Strategies to Care for Patients Being Treated in the Emergency Department after Self-Harm: Perspectives of Frontline Staff

Abstract

Introduction:

Every year, approximately 500,000 patients in the United States present to emergency departments (EDs) for treatment after an episode of self-harm. Evidence-based practices such as designing safer ED environments, safety planning, and discharge planning are effective for improving the care of these patients but are not always implemented with fidelity due to resource constraints. An aim of this study was to provide insight into how ED staff innovate processes of care and services by leveraging what is available onsite or in their communities.

Methods:

A total of 34 semi-structured qualitative phone interviews were conducted with 12 nursing directors, 11 medical directors, and 11 social workers from 17 emergency departments. Respondents were a purposive stratified sample recruited from a large national survey in the U.S. Interview transcripts were coded and analyzed using a directed content analysis approach to identify categories of strategies used by ED staff to care for patients being treated after self-harm.

Results:

Although respondents characterized the ED as an environment that was not well-suited to meeting patients’ mental health needs, they nevertheless described 4 categories of strategies to improve care of patients seen in the ED after an episode of self-harm. These included: adapting the ED environment, improving efficiencies to provide mental health care, supporting the staff who provide direct care for patients, and leveraging community resources to improve access to mental health resources post-discharge.

Discussion:

Despite significant challenges to meeting mental health needs of patients treated in the ED after self-harm, staff identified opportunities to provide mental health care and services within EDs and to leverage community resources to support patients after discharge.

Introduction

In the United States (U.S.), 12.5% of 150 million annual emergency department (ED) visits are primarily related to a mental health or substance use disorder.^1,2 A robust literature has addressed the challenges faced by ED staff in treating patients with mental health-related presentations.^3–7

Approximately 500,000 ED visits each year by patients being treated after an episode of intentional self-harm,⁸ defined as self-poisoning or self-injury which may or may not include suicidal intent.⁹ These patients are at high risk for repeat self-harm¹⁰ and suicide.¹¹ Improving care of patients who are treated in the ED after self-harm is a national priority in the U.S.,¹² yet resources to care for these patients in the ED or to follow up with them after discharge are limited.

Interventions such as screening for and assessment of suicide risk, designing safer ED environments, safety planning, and discharge planning improve the safety of patients being treated after self-harm and reduce repeat visits. ^13,14–16 Recent research suggests that, in many EDs, such evidence based practices are not routinely implemented. One study of 8 U.S. EDs found that only 26% of patients were assessed for the presence of self-harm (defined as suicide attempt, suicidal ideation, or non-suicidal self-injury thoughts, behaviors, or both),¹⁷ while a survey of U.S. ED nursing directors found that only 15.3% of EDs provided all recommended elements of safety planning to patients being treated after intentional self-harm.¹⁸ Many EDs do not have the resources required to implement evidence-based practices, such as streamlining screening processes of patients being treated after self-harm¹⁹ or hiring dedicated and trained staff (i.e., social workers, psychiatric nurses, or psychiatrists) to deliver on-site mental health care.²⁰

Further, the lack of adequate resources to provide mental health services and support to patients being treated after self-harm contributes to moral distress among staff, which has been linked to high rates of burnout and low rates of retention and job satisfaction among ED nurses. ^21–17 Research has demonstated how these stressors contribute to negative attitudes towards and erosion of empathy for patients who present to the ED after self-harm.²² However, little is known about what strategies ED staff employ to mitigate burnout and address patients’ mental health needs.

In order to inform future priorities for health services planning and improvement, we undertook a national, mixed methods study of U.S. EDs to gain a broad understanding of how evidence-based practices are implemented in different EDs and staff perspectives on barriers and facilitators to caring for patients who present after self-harm. Specifically, we examined how staff innovate processes of care and services by leveraging resources available onsite and in their communities. Given that ED staff are primarily trained to provide emergency medical rather than mental health care, this study aimed to understand how ED staff try to provide the best care possible to these patients. This paper presents findings from qualitative interviews with nursing, medical, and social work leaders from a national sample of U.S. EDs focused on the strategies they use to address the mental health needs of patients being treated after self-harm and the resources that facilitate implementation of these strategies.

