How Hospitals Can Improve Service and Outcomes for Psychiatric Emergencies


Phyllis Foxworth, Advocacy Vice President
Depression and Bipolar Support Alliance

Understanding patient and family considerations can have a great impact on successful outcomes when treating a psychiatric emergency. But how do we know what outcomes patients and families are seeking? To answer this question the Depression and Bipolar Support Alliance surveyed the DBSA community asking them about their experience at the emergency department when presenting with symptoms of agitation.

The 14-question survey was distributed to DBSA participants through chapter support groups, DBSA online properties and social media. Topics included experiences around intake information, sharing and discharge; rights and consent for treatment; use of de-escalation techniques; patient and family satisfaction; and return rates.

Patient-centered care
“Treat us like we’re human beings who really are in need of serious help. Just because we’re not bleeding, it doesn’t mean we’re not hurting.”—DBSA survey respondent.

In the DBSA Agitation and Emergency Care survey respondents were first asked what medical attention or symptom relief they hoped to receive at the emergency department (ED). Of the patients responding to this open ended question, 58 percent responded with answers that suggested they were seeking medical attention. Forty-two percent indicated they were seeking social services or therapy—services not traditionally provided by an ED.

Family members had even higher expectations that they would receive non-ED services. Sixty-one percent of family members answering this question indicated they were seeking some type of social service, a psychiatric diagnosis, or therapy for their loved. It should also be noted that, among both patients and family members, respondents anticipated that the function of the ED was to make a medication change. One family member responded: “He needed to talk to someone and probably needed to be put back on his antipsychotics.” Comments from patients included, “I thought the ER could make a medication change…” and “…I expected to be able to get the medication I needed and discharged.”

What is the role of the ED?
Emergency departments have different institutional goals and objectives for handling psychiatric emergencies. Some facilities are focused on triage, while others are better equipped to provide more extensive psychiatric treatment, including psychiatric admission. Approximately one quarter of all survey respondents indicated they had hoped that they or their loved one would be admitted. It is not clear if they understood whether or not the ED was associated with a hospital that even offered psychiatric in-patient services. Unfortunately, the public is usually unaware of these nuances and, in a time of crisis, these distinctions are not front-of-mind.

One way the ED can narrow the gap between public perception and actual services rendered is through community mental health outreach. With most medical emergencies, once the acute condition has been resolved, the patient is released with a list of referrals for long-term treatment or follow-up of the condition that brought them to the ED in the first place. Yet the DBSA Agitation and Emergency Care survey revealed that overwhelmingly patients and family members are not generally provided with information about community behavioral health centers or a list of psychiatrists. One study reveals that seventy six percent of ED directors reported limited availability of community based mental health referrals for discharged patients.

One way to ease the ED staff’s burden of educating patients and loved ones is to ask the hospital’s community liaison staff to develop relationships with local support groups such as DBSA or NAMI chapters. These local organizations provide support group meetings for both individuals living with mood disorders and their family members and can often provide group participants with a list of local mental health resources.

In addition to providing information about mental health resources, the hospital can train staff to better understand the stress patients and family members are experiencing. Training should include awareness that the public may have a different perception of services offered by the ED than that of the staff. By understanding this service gap perception upfront, staff is in a position to better assist both patients and family members navigate what for them is a complex medical system.

These strategies not only create the opportunity to better serve patients, but also have the potential to reduce the return rate. Sixty percent of all respondents indicated that they or their loved one returned to the ED within a year, and 34 percent within 60 days. Perhaps this high rate of return ED visits could be reduced if referral information were routinely provided by trained and compassionate staff.

The role of peer support.
The goals of the ED staff include stabilizing the patient’s acute symptoms and referring the patient for the appropriate follow-up care. A therapeutic alliance not only helps achieve these goals, but lessens the trauma. Having a positive first experience can go a long way in creating the desire and motivation for the patient to pursue long-term treatment once discharged from the ED. This has long-term benefits for only the patient, but the ED as well in the form of reduced return visits.

One strategy to support these goals is to employ peer-specialist. Many of the challenges that have been identified in delivering patient-centered care and achieving patient-centered ED outcomes could be resolved with the addition of peer support specialists on-staff. For example, a peer support specialist trained in de-escalation techniques could assist patients in identifying their preferred courses of treatment and communicating the requests to the medical staff. They could stay with the patient throughout treatment, assisting them in staying calm and working with them on a discharge plan and follow-up care—freeing the medical staff to attend to other medical emergencies and reducing costly boarding.

Editor’s note. This post includes excerpts from a publication Ms. Foxworth contributed to: The Diagnosis and Management of Agitation by SL Zeller, KD Nordstrom and MP Wilson. Cambridge: Cambridge University Press, 2017. Hardbound, 292 pages. It is currently available on Amazon in hardcover and Kindle formats.

Additional Reading

On Care for Your Mind

Your Turn

  • What recommendations do you have to assist the ED in delivering a more patient-centered experience when you or a loved one visits the emergency department?

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