items they could use to attempt suicide, they should be included in the contraband policy.

Discharge of patients at risk for suicide:
Before discharge into the community, re-evaluate patients for suicide risk. Develop discharge criteria that do not rely on denial of suicide ideation and contract for safety. Contracts for Safety are no longer the standard of care. Educate the patient and family on suicide warning signs, the importance of treatment adherence, and the removal of suicide means, particularly firearms. Provide patients with the phone number of the National Suicide Prevention Lifeline (1-800-273-TALK).

Safety plan:
Establish a Safety Plan with each patient at high risk for suicide. A Safety Plan is a prioritized written list of coping strategies and sources of support patients can use to reduce the incidence of suicide. The Suicide Prevention Resource Center has details on how to develop a Safety Plan.

Restraint and seclusion:
Train staff to evaluate patients for warning signs of self-destructive and dangerous behaviors, including risks of suicide and violence. Ask behavioral health patients or their representatives about preferred methods of de-escalating in a crisis to reduce or avoid the use of restraints or seclusion.  The CMS Conditions of Participation (CoPs) have strict requirements for the use of restraints/seclusion and the required documentation. Staff must be familiar with these requirements to ensure compliance.

To promote a safe work environment for staff, and to ensure appropriate management of patient behaviors, require patient population-specific restraint and seclusion training for staff. Include:

• Techniques to identify staff and patient behaviors, events, and environmental factors that may result in the need to use restraint or seclusion.
• Use of non-physical intervention skills (de-escalation).
• Choosing the least restrictive intervention based on an assessment of the patient and environment.
• Safe application of restraint and seclusion.
• Clinical monitoring expectations.
• Recognition and response to signs of physical and psychological distress.
• Clinical indications that restraint and/or seclusion is no longer necessary.
• Review of organizational policies related to the use of restraint and seclusion.
• Clinical documentation requirements (CMS).

Medication Management

Require staff to observe the behavioral health patient take their medication to prevent hoarding of the medication and later use in attempting a drug overdose.

Environment of Care

The hospital environment contains many hazards that patients can use to harm themselves or others. Hospitals have a responsibility to evaluate the environment and minimize risks. Hospitals are expected to implement an environmental risk assessment strategy. The risk assessment should be appropriate for their particular environment and patient population. The assessment must be appropriate to the unit and consider the possibility that the unit may sometimes care for patients at risk for harm to themselves or others. The Veteran’s Administrative Environmental Risk Assessment Tool or the Behavioral Health Design Guide are assessment tools hospitals can use to identify risks in the patient environment. Non-psychiatric facilities or units are not expected to remove all ligature risks from the environment. However, if a patient is identified as being a risk for self-harm and is admitted to an area with ligature risks that cannot be eliminated, then there is an expectation that the patient receives continuous 1:1 observation, even while sleeping.

The emergency department triage area is generally the first place a behavioral health patient will be seen. Triage rooms should be equipped with an emergency assistance notification system. Environmental hazards, such as sharp items, plastic trash can liners, and medications in the triage area, should be minimized as much as possible. Patients with suspected strong suicidal intent should be closely monitored while in a secluded triage room. 

Utility rooms on units rooming behavioral health patients should remain locked when not in use in order to prevent inappropriate access. Housekeeping carts on these units should also be locked when not in use by housekeeping staff.

If, after evaluation, it is determined that a patient poses a danger to themselves or others, they should be placed in a room free of items they might use to harm themselves or others.

Resources:

CMS Conditions of Participation, Appendix A

Suicide Prevention Resource Center. (2015). Caring for adult patients with suicide risk: A consensus guide for emergency departments. Waltham, MA: Education Development Center, Inc. sprc.org/edguide

http://www.sprc.org/sites/default/files/SafetyPlanningGuide%20Quick%20Guide%20for%20Clinicians.pdf

The Columbia-Suicide Severity Rating Scale (C-SSRS) For reprints for the C-SSRS contact Kelly Posner, PhD., New York State Psychiatric Institute, 1051 Riverside Drive, New York, New York 10032
https://cssrs.columbia.edu/wp-content/uploads/C-SSRS_Pediatric-SLC_11.14.16.pdf