US emergency nurses’ perceptions of challenges and facilitators in the management of behavioural health patients in the emergency department: A mixed-methods study

Emergency nurses' perspectives on mental health boarders: An integrative review

This integrative review is on emergency department nurses' perceptions on mental health patients waiting for placement. Seven articles met inclusion criteria. Themes included violence and patient safety, psychiatry and mental health support, attitudes and beliefs, education and training, emergency department workflow and environment, and long waits in the emergency department. Future research focusing on the care of mental health patients boarding in the emergency department is needed to address this issue. A limitation was that there were no focused studies on mental health boarders in the emergency department, and information had to be gleaned from articles on caring for mental health patients in emergency departments in general.

Outcomes for university students following emergency care presentation for deliberate self-harm: a retrospective observational study of emergency departments in England for 2017/2018

OBJECTIVES

Identify university-aged students and contrast their healthcare provision and outcomes with other patients in the same age group attending emergency departments for deliberate self-harm.

DESIGN

Retrospective cross-sectional observational study.

SETTING

Patients visiting 129 public hospital emergency departments across England between April 2017 and March 2018.

PARTICIPANTS

14 074 patients aged 18-23 visiting emergency departments for conditions linked to deliberate self-harm, 1016 of which were identified as university-aged students.

OUTCOME MEASURES

We study various outcomes across the entire patient pathway in the emergency department: waiting time to initial assessment on arrival at the emergency department, count of investigations delivered, discharge destination (patients refusing treatment or leave before being seen, referred to another provider or admitted to inpatient care, discharged with no follow-up) and unplanned follow-up visit within 7 days.

RESULTS

We find a statistically significant difference of 0.262 (-0.491 to -0.0327) less investigations delivered to students compared with non-students (about 8% compared with the baseline number of investigations for non-students). Stratified analyses reveal that this difference is concentrated among students visiting the emergency department outside of regular working hours (-0.485 (-0.850 to -0.120)) and students visiting for repeated deliberate self-harm episodes (-0.881 (-1.510 to -0.252)). Unplanned reattendance within 7 days is lower among students visiting emergency departments during out of hours (-0.0306 (-0.0576 to -0.00363)), while students arriving by ambulance are less likely to be referred to another provider (-0.0708 (-0.140 to -0.00182)) compared with non-students.

CONCLUSIONS

We find evidence of less-intense investigations being delivered to patients aged 18-23 identified as students compared with non-students visiting emergency departments after an episode of deliberate self-harm. Given the high risk of suicide attempts after episodes of deliberate self-harm among students, our findings may highlight the need for more focused interventions on this group of patients.

Emergency department nurses' perceptions of caring behaviors toward individuals with mental illness: A secondary analysis

AIM

The aim of this study was to determine emergency department (ED) nurses' caring behaviors toward individuals with mental illness; and the influence of stigma on their caring behaviors.

METHOD

This is a secondary analysis of a cross-sectional study with (n = 813) ED nurses working in the United States from March 2021 to April 2021. The Caring Behaviors Inventory-24 item (CBI-24) and the Mental Illness: Clinicians' Attitudes Scale-4 (MICA v4) were used to collect data.

RESULTS

The mean CBI-24 score was 4.6 (SD = 0.8).The MICA v4 had an overall sum of 53.4 (SD = 9.2). Caring behaviors and stigma were found to have significant weak inverse relationship (r = - 0.23, p <.001). Age and level of education had a significant inverse relationship with caring behaviors (r = - 0.12; r = -. 19, p <.01 respectively).

CONCLUSION

The results of this study may contribute to the quality, equity, and safety of the emergency nursing care of individuals with mental illness, thereby improving health outcomes. It is recommended that the diversity of nurses and the characteristics of the ED be taken into consideration when designing trainings, providing leadership support, and managing resources to support the care of individuals with mental illness.

Nursing Staff's Experiences of Caring for People with Mental Ill-Health in General Emergency Departments: A Qualitative Descriptive Study

While people with mental ill-health report unsatisfying experiences and poor treatment in general emergency departments, nursing staff report a lack of adequate knowledge and training. This study describes nursing staff's experiences caring for people with mental ill-health in general emergency departments. A qualitative descriptive design was used and 14 interviews were subjected to qualitative content analysis. Results show that nursing staff are dealing with uncertainty and competing priorities when caring for people with mental ill-health. Nursing staff must both take and be given the opportunity to maintain and develop confidence and independence and need support in promoting mental health recovery.

Development of Nurse-Sensitive, Emergency Department-Specific Quality Indicators Using a Modified Delphi Technique

BACKGROUND

There is no identified set of nursing-sensitive, emergency department (ED)-specific quality indicators.

