IN NORMAL TIMES, patients experiencing a mental health crisis have limited access to much-needed resources. The COVID-19 pandemic has only exacerbated the lack of access to help for patients with mental health needs. A designated psychiatric emergency service (PES) facility is one possible solution. PES facilities are designed to meet the needs of these patients at a lower cost than traditional methods of care. This article details the benefits of utilizing designated PES facilities for acute psychiatric needs and explains how a designated PES produces better patient outcomes than traditional EDs for patients in a mental health crisis. It also educates readers on how nurses can support patients who need immediate psychiatric care with a referral to a designated PES.
Mental health and COVID-19
A mental health crisis is a situation in which a person's mental state puts the person at risk for self-harm or harm to others. Any type of major life stressor can lead to a mental health crisis and severely impact a person's daily function and/or personality. In addition, the risk of suicide dramatically increases during a mental health crisis.1
Under the Emergency Medical Treatment and Labor Act, mental health crises are considered emergency medical conditions, which equates to a serious medical illness. The patient must be evaluated and not discharged until the patient is safe and stable.2
Although a mental health crisis can occur at any time, it is often triggered by a major life change. For most people, the COVID-19 pandemic has caused major life changes, including job loss and the need to take on additional supportive roles, all while being isolated from extended family and friends. As people try to adapt, increased stress levels can lead to depression, anxiety, and, ultimately, a mental health crisis.
People who never had mental health issues before the pandemic may find themselves in search of a mental health provider, only to find that offices are closed, appointments are few and far between, or telemedicine is the only option. Finding a solution to meet the unique needs of patients with mental health issues can be challenging even during normal times. To assist patients in crisis, all nurses should learn what resources are available in their community.
Traditional mental health solutions
Community-based providers, such as the National Alliance on Mental Illness and Mental Health America, typically provide reliable mental health services to patients with chronic mental health disorders. Community-based services can be effective in the areas of mental health prevention, management, and recovery. However, due largely to a lack of specialized education, training, and resources, community-based services are not calibrated to treat and care for patients with acute psychiatric emergencies.2 This limitation is intensified as community-based providers safely reopen their doors for treatment during the COVID-19 pandemic. Appointment availability has been reduced at the expense of the patient's mental health. Patients who usually have symptomatic control may see their condition worsen from lack of treatment and evolve into an acute psychiatric crisis. This group of patients must now join the group of patients without consistent care in looking elsewhere to address their immediate psychiatric needs.
With nowhere else to go, patients with acute psychiatric emergencies are usually diverted to hospital EDs. Accordingly, one of the first three discharge diagnoses is a mental health or substance abuse diagnosis.3
The high volume of patients with acute psychiatric emergencies being cared for in traditional EDs shows no signs of abatement. Psychiatric emergencies may include acute changes in behaviors, thoughts, or mood leading to an increased risk of harm to self or others, such as suicidal or homicidal ideation, psychosis, and erratic behavior. According to the Healthcare Cost and Utilization Project's trend analysis on types of ED visits from 2006 to 2014, mental health emergency visits increased 48.1%, with suicidal ideation increasing an alarming 414.6%.4
What is a designated PES?
In a designated PES, the staff is prepared to provide evidence-based solutions to patients with acute psychiatric emergencies around the clock. A designated PES is normally a stand-alone ED that is associated with an adjacent medical ED.5 Generally, it is designated as a PES by the healthcare facility it is associated with. Patients may present to the PES on their own accord or be brought to the PES by emergency medical services or police.
A designated PES has distinct advantages over a traditional ED for patients experiencing acute psychiatric emergencies. A designated PES is more cost-effective than a general ED while offering psychiatric patients compassionate care.2,6 Between 70% and 80% of patients in a designated PES stabilize successfully and return home or to outpatient dispositions in less than 24 hours.6
These services employ healthcare providers who are educated to provide rapid care.7 Their primary goal is to stabilize the patient as soon as possible. Unlike traditional EDs, a designated PES does not have a waiting room. When patients arrive, they go straight to observation and are triaged based on the level of danger to themselves or to others.
After triage, healthcare providers conduct focused medical assessments to rule out any underlying medical disorders, such as a urinary tract infection, that may be contributing to the psychiatric condition. If necessary, on-staff psychiatrists can conduct a full psychiatric evaluation followed by prompt treatment.5 Depending on the course of treatment and the patient's stability, the patient may be discharged to home or an outpatient facility or be admitted for inpatient care.2
Inside a designated PES
Most designated PES facilities have common features intended to keep staff and patients safe. Multiple checkpoints are in place with security cameras and personnel monitoring all activity. Before entering the facility, patients must hand over their belongings, which remain with security throughout their stay.
