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"Emergency Departments are often very challenged to care for individuals with mental health and substance use disorders, and it is not for lack of trying."
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Is Culture the Key to Improving Behavioral Health Care and Staff Experience in the Emergency Department?

By Mara Laderman | Wednesday, March 4, 2020

Culture in the ED

Photo by Shane Avery | Unsplash

If you are having a stroke and go to an emergency department (ED), the team has a plan for what to do. There are protocols for a variety of situations faced in the ED, such as heart attacks and gunshot wounds — so teams know how to quickly provide the right care.

In contrast, when a person who has attempted suicide or is experiencing a psychotic episode arrives, EDs often lack similar kinds of protocols. This disparity exists even though people struggling with behavioral health crises often seek care in emergency departments.

EDs are often very challenged to care for individuals with mental health and substance use disorders, and it is not for lack of trying. There has been a lot of good work in this area, but outcomes and experiences for patients, families, and ED staff can unfortunately be quite poor.

Learn how IHI's Customized Services team can help you improve behavioral health care in the ED

For many ED staff, working with patients with mental health and substance use disorders can be particularly challenging. Many health professions programs do not provide enough training on how to care for this population. As a result, some staff may be wary of caring for these patients because they do not know how best to help them.

To address this, IHI and Well Being Trust partnered on an initiative called ED & Upstream (ED & UP) to develop and test a theory of change that takes a systems approach to this problem. We theorized that by working in the health system, the community, and at the interface of the two we can make more meaningful improvements than focusing on one isolated part of the system. We partnered with eight hospitals from around the country to test a set of changes, measure progress, and demonstrated that we can make meaningful change if we can take a systems approach.

One outcome of this work is the IHI Improving Behavioral Health Care in the Emergency Department and Upstream white paper. It presents the results of the ED & UP initiative and walks through the four components of the framework we developed. It also shares improvement stories and gives health systems practical tips and guidance to put these changes into action.

The Importance of Culture Change

Many health systems come to this work saying, “How can we do a better job for this population and for our staff?”

An important aspect of this work is addressing the stigma attached to individuals with behavioral health needs. This stigma has been a big part of why behavioral health patients are treated differently than patients experiencing a medical crisis. One way to address this is to help staff understand that a behavioral health crisis is equivalently serious to a medical crisis. Someone who is having a behavioral health crisis is in as much distress as somebody who has, for example, a broken arm or chest pain.

Another important change is providing what is often called trauma-informed care or creating a trauma-informed culture. Training staff to understand the impact that previous trauma has had on patients, and how that translates into both their experience with mental illness and their experience in the emergency department, reorients the way in which staff interact with patients.

Understanding how trauma might be influencing what is happening in the ED is very powerful. It is not only important for staff to understand the histories of their patients, but also for staff to appreciate the impact their own trauma — their experiences with agitated patients, for example — might affect how they interact with patients.

Hoag Memorial Hospital Presbyterian in Newport Beach, California, one of the participants in ED & UP, implemented a trauma-informed care training for their staff and made it a requirement for new hires as part of their onboarding. The hospital then had a patient come in who was having delusions. The patient became very agitated because they thought an antianxiety medication was being pumped through the air vents.

Instead of arguing that no medications were coming out of the vents, they talked to the patient calmly. They said, “We’re going to go ask our facilities team to look into that,” and told the patient that the vents were turned off. Rather than saying, “No, that’s not happening,” they met the patient where they were and changed the way they communicated.

The usual protocol might have led to the patient being restrained or sedated. Instead, the ED team was able to calm the person. This required no additional resources or extra work. Once the patient was no longer agitated, the care team was able to initiate treatment. It led to a better experience for both the patient and the staff.

The ED & UP work helps demonstrate that it is possible to change the culture within the emergency department. We can help staff feel more comfortable and more confident when working with patients with behavioral health needs. The ED can also be more than just a way station for people with behavioral health issues, where the current options are typically admission to an inpatient psychiatric unit or discharge home with a referral. Much can be done in the ED that might benefit the patient, help them better access services in the community, and potentially even negate the need to send them to an inpatient psychiatric unit. All this translates into a better experience for patients, families, and staff.

Mara Laderman, MSPH, is a Senior Director on IHI’s Innovation Team.

Editor’s note: This interview has been edited for length and clarity.

(Having difficulty watching this video? Watch on YouTube.)

You may also be interested in:

The IHI Improving Behavioral Health Care in the Emergency Department and Upstream white paper

4 Keys to Improving Behavioral Health Care in the Emergency Department

WIHI podcast — The Benefits of Behavioral Health in the ED

How Trauma-Informed Care Can Help During Behavioral Health Emergencies

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