PURPOSE

The purpose of this study was to address the gap in quality indicators specific to the emergency care environment and identify a list of nursing-sensitive, ED-specific quality indicators across ED populations and phases of the ED visit for further development and testing.

METHODS

A modified Delphi technique was used to reach initial consensus.

RESULTS

Four thematic groups were identified, and quality indicators within each were rank ordered. Of the 4 groups, 21 quality indicators were identified: triage (6) was ranked highest, followed by special populations (4), transitions of care (4), and medical/surgical (7).

CONCLUSIONS

Many of the recommended metrics were questionable because they are nonspecific to the ED setting or subject to influences in the emergency care environment. Some identified priorities for quality indicator development were unsupported; we recommend that alternate methodologies be used to identify critical areas of quality measurement.

Public Health Surveillance of Behavioral Health Emergencies through Emergency Medical Services Data

Objective: To identify the demographic, clinical and EMS characteristics of events documented as behavioral health emergencies (BHE) by EMS. Methods: This was a cross-sectional study using the 2018 National Emergency Medical Services Information System (NEMSIS) Version 3 dataset. All events that had patient care provided with a documented impression (field diagnosis) of ICD-10 codes F01-F99 (i.e., mental, behavioral, and neurodevelopmental disorders) were labeled a BHE and included. Descriptive statistics were calculated. Results: A total of 1,594,821 (7.3%) EMS calls had a BHE impression. The most common was mental and behavioral disorders due to psychoactive substance use (42.3%). More males than females had BHEs (54.6% vs. 45.4%), and most patients were ages 18-34 (31.5%). Most BHE occurred in urban settings (89.6%). Almost half (47.9%) were dispatched with a complaint unrelated to behavioral health. Conclusion: BHEs were noted in 7.3% of NEMSIS events, and the majority were associated with substance use disorders. EMS professionals need comprehensive training on best practices for BHE. Stakeholders should have information on prevalence of BHEs to ensure proper educational standards, training practices, and resource allocation.

Care of patients with mental health issues in the emergency department: a quality improvement project

Mental health issues have increased significantly over the past decade in the US and emergency departments (EDs) often serve as a safety net to protect and support patients with mental health issues. However, many EDs in the US are not equipped to provide the level of advanced care that patients experiencing a mental health crisis require. This article describes a quality improvement project conducted in an ED in Colorado, US, to identify and address deficiencies in the care provided to patients with mental health issues. The care of patients with mental health issues in the ED can be enhanced through measures such as implementing a validated suicide risk assessment tool, reducing ligature risks, improving the physical environment and training staff in de-escalation techniques.

Experiences of registered general nurses who care for patients presenting with self-harm to the emergency department in Ireland

BACKGROUND

There are a substantial number of self-harm presentations to emergency departments (EDs) yearly throughout Ireland. Nurses often struggle with the psychosocial nursing interventions required when caring for patients who present following self-harm.

AIM

To explore the experiences of registered general nurses (RGN) who care for patients presenting with self-harm to the ED in Ireland.

METHOD

A qualitative descriptive study design was used to explore experiences of RGNs in caring for patients with self-harm in the emergency department. Data was collected using one to one interviews with a purposive sample of nine RGNs working in ED. Transcripts were analysed using Burnard's thematic content analysis framework.

RESULTS

Three themes emerged: 1) waiting for assessment/treatment in an unsuitable environment 2) caring for self-harming patients from a nursing perspective and 3) nurses' perceptions of self-harming patients.

CONCLUSION

Overall ED nurses hold a positive attitude towards patients who self-harm but acknowledge that barriers and challenges do exist when caring for this patient group. This study highlights the need for specific training on caring for patients who present to ED following self-harm.

Improving mental health education in nursing school

ABSTRACT

Nurses are at the forefront of providing care to individuals with mental illness in various healthcare settings, yet the World Health Organization and others have found that many nurses are inadequately prepared to provide mental health care. This article discusses the nurse's role in providing care to individuals with mental illness and the importance of integrating more mental health education into undergraduate nursing curricula.

Establishing Research Priorities for the Emergency Severity Index Using a Modified Delphi Approach

INTRODUCTION

The accuracy of an initial ED triage decision has been reported to drive the clinical trajectory for ED patients, and, therefore, this assessment is critical to patient safety. The Emergency Severity Index-a 5-point score assigned by a triage nurse and based on disease acuity, patient potential for decompensation, and anticipated resource use-is used both in the United States and internationally. In the US, the Emergency Severity Index is used by up to 94% of the academic medical center emergency departments. In 2020, the Emergency Nurses Association acquired the intellectual property rights to the Emergency Severity Index and is responsible for its maintenance and improvement.

