Behavioral Health in the Hospital Emergency Department

Behavioral Health (Post-Pandemic)

Monica Cooke, BSN, MA, RN-C, CPHQ, CPHRM, DFASHRM

TAKE-HOME: Hospitals must be prepared for an influx of mental health patients as the Covid-19 pandemic wanes. The pandemic has led to an increase in suicide, substance use, and depression – the impact of which has yet to be fully realized. We offer insight into this issue and specific, actionable steps that healthcare organizations can take right now to help meet this challenge.

The entire population has experienced increased stress, anxiety, and worry over the past year as a result of the pandemic. In addition, many of us are struggling with severe grief from the loss of a loved one, increased depressive symptoms, and maybe even an increase in substance use. Some will recover over time without intervention, but others will inevitably spiral down. Those who might suffer from a pre-existing minor mental health or substance use disorder may become unstable and require intervention such as therapy, medication or hospitalization.

The pandemic has led to an increase in suicide, substance use, and depression throughout the world – the impact of which has yet to be fully realized in healthcare. If we believe that the “mind controls the body”, we can predict that significant numbers of persons who have acute/chronic medical or mental health conditions will require increased healthcare intervention in the not-too-distant future.

Healthcare systems must prepare for an increase in mental health presentations across the continuum of care.

What steps do we take?

First, we must determine the current state of our organization’s ability to safely treat those who are suffering acute mental health conditions to include: depression, panic/anxiety, substance use, psychosis, etc.
Secondly, leaders must make long overdue decisions related to allocation of human resources, environment of care design and implementing policy and practices that work to maintain patients and staff safety.
Lastly, we must begin to integrate mental health care into all areas of clinical practice if we hope to improve population health in our communities.

Here are some specific ED strategies to help address the increased influx of mental health patients:

Designate a specific area where behavioral patients are treated in the emergency department.
Determine if there is a unit in the organization that can act as an overflow for behavioral patients requiring admission when there are no available beds.
Modify the ED environment of care to help ensure safety.
Identify key staff with behavioral health competencies and assign them to work with this population.
Adding psychiatric advance practice staff or skilled behavioral health nurses will help ensure safety.
Stock up on “distractions” for behavioral patients to include iPads, word games, movies, arts and craft supplies, adult coloring books, playing cards, stress balls and other stress reduction items. Offer these to patients routinely.
Provide frequent interaction and conduct a risk assessment of the patient hourly in the emergency department and on the medical/surgical units.
Modify policy to allow for the visual monitoring of more than one patient by one staff. This can be stated: “Close observation is the visual monitoring of more than one patient by a staff person for safety”.
Utilize family members or friends where appropriate to assist in keeping patients safe.
Allow time for patients to be out of their room to walk – in hallways or other safe areas.
Utilize and/or offer anti-anxiety or other appropriate medications regularly to maintain patient stability.

I hope that you find these strategies useful in preventing risks and liabilities in your organization.

If you have any questions, would like a free resource, or are interested in a behavioral health or workplace violence risk assessment, feel free to reach out for a phone discussion. We also offer online Continuing Educational training classes on Behavioral Health, Domestic and Workplace Violence. Nursing CE, Physician CME and ASHRM credits are available.

Please Contact Us if you have any questions.

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New Study Shows Adequate Acute Pain Control Achieved in the ED Without Use of Opioid Medications

While an ED opioid prescription is not typically the initial source for most people who become addicted, the fact remains that we see a lot of patients with acute painful conditions and prescribe a lot of opioids. Because of this, we need to be mindful of our prescribing practices and evaluate reasonable alternatives to these highly addictive medications.

There was a recent study published in JAMA, which compared 4 types of oral analgesics for acute pain in the emergency department. It is important because it was a head-to-head comparison of non-opioid vs. opioid pain relievers.

There were approximately 100 patients in each group, and all patients had “severe acute extremity pain.” The 4 groups received:

2 Advil^® + 2 Extra-Strength Tylenol^® (Ibuprofen 400mg + Acetaminophen 1000mg)
1 Percocet^® (Oxycodone 5mg + Acetaminophen 325mg)
1 Vicodin^® (Hydrocodone 5mg + Acetaminophen 300mg)
1 Tylenol #3^® (Codeine 30mg + Acetaminophen 300mg)

The baseline Pain Score was 8.7 across all groups. At 2 hours, both the non-opioid group and the Percocet^® group improved by 50% (Pain Score 4.3-4.4). The other 2 groups had slightly less improvement, with Vicodin^® at 40% and Tylenol #3^® at 45% pain reduction.

The authors conclude, “there were no statistically significant or clinically important differences in pain reduction at 2 hours among single-dose treatment with ibuprofen and acetaminophen or with 3 different opioid and acetaminophen combination analgesics.”

This study shows that adequate acute pain control can be achieved in the ED without use of opioids for certain painful injuries.

Final Thoughts:

While important, I consider the study incomplete because the dose of acetaminophen in the opioid groups is insufficient and not consistent with that of the ibuprofen group. A single regular Tylenol^® contains 325mg, and the recommended dose is 650mg. With extra-strength, the dose would be 1000mg. Each of the opioid groups had the recommended dose of opioids, but not the recommended dose of acetaminophen, and not the dose provided with the ibuprofen group.

In my practice, I would always prescribe 2 tabs of Tylenol #2^® instead of 1 tab of Tylenol #3^®. In that way, my patients received the same opioid dose, but with the recommended acetaminophen dose.

It is possible that with the addition of 675-700mg more acetaminophen, that opioid pain relief would have been superior to the ibuprofen group. However, this is a small point in an otherwise very important study.

Category: Clinical