Inside a PES, the physical environment is modified to reduce stimuli and patient stress. Fewer lights and medical equipment provide a more soothing atmosphere. Anything that can be used as a weapon, including cords, outlets, or equipment is not allowed in the patient's room or vicinity. Only psychiatric beds with sealed bottoms, restraint strap attachments, and ligature-proof suicide prevention blankets are present in patient rooms.8,9
The healthcare providers, nurses, and other staff at a designated PES are key to the patient's success. Clinicians are educated on the complexities of acute psychiatric disorders, allowing them to be sensitive to the nature of the problem. Clinicians and hospital staff are provided ongoing safety training in managing behavior through verbal de-escalation techniques, prevention and management of aggression, and appropriate use of chemical and physical restraints and seclusion.5,7
The nurse's role in a designated PES is crucial to a positive patient outcome. In an American Psychiatric Nurses Association 2016 survey, 84% of psychiatric nurses said their hospitals provide education on common psychiatric issues. A large majority also stated they were not afraid of patients presenting with mental health disorders.10 Specific education and training on psychiatric disorders reduces the need for restraints, maintains staff and patient safety, and keeps patients calm.11 As a result, clinicians are better equipped to create rapport while encouraging patients to participate in their own care.
Making trauma-informed care a priority
Another distinction between traditional EDs and designated PES facilities is how clinicians' interactions with patients are guided by trauma-informed care, which considers that any patient may have experienced traumatic events, and these experiences influence the patient's behavior and coping abilities.12
The Substance Abuse and Mental Health Services Administration (SAMHSA) defines trauma as emotional harm stemming from abuse, neglect, loss, disaster, war, and other emotionally harmful events.13 SAMHSA recognizes a history of trauma as “an almost universal experience of people with mental and substance use disorders.” SAMHSA's trauma-informed approach teaches clinicians how they can provide patient-centered care by modifying their interactions with the following guidelines:
- Clinical providers and hospital staff of all levels have a basic realization about trauma and understand how trauma can affect their patient.
- Clinical providers and hospital staff can recognize the signs of trauma.
- Clinical providers and hospital staff are committed to providing a physically and psychologically safe environment by responding with the principles of a trauma-informed approach to all areas of functioning.
- A trauma-informed approach seeks to resist retraumatization of patients and staff.13-15
Social workers are commonly employed in a designated PES. Social workers who are knowledgeable about available community resources can coordinate care to ensure follow-up and continuity of care.
The type of care a patient receives in a designated PES versus a traditional ED increases the likelihood of discharge to less restrictive care than inpatient admission and reduces readmissions for the same diagnosis in a 30-day period.2 For nurses who work in areas that do not have a designated PES, see Recommendations for hospitals and traditional EDs.
Nurses should have a basic understanding of the proper steps to take with patients experiencing a mental health crisis. Patients are usually functioning at their lowest capacity during this time, so the nurse should first focus on remaining calm, expressing concern, and de-escalating the situation. If the patient is in a life-threatening situation, the nurse should call 911 and explain that the patient is experiencing a mental health crisis.1
If the patient is stable enough to voluntarily check into a designated PES, the nurse should get consent to notify the patient's emergency contact to bring the patient's health records, medications, and insurance card. The nurse should prepare the patient with what to expect in the designated PES, such as prolonged boarding times and the amount of security present, but also explain that a designated PES is the best place to go for mental health crisis, patient-centered care.
Nurses should be familiar with the location of the closest designated PES, as well as other mental health services offered in their area, in the event a referral is needed. In addition, SAMSHA publishes a yearly national directory of public and private mental health treatment facilities by state and city. The directory includes codes for the type of service offered as well as preferred language.16 Many state and city programs also offer crisis intervention at no cost. In addition, patients can be referred to a crisis intervention hotline such as the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or United Way hotline at 2-1-1. Both services are available 24/7 to provide free, confidential crisis support. Other resources are available online. (See Resources for optimal psychiatric emergency care.)
One of the most important things nurses can do for a patient is follow up after discharge. The recovery process after a mental health crisis requires ongoing care, treatment, and support.1 Patients will typically have a scheduled appointment with a mental health professional within the following weeks. Encouraging the patient to attend the follow-up appointment facilitates open lines of communication, increases engagement in the treatment plan, and decreases the likelihood of another acute psychiatric emergency.6
There are many ways in which hospitals can work to improve their services to these patients. Here are a few ideas:
- Hospital clinicians should be educated on the specific needs of mental health patients.
- An experienced mental health advanced practice nurse or psychiatrist should be available to the ED at all times, either in person or via telehealth capabilities.
- All staff should be trained in crisis prevention intervention strategies and de-escalation techniques.
- Hospitals can apply for federal aid to help improve mental health services. For example, SAMHSA's COVID-19 Emergency Response for Suicide Prevention grant can be used for any ED seeking to expand its mental health capacity through a designated PES.