OBJECTIVE

The purpose of this study was to establish a research agenda for the improvement of individual and institutional understanding and use of the Emergency Severity Index.

METHODS

Modified Delphi process was used with 3 rounds of data collection.

RESULTS

Round 1 yielded 112 issues, which were collapsed into 18 potential research questions in 4 general categories: education and training (6 questions), workplace environment (3 questions), emergency care services (7 questions), and special populations (2 questions). These questions were used in round 2 to establish importance. Round 3 yielded a rank ordering of both categories and research questions.

DISCUSSION

The research priorities as set through the use of this modified Delphi process align well with current gaps in the literature. Research in these areas should be encouraged to improve the understanding of educational, environmental, and process challenges to emergency nurses' triage decisions and accuracy of Emergency Severity Index assignments.

Emergency department nurses' care of psychiatric patients: A scoping review

The emergency department (ED) is a difficult place for psychiatric patients. However, individuals with mental illness often use the Emergency Department as a primary source of healthcare. This study was conducted to identify and examine published literature related to ED nurses' care of individuals with mental illness and to identify associated research gaps. A scoping review within the Arksey and O'Malley [11] framework was undertaken to answer, "what factors influence ED nurses' care of individuals with mental illness?" Sixteen studies met the inclusion criteria. The PRISMA method [16] was used to illustrate the flow of studies. The review resulted in three main themes influencing ED nurses' care for psychiatric patients. These were concerns related to environment; beliefs and perceptions; and knowledge and confidence. The results are described and framed within Biddle's role theory [33], and the gaps in the literature related to research and recommendations for specific investigations are presented.

Counseling Suicidal Patients About Access to Lethal Means: Attitudes of Emergency Nurse Leaders

INTRODUCTION

For ED patients at risk of suicide, counseling to reduce access to lethal means (including firearms) is recommended yet not routine. To enhance practice uptake, we sought to examine the attitudes and beliefs of emergency nurse leaders concerning the acceptability and effectiveness of lethal-means counseling.

METHODS

We invited a nurse leader (ED nurse manager or Chief Nursing Officer [CNO]) at each hospital-based emergency department in the 8-state Mountain West region of the United States to complete a closed-ended telephone survey. Questions assessed current practices and leaders' views on suicide prevention and lethal-means counseling. Reponses were weighted to all eligible hospitals to adjust for nonresponse.

RESULTS

From 363 eligible hospitals, 190 emergency nurse leaders responded (overall response rate: 52%). Emergency nurse leaders thought providers at their emergency departments did an excellent job of safety counseling (74%) for suicidal patients. Most respondents believed that talking about firearms with suicidal patients is acceptable to patients (77%), supported by hospital administration (64%), effective in preventing suicide (69%), and something that providers should do (91%). However, the majority also had doubts about whether suicide is preventable (60%).

DISCUSSION

Despite expressing high levels of support for the acceptability and effectiveness of lethal-means counseling, high proportions of emergency nurse leaders expressed skepticism regarding the preventability of suicide, a finding consistent with previous work. Our results support the need to address and modify misperceptions about prevention of suicide in any efforts for widespread implementation and dissemination of lethal-means counseling.

Economic Evaluation of Midazolam-Droperidol Combination, Versus Droperidol or Olanzapine for the Management of Acute Agitation in the Emergency Department: A Within-Trial Analysis

BACKGROUND

The combination of midazolam and droperidol has proven superior to droperidol or olanzapine monotherapy in the management of acute agitation in emergency departments (EDs).

OBJECTIVE

This is the first economic analysis to evaluate the cost-benefit and cost effectiveness of the midazolam-droperidol combination compared with droperidol or olanzapine for the management of acute agitation in EDs.

METHODS

This analysis used data derived from a randomised, controlled, double-blind clinical trial conducted in two metropolitan Australian EDs between October 2014 and August 2015. The economic evaluation was from the perspective of Australian public hospital EDs. The main outcomes included agitation management time and the agitation-free time gained. Sensitivity analyses were undertaken.

RESULTS

The midazolam-droperidol combination was the least costly regimen (Australian dollars [AU$]46.25 per patient) compared with the droperidol and olanzapine groups (AU$92.18 and AU$110.45 per patient, respectively). The main cost driver for all groups was the cost of the labour required during the initial adequate sedation. The combination afforded an additional 10-13 min of mean agitation-free time gained, which can be translated to additional savings of AU$31.24-42.60 per patient compared with the droperidol and olanzapine groups. The benefit-cost ratio for the midazolam-droperidol combination was 12.2:1.0, or AU$122,000 in total benefit for every AU$10,000 spent on management of acute agitation. Sensitivity analyses over key variables indicated these results were robust.

