Emergency Department Care Experiences: History
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Contributor:
Carolina Navas
,
Laura Wells
,
Susan A. Bartels
,
Melanie Walker

Emergency departments (EDs) are an important source of care for people with mental health (MH) concerns. It can be challenging to treat MH in EDs, and there is little research capturing both patient and provider perspectives of these experiences. 

  • emergency department
  • mental health
  • care experiences
  • quality improvement

1. Introduction

Mental health (MH) concerns represent one of the top causes of disability in North America, with approximately 1 in 5 adults experiencing a mental illness in any given year [1][2]. A 2018 study examining the prevalence of MH concerns estimated the weighted average 12-month prevalence of MH concerns in North America to be 22.5%, highlighting the significant impact MH concerns have on public health [3]. MH concerns affect behaviours, moods, and thought processes, and range in severity [1]. Mood disorders, anxiety disorders, post-traumatic stress disorder (PTSD), schizophrenia, and borderline personality disorder (BPD) are among the MH diagnoses most commonly reported in North America [1][2]. Suicidal ideation (SI) and substance use disorders often co-occur with MH concerns [1].
Individuals who identify as being a part of equity-deserving groups, including those who identify as ethnic minorities, those who are of low socioeconomic status, and those who are vulnerably housed, are disproportionately negatively impacted by MH [1][2][4][5]. The COVID-19 pandemic has further exacerbated the impact of mental illness in North America, with the proportion of Canadians reporting excellent or good MH decreasing from 68% in 2019 to 55% in June of 2020 [6] and a 93% increase in the number of Americans seeking help for anxiety and depression [7].
People with MH concerns receive most of their care at the community level through outpatient services. However, urgent care at the emergency department (ED) is an important aspect of the MH care continuum [8]. A wide range of MH concerns are addressed at the ED, with suicidal ideation and attempts being leading causes of ED help-seeking among MH patients [9][10][11]. EDs can provide access to psychiatric assessment as well as opportunities for connections and referrals to community organizations that are otherwise often difficult to obtain [8]. MH care in community settings can also be difficult to efficiently access due to long wait times for services [1], inadequate insurance coverage [4], and lack of public funding for services [4][5]. As a result, people with MH concerns visit the ED at disproportionately higher rates for both urgent and non-urgent concerns [12][13][14]. In fact, people with MH concerns are almost five times more likely to be frequent ED users (i.e., individuals with at least four ED visits in the past year) in comparison to patients with no MH concerns [15]. National Canadian and American data shows that MH concerns represent 9.8% and 12% of all ED visits, respectively [16][17]. This high frequency of use contributes significantly to overcrowding and congestion in the ED [18][19].
Treating MH concerns in the ED can be challenging given the volume of total patients, limited face-to-face time between patient and provider and complexity of psychiatric cases [19][20]. Additionally, perceived negative attitudes and stigmatizing behaviours among health care providers (HCPs) can interfere with effective treatment for people with MH concerns [19][21][22][23]. These challenges are further compounded by system-level issues that prevent HCPs from providing the quality of care that is necessary for people with MH concerns, including lack of appropriate training on MH, lack of standardized approaches to risk assessment and treatment of MH concerns, and reduced access to MH specialists in the ED [24][25]. Despite these barriers, people with MH concerns continue to seek support through EDs because, for most individuals in a MH crisis, the ED is the most accessible way to receive immediate care.
Research demonstrates that patient experience and satisfaction are important outcomes of interest among this population [24]. If people with MH concerns, who already experience higher rates of morbidity and mortality, are satisfied with their healthcare, they will be more likely to seek help when they feel unwell and are less likely to require hospital readmission [24]. However, patient ED care experiences are underrepresented [24]. Although there have been individual studies and reviews on either patient or provider perspectives of ED care for people with MH concerns, the experiences of both have not been reviewed collectively. It is important to systematically evaluate the totality of evidence including perspectives of patients and HCPs to better understand the perceived facilitators and barriers to good ED care experiences and to identify strategies that will improve care for people with MH concerns. 

2. Convergent Perspectives

Both patients and providers viewed the ED as a resource to connect people with MH concerns with the appropriate community care. However, they also described a significant lack of accessible community-based MH services, and a need for improved collaboration with EDs. Lack of information about resources, poor connections with hospitals, and overcrowding in community services were all reported by patients and providers as barriers to accessing appropriate services, all of which led to increased care-seeking by people with MH concerns in the ED. To improve ED care for people with MH concerns, investments should be made to increase the capacity of community services to support this population, in addition to strengthening and expanding existing connections between hospitals and community services [26][27]. This may facilitate a greater number of people with MH concerns seeking specialized community-based care and reduce non-emergent MH-related visits to the ED, thus decreasing ED wait times [26].

3. Divergent Perspectives

Patients perceived interpersonal factors, such as negative attitudes and behaviours from staff, as heavily influencing their care experiences. Simultaneous consideration of both patient and provider perspectives, however, suggests greater issues exist at the environmental and system levels. Insufficient specialized psychiatric staff, inadequate staff training and knowledge, and lack of organizational support often led to poor understanding of MH concerns and presentations, thus reinforcing inaccurate or negative stereotypes of people with MH concerns. These environmental and system-level issues manifest at the interpersonal level and are perceived by patients as poor communication, lack of caring from HCPs, diagnostic overshadowing, and ED environments that exacerbate their MH concern(s).

4. Approaches to Care

It has been well-established that diagnostic overshadowing can result in the misdiagnosis of people with MH concerns in the ED, causing delays in treatment and, resultantly, potential negative health outcomes [28][29][30]. Ensuring accurate diagnoses are made in the ED is therefore imperative to help improve care experiences for people with MH concerns [30]. Schefer and colleagues (2014) described the importance of psychiatric liaison staff in reducing the occurrence of diagnostic overshadowing among people with MH concerns by encouraging further assessments of patients that have been cleared by ED staff [29]. Educational interventions can also play an important role in addressing this issue. Clarke et al. (2006) showed that MH education for staff led to a significant decrease in the number of people with MH concerns that were under-triaged, and providers were more likely to assign the correct level of urgency to people with MH concerns [31]. Medical education programs that incorporate MH concerns and specialized training can, therefore, help ensure the proper and compassionate treatment of people with MH concerns [28].
Another strategy to improve care experiences for people with MH concerns is adopting trauma-informed care. Trauma-informed care is important to providing effective MH care as it minimizes the effects of traumatic experiences for patients [32][33]. Trauma-informed care can improve HCPs’ knowledge of MH, foster productive communication and relationships between providers and patients, and can reduce the use of harmful practices such as physical restraint [32][33]. Hall et al. (2016) demonstrated that adopting a trauma-informed care approach among nursing staff led to increased knowledge about the impacts of trauma and a broader understanding of the experiences of people with MH concerns [32]. However, the authors noted that prior to the widespread implementation of trauma-informed care interventions, there should be an appropriate attitude shift among staff and support at the organizational level [32].
Based on the perspectives of both patients and providers, it is evident that when people with MH concerns seek care in the ED, there are a series of complex, interconnecting factors that contribute to the care experience. These factors translate to a series of interpersonal, organizational, and systemic issues that create sub-optimal care experiences. Ongoing assessment, evaluation, and intervention are necessary across these levels, with a particular focus on the healthcare system as a whole, to address these long-standing barriers.

This entry is adapted from the peer-reviewed paper 10.3390/healthcare10071297

References

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