Improving outcomes by recalibrating our approach
When a patient arrives to an emergency department, the presenting problem is assessed and addressed with disposition determined. If the patient is there for a behavioral health reason, a cursory medical assessment is done, and then he or she is moved along to psychiatric assessments.
The challenge many of us clinicians have seen over the years is that chronic and acute medical conditions are sometimes overlooked in mental health patients who aren’t able to communicate for any number of reasons – mental state, lack of support person, level of delirium or intoxication, etc. And it’s not just at the point of entry, it continues through the care cycle.
We also know there’s an unfortunate relationship between mental illness (including substance abuse) and chronic diseases like diabetes, heart disease, and cancer.
So it’s clear to me – as I’m sure it is to many of you – that while a comprehensive assessment is difficult when a patient is in a mental health crisis, we must de-compartmentalize our approach to improve the patient’s overall care and safety.
The pandemic-driven health decline
The Covid-19 pandemic has exacerbated the situation. Research published in JAMA Psychiatry (Feb. 2021) found that the median number of emergency room visits for mental health conditions, suicide attempts, and substance abuse were higher compared to the same period in 2019. This was despite a decrease in overall emergency department visits during the pandemic. Consider, too, this CDC statistic: there were 93,000+ drug overdose deaths in 2020. The year before there were 72,000 – that’s an increase of 21,000!
Mental health emergency visits and drug overdose deaths have been on the rise during the pandemic. How can we, as a health care community, provide a safer environment for mental health patients and improve outcomes?
The mental and physical health (lack of preventive and maintenance care) of people has declined precipitously over the past 16 months. More than ever before, emergency and inpatient clinical staff need to de-compartmentalize mental and physical patient complaints and disease processes.
Do Something – STAT!
Psychiatric nurses must be able to adequately assess mental and physical stability. Acute medical conditions and events can occur at any time and we must be vigilant.
As a former nursing director, I saw situations like a seemingly minor respiratory infection progressing to sepsis and death, a patient with uncontrolled diabetes and severe hypertension experiencing a pulmonary embolism, an unknown alcoholic becoming delirious, a teenager with neurological symptoms who is found to have an undiagnosed brain tumor, and the list goes on.
Be aware and prepared
General medical practice education and skills should be reviewed and reinforced periodically to stay current – for all nurses, across all specialties. Experiences like those I saw above can cause grief for nurses who don’t feel fully prepared to manage medically compromised patients. Listening to a patient’s physical complaints is essential. Critical thinking skills must be applied.
Nurses must be proficient in performing mental and physical health assessments.
Although most psychiatric patients are not admitted for a specific medical problem, that patient may have an unidentified internal crisis brewing. Example conditions that nurses need to be aware of, even when the patient is being seen for mental health reasons:
- Alcohol Withdrawal
- Cerebrovascular Accident
- Myocardial Infarction
- Pregnancy complications
- Respiratory Distress
- Medical problems related to restraint, seclusion, and falls
- Antipsychotic medication side effects
Know when to escalate
Keep current on your knowledge of hospital escalation policies. Patient concerns or medical issues like those listed above should be escalated if the nursing staff believes a negative patient outcome may result from delayed treatment. Escalation to supervisory staff and/or event report notification should be the routine, not the exception, and align to hospital policy.
Plan and document
Accurate documentation is critical. First and foremost, for the care of your patient. But also, because we all know too well that complaints and grievances are the primary reason survey agencies visit (outside of routine surveys).
Document your observations and actions taken following escalating and acute medical issues
Include active medical problems in the initial nursing care plan and the interdisciplinary treatment plan with patient goals, target dates, and appropriate staff interventions
Update the care plan following any acute medical change or problem resolution
Notate progress, or lack of progress, toward treatment goals
Keep current with the CMS State Operations Manual, A-0396 §482.23(b)(4), which says the hospital must ensure that the nursing staff develops and keeps current a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs.
Better prepared, better outcomes, lower risk
If clinicians and nurses don’t feel fully prepared to manage medically compromised patients, it can cause them much grief and negatively affect the quality of the care they’re so committed to providing.
But also, regulatory agencies expect the same quality of patient care no matter the setting. If a patient is admitted for an acute psychiatric problem, how that patient’s medical problems are assessed, treated, managed, and documented would receive the same level of surveyor scrutiny as those of a patient in a non-psychiatric unit.
It works the other way as well – surveyors review and cite deficiencies regarding psychosocial and risk assessments, care, and referrals for emergency, labor and delivery, and critical care patients, etc.
Perspective that leads to improved care
Emergency and inpatient psychiatric care is more challenging than ever due to long-lasting medical and psychiatric effects related to the pandemic. De-compartmentalizing how we treat patients in emergency, inpatient and outpatient situations will help address some of these challenges.
Hospitals succeed when there’s broad awareness of changing patient population dynamics and the challenges faced by patients and staff alike. This can accordingly elevate the care, treatment, and services you provide.
I encourage all members of the health care community – and particularly nurses – to foster this understanding and create an environment informed by it as we seek to care for those who need psychiatric help, medical help, or both.