An acute mental health area in the ED? Patients suffering from an acute psychological or psychiatric crisis have unique and often complex requirements. An Emergency Department (ED) should have adequate facilities for the reception, assessment, stabilisation and initial treatment of patients presenting with acute mental health problems. It is not intended that this should reproduce the facilities of dedicated mental health admission centres, nor be used for prolonged observation of uncontrolled patients. The main purpose of such an area is to provide a safe and appropriate space for interview and stabilisation. Acute mental health presentations have the potential to disrupt the normal operation of an ED. Conversely, the busy environment of an ED may not be conducive to the care of patients with acute mental health crises.

Patients presenting with symptoms of an acute mental health crisis may have co-existent medical problems which require concurrent management. Life-threatening illness or injury remains the first priority, and should be managed within the appropriate clinical area of the ED. In the interests of good patient care, uncontrolled patients should never be left unsupervised in any area of an ED and the acute mental health area should be remote from paediatric areas. From ACEM:

Description of Areas Ideally the facility should contain at least two separate but adjacent areas: Interview Room This room should have two exit doors, swinging outward and lockable from outside, to allow for the escape of staff members when one exit is blocked. One door should be large enough to allow a patient to be carried through it and consideration should be given to the installation of a "barn door" (where upper and lower sections of the door can be opened independently or together). This type of door has the advantage of allowing direct observation of, and communication with, a patient inside the room without staff being required to enter the room. This room should also be:

• decorated in muted colours 
• shielded from external noise 
• furnished with only soft furnishings with no hard edges (furniture made mostly of foam rubber have an advantage in this regard) 
• designed in such a way that direct observation of the patient by staff outside the room is possible at all times. 
• arranged to ensure that patients have no access to air vents or hanging points. 
• fitted with a smoke detector 
• fitted with a duress alarm at each exit. 
• Electricity and medical gases should not be available to the patient. 
• The patient must be able to be directly observed. This may be backed up with closed circuit television for the safety of staff.
• The room is required to be of sufficient size to enable a restraint team of five members to surround a patient within the room, yet allow sufficient separation between the patient and restraint team to make it difficult for the patient to strike any member of the team. Because of this, and the need to avoid enclosed spaces for agitated patients, the room should ideally be square (or near square) in shape and at least 16m2 in floor area.

Examination/Treatment Room This should be immediately adjacent to the interview room. It should contain adequate facilities for physical examination, however the inclusion of unnecessary and easily dislodged equipment should be avoided. If operational policy dictates that IV sedation is to occur in this area, it should contain the appropriate facilities and monitoring equipment, mounted out of reach of the potentially violent patient. It should contain the minimum of additional fittings or hard furnishings that could be used to harm an uncontrolled patient or staff. It should be of sufficient size to allow a restraint team of five people to surround a patient on a standard Emergency Department bed and should be at least 16m2 in floor area.

---------------------------------------------- Gerard O’Dea is a conflict management, personal safety and physical interventions training consultant.  He is the training director for Dynamis, a specialist provider of personal safety and violence management programmes and the European Adviser for ‘Verbal Defense and Influence’, a global programme which addresses the spectrum of human conflict.  www.dynamis.training