Safely Serving the Mentally Ill in Hospitals

One of the most challenging trends I see in the healthcare environment is the increasing influx of persons suffering from mental illness, especially into Emergency Departments. This is largely due to the closings and downsizings of community and regional mental health facilities and resources that are happening nationwide. Those with mental health issues, then, have fewer places to go and the ER is often the last and only resort, especially when they are in crisis. A police chief in a midwestern city told me that the mentally ill have two places to go for help in his city, the ER and the jail.

It should be noted that the mentally ill are not more violent than the general population and, in fact, are more likely to be the victims of violence. The concern here is that they often present at the ER when facing the stress and higher acuity of a crisis and that their entry into the ER and general hospital/clinic environment may be an escalator to disruptive behavior, especially where the environment is not conducive to such care and where staff have not been properly trained. Being held for hours, days or even weeks in an ER treatment room or hallway, surrounded by hectic activity and noise, as too often happens, would test anybody's patience and sanity. Likewise, the typical ER environment and staff mindset is fast moving and highly reactive, while mental health issues tend to be crises in slow motion, a substantial and often frustrating paradigm shift for the average ER caregiver.

The following are suggested considerations for more safely serving and caring for the mental health population, noting that much will also apply to patients and even family members who are experiencing delirium or drug or alcohol impairment:

·        Multi-disciplinary   Nothing should be planned without a multi-disciplinary approach sharing the expertise of at least those responsible for Security, Safety, Risk/Legal, Human Resources, Behavioral Health and Clinical. It is especially important to have a psychiatric/behavioral health presence. While many hospitals have the luxury of such staff on duty, many do not have such experts employed. In such cases efforts should be made to retain outside behavioral health support and guidance.

·        Staff Training   All staff who will interact with persons suffering from mental illness should receive mandatory training on how to sensitively and safely work with this population, including at least all ER and Security staff. Often related staff such as patient obervation sitters and nurse managers in general population units also receive this training. Such training should at least include understanding the various types of mental illness, how to approach, the introduction, the assessment, de-escalation, active listening, howing empathy, building rapport, physical positioning, situational awareness (including managing and owning doors), negotiating, and safely managing and responding to threatening and violent behavior.

·        Crisis Units   Many hospitals are placing separate behavioral health observation or crisis units within or adjacent to ER's in which those with more acute issues can be safely contained and served. Note that such a unit should not be, as I often see, just an open ER wing or pod with typical treatment rooms and untrained staff. Similarly, some ER's are installing dual-use treatment rooms in which a screen can be lowered to block off equipment, wires and tubes to alternately use the room as an observation or seclusion room.

·        Patient Advocate   Just like all of us, persons suffering from mental illness need to connect with other persons and they need a voice. One can feel all the more alone and fearful when surrounded by the unfamiliar, frantic and dramatic atmosphere of the average ER. Measures that can help could be patient safety reps or advocates with mental health backgrounds who work closely with the patients, gauging the milieu and providing support, early intervention and even friendship.  

·        Respectful and Engaging Culture   The hospital, as part of its nurturing and patient centric mission and values, should foster a consistently respectful, welcoming and engaging culture among all employees, no matter whom they are encountering. How one is treated during their first encounter can set the tone to follow. Although rare, I have seen hospitals where staff avert their eyes, avoid contact or send exasperated, superior, fearful or even disgusted signals when they encounter persons who appear to be suffering with mental health issues.      

·        Crisis Response Teams   While most hospitals have crisis response teams, there has been an evolution of this practice in recent years. For example, where such teams used to be the response of all able-bodied staff, the presence of a mass of onlookers does little to de-esclate and help manage the situation. The trend today is to establish teams of appropriate staff who have been trained on crisis intervention and team response. Team members understand who is taking the lead and what their various responsibilities are.

·        Law Enforcement Involvement   I'm seeing more law enforcement agencies training their officers on crisis intervention and safely and sensitively dealing with persons with mental illness. Police departments face a challenge similar to the hospitals and clinics in that they have fewer resources they can call upon to assist the mentally ill they encounter. The too frequent result is they take these folks to the nearest hospital ER, prolonging the frustrating cycle . Healthcare systems should have strong working relationships with their local law enforcement agencies. Because these agencies face a similar challenge, it may be advisable for the local or regional healthcare systems and law enforcement agencies to partner to foster the restitution of mental health resources within their communities and regions.

·        Security and Violence Management Assessments   It can be useful to commission independent and objective, interview intensive, security and violence management assessments to determine true and present risks and vulnerabilities and, in light of those, evaluate and recommend best and most cost effective procedural and physical protective measures based upon best practices and industry standards as well as the organization’s/facility’s particular culture, values, history, location, functions, layouts and budgets. Such assessments have the added benefit of demonstrating the Administration’s concern for the safety and welfare of its people as well as eliciting better buy-in for new measures and procedures.

·        Early Intervention Threat and Risk Assessments   A powerful tool to keep staff and patients safe are proactive team-based patient threat and risk assessment and management processes to as early as possible identify patients (and family members) with a proclivity toward violence, assign a level of risk and make a plan for safe care, based on the determined risk level, as the patient moves through the hospital and system. These interdisciplinary teams are often made up of representatives of Security, Safety, Nursing, Human Resources, Risk/Legal, Behavioral Health/Psychiatric and de facto members from the department or unit affected.

·        Protective Security Measures   Consider appropriate physical and procedural security measures including facility and/or unit access/egress control and prompt lockdown capabilities, local law enforcement liaison and support, reporting and trending processes, background screening, staff training, worn identification, visitor screening and management (days and evenings), video cameras and monitoring, security officer support, internal communications measures, alarms including panic/duress alarms, contraband detection, identifying escape routes and safe rooms/shelters, lighting, barriers and fostering a strong level of protectiveness, awareness, involvement, engagement and ownership by all employees. They all should know they are active members of the Security and Safety Team.

·        Patient Observations   Most states have some version of involuntary psychiatric patient hold process, often for 72 hours. I've encountered many varieties of patient observation processes from one-on-one observations, one on many, dedicated sitter teams or using security officers or whomever is available as "sitters." I've also seen problems arising from these processes including sitters allowing escalation or elopements, sitters not paying proper attention, sitters not trained, and security officers used on observations, often a major drain of security officer time and resources. Patient observation processes should be well planned, with supporting policies and crisis intervention training. Ideally, security officers should not be used for this duty unless the patient is imminently a threat to him/herself or others.

Dick Sem, CPP CSC of Sem Security Management has over 40 years’ security and violence management experience. He serves large and small healthcare systems across North America in almost every state performing comprehensive security and violence management assessments, targeted assessments (of ED, Security Department/Program, Workplace Violence Program, Accessibility, Outlying Facilities, etc.), development of related policies and plans, expert witness service and training.  

Dick Sem, CPP CSC – Sem Security Management – dick.sem@semsecurity.com – 262-862-6786