Guidelines Help ED Nurses Identify Behavioral Health Patients

Emergency departments across the United States are seeing an increase in patients with behavioral health and substance abuse issues. A report by the Agency for Healthcare Research and Quality found that the ED visit rate for mental health/substance abuse diagnoses increased 44% from 14.1 to 20.3 visits per 1,000 population between 2006 and 2014. In 2018, nurses in Cleveland Clinic Fairview Hospital’s emergency department formed a task force to create guidelines to quickly identify patients with behavioral health problems and ensure their safety and continuity of care.

“We wanted to make sure that all potential behavioral health patients were identified regardless of the underlying cause to avoid possible issues with elopement, agitation or harm to themselves or others,” says Lisa Montanaro, BSN, RN, CEN, EMT-P, a clinical nurse in Fairview Hospital’s emergency department and a member of the task force.

An algorithm guides nurses’ decision-making

The task force, which included ED nurses from all experience levels and shifts, held several roundtable discussions to discuss the challenges of identifying and caring for patients with behavioral health issues. The group referenced hospital policy, as well as admit and transfer processes for behavioral health patients, then developed standard-of-care guidelines for the population that were subsequently approved by ED leadership.

The guidelines utilize an algorithm to help nurses rapidly ascertain the appropriate next steps upon patient arrival in the ED room. First, nurses determine if the patient has impaired judgement, including the following:

• Suicidal/homicidal thoughts or acts.
• Psychiatric episode/mental health crisis.
• Substance abuse/overdose/addiction problem.
• Confusion/dementia/delirium.

If a patient meets those conditions, or the nurse suspects an issue but is unclear, then a physician or physician’s assistant is called upon to examine the patient immediately. If the patient is deemed a flight risk, then he or she is not permitted to leave the ED and several safety measures are immediately enacted.

“Our caregivers stay with that patient until a provider comes in and does an evaluation,” says Montanaro. “If the provider states the patient can’t leave the ED on his or her own, then we place the patient in a violet gown to stand out from other patients.” No other patients in the hospital wear violet gowns, so they are easily identifiable.

In addition, nurses inform security personnel about behavioral health risk patients, and the patient’s belongings are searched and scanned with security wands. All belongings, including mobile phones, are placed in a designated locker. Caregivers slide a door over the head wall to lock away all cords and monitors, unless needed. Nurses put a “suitcase” marker on the room door to indicate the patient is a flight risk. Finally, the algorithm leads nurses through other steps to take depending on whether or not the patient requires a sitter.

Education contributes to successful roll-out

An equally important measure to creating the behavioral health patient guidelines was educating nurses on the guidelines and assessing their understanding. Montanaro and others on the task force educated all nurses during a session devoted to other nursing competencies. (New nurses are educated during onboarding.) Then, laminated algorithms were placed in patient care areas and at the lead nurse’s desk for quick reference.

Montanaro also conducted pre-education and post-education assessments to ascertain nurses’ understanding and retention of the information. The assessments included five different patient scenarios related to at-risk discharge behaviors and the nurse’s ability to identify the following about each patient in the scenario:

• Does the patient have the capacity to make his/her own decisions?
• Is the patient allowed to leave on his/her own?
• How soon does the licensed independent practitioner (LIP) need to see the patient?
• Should all belongings be removed and secured outside the patient room?
• Should the violet observation gown be used?
• Should additional safety measures by taken, such as a remote or bedside sitter for continuous observation?

“We wanted to duplicate scenarios that happen in real life to see if nurses were making the right decisions,” says Montanaro. After conducting education sessions, the percentage of correct responses from caregivers increased from just over 40% to nearly 80%.

Montanaro and Kelley Mariner, ADN, RN, a clinical nurse in the ED, member of the task force and co-chair of the department’s Shared Governance Council, presented a poster about the guidelines entitled “Can This Patient Leave?” during Shared Governance Week in 2019. Last year, implementation of the behavioral health patient guidelines also received a Cleveland Clinic Innovation Inventory Award, which recognizes innovative ideas brought to life by individuals or teams within their units or departments.

“Since implementing the guidelines, our staff is much clearer on expectations and how we explain our actions to patients,” says Montanaro. “Consistency in care and safety are the biggest benefits of this new best practice.”