The environment of the emergency department is often stressful, but it can be especially traumatic for patients experiencing behavioral health emergencies. Mara Laderman, IHI’s Director of Innovation, sat down with us to talk about how a trauma-informed care approach can yield better outcomes for patients and providers.
What is trauma-informed care? How does it differ from how behavioral health emergencies are typically addressed?
Trauma-informed care is an approach that is applicable to any part of the health care system, but is especially effective for rethinking how care is provided in the emergency department (ED) and improving interactions between patients and providers. The goal of this approach is to deliver care that understands the impact of trauma and proactively seeks to avoid retraumatizing patients while providing supportive, high-quality care.
The physical environment and policies of the ED can unintentionally retrigger individuals who have a history of trauma and are experiencing a behavioral health emergency. In many hospitals, when a patient experiencing a psychiatric emergency arrives at the ED, they’re often asked to surrender their clothes and personal belongings in exchange for scrubs that differ in color from those of other patients. Staff who are pressed to respond to emergencies as quickly as possible can communicate in ways that exacerbate the stress patients are already experiencing. These protocols are established to ensure patients stay safe, but can inadvertently dehumanize patients and further stigmatize those experiencing mental health challenges.
What would trauma-informed care in the ED look like? How would it benefit patients, families, and providers?
One key component of trauma-informed care is reshaping the environment to avoid retraumatizing patients. Patients experiencing a psychiatric emergency are often required to wait for long hours in either a hallway or a ligature-resistant room to prevent self-harm. This sterile and unfamiliar environment, combined with the overall stressful environment in many EDs, can further traumatize individuals. Some EDs are redesigning waiting areas to provide a sense of comfort and normalcy by adding recliners and distracting activities such as games and television. This space allows staff to monitor patients in a more relaxed environment apart from the ED without implementing dehumanizing and, often, counterproductive protocols.
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Another key aspect of trauma-informed care is raising awareness among staff about the impact that trauma has on both patients and staff. Partnering with peer coaches can provide effective support for patients experiencing a behavioral health emergency. These coaches are especially effective because they combine lived experience with mental illness and formal training. Peer coaches can share their stories and empathize with patients as they support them through their ED visit. This partnership can help not only patients, but also peer coaches as they continue in their own recovery.
Many health systems, including those that have partnered with the Institute for Healthcare Improvement and the Well Being Trust in the ED & UP Learning Community, are working to help staff understand how their own past trauma can impact their mental health and how they provide care. Experiences from their personal and professional lives can inform how providers view and respond to their patients. Trauma-informed care training is a good place to start, but training alone is insufficient to change the culture of how the ED team approaches caring for patients with behavioral health needs.
Can trauma-informed care save costs and time for the ED?
Cost is not a primary driving factor for organizations seeking to creating a trauma-informed culture in the ED. However, costly issues such as patients returning to the ED or boarding patients (experiencing long wait times in the ED before receiving care) can both be mitigated by caring for patients with a trauma-informed approach. Many strategies for delivering trauma-informed care are not particularly expensive since there is no need to purchase new equipment or hire additional staff.
Trauma-informed care can also be helpful for improving both perceived and actual staff safety. Evidence suggests that providing trauma-informed care can reduce agitation and, thus, aggressive behavior toward staff. When we define value as patient outcomes and safety over cost, trauma-informed care is worth the investment.
Mara Laderman, MSPH, is a Director on IHI’s Innovation Team. Her recent work focuses on integrating behavioral health across the continuum of care and improving health equity.
Editor’s note: This interview has been edited for length and clarity.
You may also be interested in:
SL21: Creating the Conditions for Intergenerational Well-being
SAMHSA’s Guiding Principles of Trauma-Informed Care
WIHI – Violence Prevention and Community Health
Mental Health and Well-Being is a featured track at this year's IHI National Forum.