Care and Safety of Mental Health Patients in Hospital Settings
June 1, 2017
The Emergency Medical Treatment and Active Labor Act requires that all hospital Emergency Departments (EDs) medically screen all patients seeking care in the ED—including evaluation and stabilization of patients suffering from mental illness. According to the Agency for Healthcare Research and Quality up to 12 million Emergency Department (ED) visits per year, or about one out of eight patients, are patients suffering from some form of mental health disorder or substance abuse. The impact these patients have on the ED and hospital is far greater than the impact made by other types of patients. Many of these patients are suicidal and present a host of safety issues to themselves and others. Elopement is a risk among these patients; they are likely to run away if given the opportunity. Mental health patients greatly impact hospital staffing resources. During an interval suicide watch, patients must be checked on by a nurse, doctor, or guard to ensure that he/she is well, usually every 15 or 30 minutes. In severe cases, a patient is placed under continuous watch, where a sitter is within arm's reach of the patient.
A poll from the American College of Emergency Physicians found more than one in five emergency physicians stated they have patients waiting two or more days for in-patient psychiatric beds, otherwise known as patient boarding. This is in part because many emergency rooms are not equipped to handle people with serious mental health issues. They do not have psychiatrists or other mental health clinicians on staff to assess and treat mental health problems. Compared with other types of patients, people with mental health conditions rely more on the emergency department for treatment and are more often admitted to the hospital from the ED. In addition, there is a shortage of mental health facilities and beds.
Many technology based practices are being leveraged to ensure the safety of patients and reduce the impact of caring for patients while in the ED and as an inpatient.
Emergency Department Tools
ED’s are using a variety of measures to protect the safety and well being of mental health patients and others. A majority utilize physical sitters or security for the monitoring of mental health patients. Other EDs use high definition (HD) video cameras to assist in monitoring. Video cameras monitored by guards are placed within an ED to protect the safety of staff and visitors. They are placed in the entry leading into the ED, hallways, and nursing stations. The guard monitors the video feeds and communicates with staff as needed.
A contained area within the ED can provide a quieter setting for the mental health patient; a “mental health area” of a few rooms in a portion of the ED specifically intended for psychiatric emergencies. After patients are medically cleared, they are placed in the special area. The rooms are supplied with fixed high-definition cameras to assist in patient monitoring, and the observers are housed in the ED or other location. They can quickly activate staff or security if needed. A single observer can closely monitor four or more patients at one time thereby reducing in-room sitter costs. A potential downside of these areas is that for many patients the separation and observation feels punitive and may heighten their symptoms.
When a psychiatrist is not available, bi-directional audio and video is a tool for patient evaluation. Having a psychiatrist available to see and speak with patients—either in person or via telemedicine— to make decisions about placement and treatment modalities has been shown to decrease the need for inpatient admissions and the psychiatrist can begin a treatment regimen. Genoa Telepsychiatry is one company providing this service. Their websites states that research of approximately 100,000 consumers has found telepsychiatry to be more effective and even preferable to in-person care. This form of telemedicine is relatively inexpensive to deploy as it only requires a single mobile cart with high-definition audio and video capabilities; no medical devices are needed.
Inpatient Tools
Video cameras monitored by patient observers, nurses, or guards are strategically placed within a behavioral or mental health unit: entry/hallway leading to unit entrance, hallways within the unit, nursing station area, social activity areas or day rooms, occupational/activity therapy and group therapy rooms, and seclusion/restraint rooms. Fixed HD cameras are placed in the ceilings in mental health patient rooms to monitor patient safety. These cameras are vandal-resistant and built for durability. Some, but not all, hospitals include bi-directional audio capabilities. Typically, an observer trained in caring for mental health patients monitors the patient and communicates with patient and staff as needed. The observer can watch a greater number of patients, the actual number dependent on the acuity and activity level of the patients.
Hospitals are implementing video motion detection analytics and event notification capabilities of high-definition IP cameras. Analytics consists of embedded software that runs on the camera or monitoring workstation to provide alerts when people or objects cross a user-defined line such as entering a room, entering a bathroom or getting out of bed.
In some facilities, a psychiatrist in a remote location performs rounding, consultative, and other psychiatric services using an Audio/Visual mobile cart with the assistance of a bedside clinician. Many of these services are provided on-demand.
Videoconferencing solutions that provide bi-directional audio and video capabilities are used for involuntary admission court hearings when it is in the best interest of the patient to not be there in person or when a judge is unable to appear in person at the hospital.
mHealth Tools
mHealth is the use of mobile and wireless devices to improve healthcare services and outcomes. It is hoped that mHealth technology will reduce patient visits to the ED and inpatient admissions by providing preventative tools to manage symptoms and intervening when needed to help reduce relapse and promote recovery. The National Institute of Mental Health (NIMH) is the largest funder of research on mental disorders in the world and they have awarded 404 grants totaling 445 million for studies of computer-based interventions designed to prevent or treat mental health disorder.
In 2016, Lantern, a startup that offers online coaching and cognitive behavioral-therapy tools received over $22 million funding to date for a digital mental-health company. It offers programs on stress, anxiety and body image. Pacifica is an app for your phone that provides tools that provide cognitive behavioral therapy, mindfulness meditation, relaxation and mood and health tracking. Rise Up + Recover is one of several of food addiction phone apps that allow a person to track meals, emotions, behaviors and thoughts. It also provides information about valuable resources such as dietitians, therapists and center which may help reduce the need for the person to go to the ED for assistance. Sober Grid is an app for those people who are in recovery and in need of a sober social network. Lyra Health’s (received $35 million funding in 2015) model is different than the guided self-help apps just described. Employers purchase the Lyra Health solution for their employees and family members to be referred to the appropriate mental health practitioners.
Other types of technology include the Fisher Wallace Simulator, a FDA-approved neurostimulation device to help treat depression, anxiety and insomnia. The patient places a headband-like device over their temples. The band stimulates the brain to release serotonin and dopamine, which reduce stress and increase feelings of happiness. Second Life is a virtual reality program that allows patients to explore different identities and test different behaviors in a safe environment. One program, The T2 Virtual PTSD Experience, “invites you to endure the causes, confront the symptoms, and discover the help available for combat-related PTSD in this serious role-play adventure.”
Use of mHealth technologies does come with issues. There is very limited regulation and providers, users/patients and technologists are working to resolve issues involving security, liability, reimbursement, controlling data, and delivery of services.
Technology is becoming more prevalent within the ED, acute care and guided self-help environments. It is most commonly seen in the form of video surveillance, telemedicine, and mHealth. It is providing enhanced safety and treatment protocols, reduced wait times, social support networks, and on-demand treatment and tracking. It is hoped that technology will reduce patient visits to the ED and inpatient admissions while supporting mental health disorders and providing more timely and cost effective patient care.