Nurses can also help to raise awareness both inside and outside of their facility. This short list details various ways to get involved and make a difference:
- Depending on the hospital's budget, advocate for a designated PES in the form of a building, unit, or room.
- Continue to educate yourself about available mental health resources and patient rights.
- Volunteer with local mental health organizations and assist with programs and events.
- Combat mental health stigma by educating the community in the local media.
- Support legislation focused on the benefits of expanding mental health services and implementing fair reimbursement rates for services.
- Give tax-deductible donations to local or national mental health organizations fighting to keep mental health a major topic.
Recommendations for hospitals and traditional EDs5
What if a designated PES facility is not available in your community? Nurses should know how their traditional EDs operate when patients with acute mental health needs enter their doors. Consider the following best-practice recommendations:
- Implement mental health triage into triage protocols. Always triage with safety considerations as a priority for patients presenting as violent, aggressive, or suicidal.
- Fully scan the patient and all belongings with a metal detector (handheld wand or walk-through scanner).
- Remove all of the patient's belongings, including streetwear, and store them with hospital security.
- Provide the patient with paper scrubs.
- Set up safe areas or rooms in the ED away from high-traffic areas. These safe areas should include safe beds, linens, and soothing lights that are approved for use with psychiatric patients. Remove all devices that could be used as a weapon and items that could be used as ligatures.
- If an in-patient mental health unit is on hospital grounds, have an experienced mental health nurse available for consultation in the ED.
- Assign an experienced mental health technician, safety companion, or member of the ED staff to keep watch over the patient and maintain security in the immediate vicinity at all times, if possible.
- Calmly communicate expectations to reduce increasing anxiety and assess the patient holistically.
- Keep the patient informed about the plan of care.
- Obtain collateral information if possible regarding the patient's history and condition.
- Conduct a mental status exam and use valid screening instruments or tools to assess suspected mental health conditions.
Resources for optimal psychiatric emergency care
Nurses, nurse leaders, or hospital leaders can use the following resources to help ensure that, whether through a designated PES or through the general ED, their hospital is providing optimal psychiatric emergency care for patients.
- SAMHSA's National Guidelines for Behavioral Health Crisis Care — A Best Practice Toolkit
- This toolkit, provided by the federal government, was designed to advance national guidelines in crisis care and help healthcare providers, mental health authorities, and other stakeholders develop a successful structure for crisis systems that meets community needs.
- Emergency Care Psychiatric Clinical Framework
- The American Psychiatric Nurses Association offers this clinical framework for emergency psychiatric care to help hospitals provide a consistent practice model for patient care. This document includes six principles for providing emergency psychiatric clinical care as well as a list of clinical evaluation guidelines.
- The Joint Commission
- The Joint Commission's website lists its requirements for compliance with National Patient Safety Goals (NPSG) 15.01.01 regarding suicide prevention in healthcare settings. This NPSG is designed to improve the quality and safety of care for those treated for behavioral health conditions and those who are identified as high risk for suicide. Additionally, The Joint Commission's site offers additional resources, including general suicide reduction tools, webinars, and more.
1. National Alliance on Mental Illness. Navigating a mental health crisis: a NAMI resource guide for those experiencing a mental health emergency. 2019. www.nami.org/Support-Education/Publications-Reports/Guides/Navigating-a-Mental-Health-Crisis/Navigating-A-Mental-Health-Crisis
2. Zeller S. Hospital-based psychiatric emergency programs: the missing link for mental health systems. Psychiatr Times
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4. Moore B, Stocks C, Owens P. Statistical brief #227: trends in emergency department visits, 2006-2014. Healthcare Cost and Utilization Project. 2017. www.hcup-us.ahrq.gov/reports/statbriefs/sb227-Emergency-Department-Visit-Trends.pdf
5. Rubio-Valera M, Luciano JV, Ortiz JM, Salvador-Carulla L, Gracia A, Serrano-Blanco A. Health service use and costs associated with aggressiveness or agitation and containment in adult psychiatric care: a systematic review of the evidence. BMC Psychiatry
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8. Norix Group Inc. Psychiatric beds, mental health bed, behavioral healthcare bed. 2020. www.norix.com/markets/healthcare
9. Ferguson Safety Products. Suicide prevention products. 2020. www.preventsuicide.com/suicide-prevention-products
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12. Molloy L, Fields L, Trostian B, Kinghorn G. Trauma-informed care for people presenting to the emergency department with mental health issues. Emerg Nurse
13. Substance Abuse and Mental Health Services Administration. SAMHSA's concept of trauma and guidance for a trauma-informed approach. 2014. www.store.samhsa.gov/system/files/sma14-4884.pdf
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16. Substance Abuse and Mental Health Services Administration. Behavioral Health Services Information System Series: National Directory of Mental Health Treatment Facilities
. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2020.