Nurse's Station

Psychiatric Patients in the ER: Challenges Faced by Emergency Nurses



Is a Psychiatric Crisis Grounds for ER Admission?

Does a mental health crisis warrant admission to the emergency room? The answer to this question isn’t always completely clear, and it’s often ambiguous whether mental illness could or should be treated in an ER setting. This uncertainty can affect care. In some cases, patients who may very well be a danger to themselves or others might be dismissed as a nuisance.

This is especially problematic with people who self-harm. Patients who present repeatedly with suicidal behavior are challenging to treat, and with a lack of specific psychiatry knowledge and skill, many ER workers hold a negative attitude toward those who attempt or succeed at harming themselves.

The Challenges of Triage for Psych Patients

The Emergency Severity Index Version 4 does contain a brief reference to psychiatric patients, specifically in the context of level 2 (high risk). However, the ESI is broadly designed for all emergency room patients, and does not cover the subtleties of triage and ER admission for psychiatric issues. Both Canada and Australia have developed separate acuity rating systems for mental health symptoms. Australia’s Mental Health Triage Scale (MHTS) is particularly comprehensive.

The Australian reference guide recommends that triage ratings for mental health symptoms should correspond to the risk of something going wrong. It lists several factors: risk of aggression, risk of self-harm, risk of leaving, and risk of a physical or medical problem. The system incorporates a time interval, determining how long a patient can safely wait before getting medical attention.

It’s also important that emergency workers don’t make assumptions about psychiatric disturbance. There have been many cases where something appeared to be a mental health issue, but further testing revealed an underlying organic cause. Typical triage protocols like basic history and vital signs should not be overlooked.

Overall, the ESI approach to psychiatric patients is lacking in detail and guidance, making it difficult to ensure quality care. Research is needed to improve the ESI process to better accommodate the needs of mentally ill patients.

Additional Education May Be the Answer

Mentally ill patients, especially those who present to the ER with suicidal behaviors or ideations, are a massive challenge for emergency nurses. The Emergency Nurses Association has made recommendations in the past for improving education on mental illnesses for non-psychiatric nurses and physicians, as well as creating more detailed guidelines for dealing with urgent psychiatric care.

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