Methods

Study Design and Sample

Between May 2017-January 2018, a national quantitative survey (described elsewhere^18,23,24) to assess availability of key mental health services for ED patients in the U.S. was sent to a random sample of 665 ED nursing leaders, with 513 (77.1%) responding. For the qualitative follow-up study described here, respondents were selected from the 513 hospitals to achieve a maximum variation sample²⁵ across the following criteria: specialty (nursing directors, medical directors, and social workers/care managers); hospital size (<23,000, 23,000–64,000, >64,000 annual ED discharges), mental health staffing availability (high and low); and performance (high and low). High availability of mental health staffing was defined as an ED that had either: a) mental health staff (adolescent/adult psychiatrists, psychologists, psychiatric nurses) during and after standard weekday hours and on weekends or b) a social worker during and after standard weekday hours and on weekends with mental health staff available at any of these times. High performance EDs were defined as routinely conducting all of the following: scheduling outpatient follow-up care for patients before they leave the ED; assessing current/past suicidal ideation and access to means; and conducting safety planning processes.²⁴

For each site, a research coordinator contacted the nursing director via email with a request to participate in an interview. For those indicating interest, a health services researcher with expertise in qualitative methods conducted the semi-structured interview over the phone. At the conclusion of the interview, the interviewer asked the nursing director to identify the medical director and a social worker involved in discharge planning. Medical directors and social workers were contacted separately by the research coordinator and invited to participate in an interview; those who consented were contacted and interviewed separately by phone. Medical directors were interviewed by an ED physician clinical-researcher and social workers were interviewed by a social work researcher with emergency psychiatry experience. Prior to starting the interview, the interviewer discussed the goals of the study, answered any questions, and obtained verbal informed consent from the study participant. Interviewers were blinded to the ED characteristics when conducting the interview.

Interviews were completed between May 2018 and June 2019 and averaged approximately one hour. At 5 sites, interviews were completed with the nursing director and one other provider—either the medical director or social workers — but not the third provider at that site. In those cases, a medical director or social worker from an ED with similar characteristics (size, mental health staffing, performance) was recruited to complete an interview. A total of 34 interviews were conducted with 12 nursing directors, 11 medical directors, and 11 social workers from 17 different EDs. Participants were compensated $200 for their time. Study procedures were approved by the University of Pennsylvania Institutional Review Board (Protocol #824563).

Data Collection and Management

An interview guide was piloted with 3 participants from each staff category and refined iteratively to arrive at a final guide which covered: (1) how patients being treated after self-harm are triaged and assessed upon arrival at the ED; (2) resources available for managing and treating mental health issues in the ED; (3) processes for discharging patients treated after self-harm to outpatient or inpatient settings and following-up with them after discharge; and (4) future plans for programs or processes to address mental health needs of patients being treated in the ED after self-harm. For each of these topics, interviewers probed for barriers and facilitators. Interview transcripts were reviewed iteratively and interviews continued until theme saturation was reached.²⁶ All interviews were digitally recorded, transcribed verbatim and entered into Atlas.ti Version 8 (GmbH; Berlin, Germany).