CONCLUSIONS

The midazolam-droperidol combination may be a cost-saving and dominant cost-effective regimen for the treatment of acute agitation in EDs as it is more effective and less costly than either droperidol or olanzapine monotherapy.

Assessing for Occult Suicidality at Triage: Experiences of Emergency Nurses

INTRODUCTION

Screening for suicidality is a critical nursing function at the initial ED encounter. Suicide is the tenth leading cause of death in the United States, and a substantial percentage of people who die by suicide present for health care in the year before their deaths. The emergency department provides health care professionals with a critical opportunity to identify patients at risk for suicide and intervene appropriately.

METHODS

Qualitative exploratory study using focus-group data.

FINDINGS

Effective and accurate suicidality assessment occurs not by asking a single question but also with the assessment of patient behaviors and presentation (appearance, hygiene, etc). When emergency nurses suspected occult suicidality, additional actions (finding private space, keeping patients safe, and passing on information), took priority.

DISCUSSION

The Joint Commission recommends using clinical judgment tools for the final determination of safety for a patient at suspected risk of suicide, as research findings suggest that a screening tool can identify persons at risk for suicide more reliably than a clinician's personal judgment. Our participants report that when they assessed suicide risk at triage, it was usually by asking a single question such as "Do you have thoughts or plans to harm yourself?" and they expressed concern about the effectiveness of doing so. Participants described their efforts to improve suicide screening across the duration of the patient's ED stay through an iterative process of assessment that included further probing and eliciting, evaluating, and reacting to the patient's response.

Use of a Standardized Procedure to Improve Behavioral Health Patients' Care: A Quality Improvement Initiative

PROBLEM

Meeting the complex needs of behavioral health (BH) patients in the emergency department is an ongoing challenge. Delays in care can have adverse consequences for patient and staff safety and delay transfer to specialized care.

METHODS

A quality improvement, nurse-driven initiative using a standardized procedure (STP) was developed and implemented in our busy Southern California Emergency Department, which focused on improving time to first medication and reduction of restraints. The project used a multidisciplinary team to develop the STP scoring tool and corresponding medications. Improvement was seen in all quality metrics. Time to first medication decreased from 43 minutes to less than 5 minutes. Adopting the STP resulted in a 50% decrease in use of restraints and time in restraints. Staff injuries remained low, with less than 3.6% of staff sustaining physical injuries.

DISCUSSION

The STP is an effective method to initiate immediate treatment of patients with signs of anxiety and aggression and thus reduce risk of violence. Additional benefits are reduced time to disposition and earlier initiation of specialized BH care. This process can be replicated in other emergency departments with similar clinical environments through the use of STPs or protocols based on state regulations. Contribution to Emergency Nursing Practice.

Don't Label Me: A Qualitative Study of Patients' Perceptions and Experiences of Sedation During Behavioral Emergencies in the Emergency Department

OBJECTIVES

Behavioral emergencies are commonly seen in emergency departments (EDs). Acutely agitated patients can be difficult to manage and sedation may be required to decrease dangerous behavior and to ensure the safety of both the patient and the staff. While the experience of staff caring for this population has been reported, patients' experiences with their overall management remains unknown. We aimed to describe the perceptions and experiences of patients regarding the use of sedation during acute behavioral emergencies.

METHODS

Face-to-face semistructured interviews were conducted with adults aged 18 years or older, who had received parenteral sedative medication for the management of a behavioral emergency and were deemed capable to participate. The participants were asked about their experiences of receiving care in the ED during the episode and their perceptions of sedation. All interviews were transcribed verbatim and analyzed thematically.

RESULTS

Data saturation was reached after 13 interviews. Two broad themes emerged: trusting relationships and needs or wants following sedation. A trusting relationship is built through 1) confidence in care, 2) sedation as an appropriate treatment, 3) insight into own behavior, and 4) humane treatment. Four subthemes of needs or wants were identified: 1) empathy, 2) debrief, 3) addressing concerns, and 4) follow-up.

CONCLUSIONS

A trusting relationship was identified as crucial to minimize the negative impact of coercive measures used to manage behavioral emergencies. Participants expressed similar needs to patients presenting with medical problems. This study illustrates their needs for compassionate communication, adequate information about the treatment provided, and follow-up care.