By Solveig Dittmann, RN, BA, BSN, CPHRM, Senior Risk Specialist

It’s estimated that more than 26 percent of Americans ages 18 and up suffer from a diagnosable behavioral health disorder. That’s about one in every four adults. These behavioral health issues are increasingly finding their way into surgery units across the nation.
 
In our last article, we talked about maximizing safety and minimizing exposures when managing behavioral health patients in an emergency department. Today, we’re discussing how to manage behavioral health issues in surgical environments.
 
Many of the inherent risks are the same, including inadequate assessment of behavioral health and psychiatric patients, threat to safety of staff and other patients, training deficiencies, and staffing shortages. Most of the same strategies for ensuring safety and minimizing these risks in emergency departments also apply to surgical units. But there are some nuances to consider for the surgical process.
 
Behavioral health risks can occur during different stages of the surgical process.
 
Issues may arise at any time: before, during, or after surgery.
  • Admittance and pre-op. The preoperative assessment of various neurochemical, behavioral, cognitive, and emotional factors is even more critical when evaluating patients with a behavioral health issue. It’s crucial for physicians and nurses to be able to recognize patients with behavioral health issues including psychosis, substance abuse and withdrawal, delirium, anxiety, aggression, bipolar disorder, or suicidal behavior. If family members are involved, make sure to use their input to gain insight into the patient’s medical and psychiatric history.
  • During surgery. It’s vital to monitor patients carefully. Care providers must have complete information about any psychiatric treatment regimen the patient has been undergoing, and any prescriptions the patient is taking to avoid drug interactions during surgery.
  • Post-op. Patients with mental health issues often develop changes in behavior, psychomotor agitation, delirium, or other cognitive disorders following surgery. These complications can slow the patient’s surgical recovery and minimize the effects of medical treatment.
 
Disruptions in routine can contribute to behavioral health risks.
 
Especially for individuals already suffering from mental health disorders, a disruption in routine can exacerbate problems. Unfortunately, the surgical process essentially guarantees that daily routines will be significantly altered. This can put a great deal of emotional strain on patients, and it may contribute to a rise in behavioral health risks.
 
Patients must be monitored for any changes in behavior, and systems must exist to respond to agitated patients effectively. Research published in the Western Journal of Emergency Medicine, Verbal De-Escalation of the Agitated Patient, shows that while many facilities focus on restraints and medications, verbal de-escalation techniques provide positive outcomes in many situations.
 
Common complications spur changes in behavior
 
Complications from the surgery itself may lead to additional risks. Patients may experience common complications, such as fever and infection after surgery. In some cases, this can contribute to delirium. Postoperative delirium is especially common among elderly patients. Delirious patients may experience emotional changes, becoming angry, paranoid, or depressed when they had previously been calm and cooperative.
 
Staff must be trained on identifying vulnerable individuals, monitoring patients for behavior health disturbances, and responding in ways that de-escalate the situation.
 
Withdrawal issues can make behavioral health risks worse
 
Substance abuse is a widespread problem. According to the National Center for Biotechnology Information, for every 100,000 individuals, 843.2 will experience alcohol dependency, and 220.4 will experience opioid dependency.
 
Being in the hospital for a prolonged period for surgery can result in withdrawal issues for patients with substance dependency. This may result in a wide range of symptoms, including insomnia, anxiety, nausea, and tremors.
 
A patient does not need to be addicted to illegal drugs for severe symptoms to occur. Alcohol withdrawal, for example, can lead to symptoms including hallucinations and seizures. Some prescription drugs also result in dependency, and if medication is not maintained throughout the surgery process, withdrawal symptoms may occur. Any health issues, including mental health issues, being treated by the prescription medicine may also worsen as a result.
 
The problem of substance abuse is not going to disappear anytime soon, so hospitals must take measures to minimize the harmful impact on the surgical process.

The patient’s use of both street drugs and prescribed medication must be determined, and possible drug interactions that could occur during the surgery process must be anticipated.  
  • Patients may attempt to conceal or understate their substance dependency. For this reason, medical staff must be trained in spotting the signs of substance abuse and withdrawal.
  • Withdrawal symptoms won’t present immediately, so continued observation is necessary. 
  • If substance abuse is identified, steps must be taken to keep both the patient and the staff safe. 
For a broader look at how to maximize safety and minimize exposures, see the five key steps in our last behavioral health spotlight article.
 
Surgical facilities concerned with minimizing risk cannot afford to ignore behavioral health matters. At Coverys, we specialize in medical professional liability risk management.