Data Analysis

We used a directed content analysis approach to extend on prior literature describing implementation of evidence-based mental health care in EDs; specifically, a goal of our analysis was to understand from the perspectives of ED staff how challenges to meeting mental health needs of patients manifest in real-world settings, and to identify strategies ED staff employ to mitigate these challenges.^27,28 Authors conducted open coding of the first 24 interviews, keeping memos about preliminary patterns and emerging themes. The lead qualitative researcher led the team in generating preliminary codes through iterative review of memos and transcripts; through this process, two authors developed a final codebook (codes, definitions, and examples of coded text). Using the codebook, all transcripts were coded by one coder then reviewed and audited by a second coder. Using the constant comparative method,²⁹ three team members met weekly and reviewed coded text to create summaries including identification of recurrent patterns (i.e., themes), as well as outliers and exemplar quotes for each theme. There were minor discrepancies, which were resolved through group review until consensus was reached. Results presented are an analysis of responses to questions about barriers to providing mental health care, innovative approaches and initiatives to provide high quality mental health care, and facilitators in accomplishing these initiatives for patients being treated after self-harm. See Supplement 1 for our COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist.³⁰

Results

Interviewees across all disciplines and sites characterized the ED as an environment better suited to addressing physical health emergencies, rather than patients’ mental health emergencies and ongoing mental health needs. Most respondents reported challenges with implementing evidence-based practices, such as safety planning or following-up with patients post-ED discharge. ED staff universally endorsed the importance of promoting a safe environment and supporting mental health needs of patients being treated after self-harm as beneficial to both patients and ED staff. In the absence of sufficient resources in the ED environment, respondents nevertheless identified several facilitators to support mental health programming in the ED and reported strategies to adapt existing ED resources or leverage community resources to support the needs of patients being treated after self-harm and of staff who care for these patients. Analyses did not reveal distinct patterns or differences between sites based on provider specialty, hospital size, mental health staffing availability, or performance. Table 1 provides a summary of themes and their definitions with illustrative quotes.

Table 1.

Qualitative Themes and Exemplar Quotes

Theme	Brief Definition	Quote(s)
1. Facilitators of Strategies to Support Patients’ Mental Health Needs	Efforts to meet patients’ mental health needs in the ED were facilitated by the following: collaborations between hospital leadership and front-line staff; collaborations between the ED/the health care system and community partners; ‘local champions’ (i.e., staff who advocate on behalf of patients’ mental health needs); academic or research staff affiliated with the health care system.	“We have an emergency medicine research group who is phenomenal. And they work really well with the clinical setting as well to help us initiate things and implement. I think we're just lucky to have those resources at our fingertips.” – Nursing Director 12 (high performance, high availability ED)
2. Creating Efficiencies in Mental Health Care	Technology-based strategies included: having mental health staff off-site assess patients via telehealth; using video cameras to enable ED staff to observe multiple patients from a central location; using analytic software to review patterns of ED use and identify times with the highest volume of patients with complex mental health needs to schedule mental health-trained staff. Non-technology strategies included: grouping patients with mental health needs together in one area of the ED; risk-stratifying and color-coding patients based on their mental health needs. Medication management strategies included: providing standardized order set for psychiatric patients; discharging patients with a 30-day supply of essential medications.	“…telehealth decreases the wait times. For the most part, patients don't care anymore whether you're seeing them in person or seeing them electronically. Very few give pushback.” – Medical Director 1 (high performance, low availability ED) “Cohorting the patients has been helpful…it's been easier to have [psychiatrists] just see all the patients in one area and have face-to-face discussions with the ED doc about the care plan.” –Medical Director 8 (low performance, high availability ED) “We do an assessment of the patient’s ability to obtain their medications or willingness to obtain their medication and, if they have a history of not following through with the obtaining their medications, we will send them home with a 30-day supply that’s been provided by the hospital… that’s been very successful.” – Nursing Director 11 (high performance, high availability ED)
3. Addressing Challenges to PostDischarge Follow-Up	Very few sites had the capacity to follow-up with patients with mental health needs after discharge from the ED, with a few exceptions. Some EDs that did not have these resources leveraged community resources to provide mental health support for patients after ED discharge; These resources were often intended to serve people with substance use disorder and mental health needs and/or involved a peer specialist. Examples included: linking recovery coaches to patients after discharge; connecting case workers to juveniles with a history of self-harm; and home visits conducted by an interdisciplinary team (e.g., nurse, paramedic, peer).	“Our [ED] does not do it, but we have a group of nurses in the hospital who do follow-up calls for the discharged patients…. They encourage the patient to follow-up with their physician if they haven’t… help them figure out how to get a ride if they need it, things like that.” – Social Worker 7 (high performance, high availability ED) “We just started a program primarily for overdoses... the police departments are notified if any squad picks up an overdose. Once they’ve got that patient’s name, about a week after discharge a social worker, a past recovering user, and a police officer go to the patient’s home, knock on the door and say ‘We’re just following up. How are you doing? Are you interested in treatment?’ … It can be 2 days from the time of discharge; it can be two years from the time of discharge. If they [patient]show up at this specific address in downtown [nearby city] and show that card, they will immediately be entered into a treatment program.” – Nursing Director 2 (high performance, high availability ED) “The National Alliance for the Mentally Ill [NAMI] has obtained grants and hired three peer support specialists specially trained in acute care with EDs. These are people that themselves have either had a mental healthor an addiction issue and have gotten specialized training. We're blessed… They are stationed in the ED during the hours that the ED has deemed high volume hours relative to patients with psychiatric [issues] and substance usage.” –Medical Director 9 (low performance, low availability ED)
4. Supporting ED Staff Who Provide Care for Patients being treated after Self-Harm	Support came in the form of management strategies, training, and emotional support. Management strategies included hiring staff with specialized mental health training (e.g., psychiatric nurses) and minimizing burnout by allowing staff to work on compressed schedules to have more days off. Trainings included educating ED staff on mental health-related topics such as non-violent crisis intervention and assessment and triage of patients being treated after self-harm. Finally, staff who care for patients being treated after self-harm were provided emotional support through debriefing sessions. A partnership with a community program brought in a young person who had previously struggled with opioid addiction and self-harm behaviors to talk with ED staff about his experiences; the program helped staff better understand patients and protected against staff burnout.	“We have a team that will come in and debrief the staff, because that is such a hard time, especially when they are young kids. Unfortunately, within the organization we’ve had a number of staff kids that belonged to staff members of the organization, that have come in this way [after self-harm], and that’s been really tough on the staff. So having the ability to call a team to say, no matter what time it is, they’ll come in and they’ll debrief you. It has given the team the outlet they need to come to work the next day.” -Nursing Director 2 (high performance, high availability ED)
5. Creating Safe and Supportive Spaces	Although ED staff described the ED as ill-equipped to care for people being treated after self-harm, they shared strategies for modifying ED rooms to make them safer and programs to bring on-site therapeutic services to patients (e.g., yoga, music therapy).	“We have two mental healthrooms that we’ve set up to have very little furniture, we can take the mattress off the bed and put it on the floor and so we’ve kind of cleared those areas so we have the most minimal things available to them.” – Nursing Director 6 (low performance, high availability ED) “… ‘guests’ come in, like activity therapists and the yoga instructor and there’s music therapy, [and] there’s other employees here who volunteer their time.” – Social Worker 3 (low performance, low availability ED)

1. Facilitators of strategies to support patients’ mental health needs

ED staff who identified strategies to care for patients being treated after self-harm said these efforts were facilitated through collaborations between hospital leadership and front-line staff, or between the health care system and community partners. They cited the importance of “local champions,” i.e., staff who advocated on behalf of patients with mental health needs. Finally, some respondents described the important role of collaboration with academic affiliates to support initiatives to provide mental health care for patients. ED staff described 4 strategies to support care of patients being treated after self-harm: creating efficiencies in mental health care; addressing challenges to post-discharge follow-up; supporting ED staff who provide direct care for patients; and creating safe and supportive spaces.

2. Creating efficiencies in mental health care

Respondents described strategies for creating efficiencies to provide mental health care to patients in the context of limited resources. Various forms of technology were described as key tools in this effort. For example, staff from a high performance, low resource, large health care organization that shared a mental health care team among 3 EDs used telehealth to reduce long waits for assessments by eliminating lengthy travel times for mental health staff between sites.

While staff at several sites described challenges to having enough mental health-trained “sitters,” (i.e., hospital staff trained to observe patients in-person for safety monitoring), some described how video-monitoring technology enabled one staff member to observe several patients at a time.

A nursing director at a high performance, low availability facility described how leadership used analytic software to identify the times of day and days of the week when the ED received the highest volume of patients with complex mental health needs and schedule staff with appropriate training during times when they were most needed.

Participants cited strategies to ensure patients had access to medications after discharge in order to decrease repeat ED visits. Staff at one ED described having “a standardized order set” at discharge for patients with mental health needs. In another example, a high performance, high availability ED assessed each patient for ability to obtain medications after discharge; those who faced challenges in obtaining medications were discharged with a 30-day supply covered by the hospital after careful consideration by the treatment team based on perceived risk as determined by clinical assessment.

Respondents also described non-technology strategies for creating efficiencies, such as grouping all patients with mental health needs in one area of the ED or risk-stratifying and color-coding patients based on their mental health needs. A medical director at a low performance, high availability ED identified benefits of ‘cohorting’ patients with mental health needs, including patients being treated after self-harm, which made it easier for an attending psychiatrist to see and discuss patients in one area of the ED.

3. Addressing challenges to post-discharge follow-up

Very few sites reported having the capacity to follow-up with patients after discharge. One high performance, high availability facility had a group of nurses who called every patient discharged from the facility to encourage recommended follow-up care.

Staff at EDs that did not have these resources talked about how they leveraged community resources to provide mental health support for patients post-discharge. Respondents frequently drew parallels between patients being treated in the ED after intentional self-harm with patients being treated in the ED after an accidental substance use overdose, noting these patients were often dealing with the same issues leading up to their ED visit, were in need of non-medical care (i.e. mental and behavioral health services) while they were in the ED, and could similarly benefit from post-discharge follow-up. Thus, much of the follow-up service needs and services mentioned by ED staff focused on patients who were seen in the ED for repeat visits related to intentional self-harm or substance use disorders. One example described by a nursing director at a high performance, high availability site involved a collaboration between the hospital, a community-based organization, and local law enforcement; the program served patients both patients discharged after being treated for an overdose and those being treated after intentional self-harm.

Participants talked about the value of peer support specialists to facilitate post-discharge follow-up that helped decrease subsequent hospitalizations. These interventions included linking recovery coaches to patients post-ED discharge; connecting case workers to youth with a history of self-harm behaviors; and home visits conducted by a nurse and a paramedic. A medical director from a low performance, low availability site said their ED benefitted from a partnership with a local chapter of the National Alliance for the Mentally Ill (NAMI) which had grant-funded positions for peer-support specialists with training in emergency medicine and mental health stationed in the ED during times of high volume for patients with comorbid psychiatric and substance use concerns.

4. Supporting ED staff who provide care for patients being treated after self-harm

Respondents talked how support for ED staff who care for patients with mental health needs and protecting staff from burnout was vital to providing high quality care for patients being treated after self-harm. A nursing director at a low performance, high availability ED said the organization hired staff with specialized mental health training (e.g., psychiatric nurses) to minimize burden on other ED staff. A social worker at a high performance, low availability ED outlined how social work staff were allowed to work on a compressed schedule in order to have several days off in a row. ED staff also cited trainings to support staff, including non-violent crisis intervention and assessment and triage of patients being treated after self-harm. At one high performance, high availability ED a nursing director described a program that brought in a mental health team to debrief and provide emotional support to staff after challenging incidences involving patients being treated after self-harm, noting that the program helped ED staff process difficult situations.

Another nursing director at a high performance, low availability site described a partnership with a community program that brought in a young person who had previously struggled with opioid addiction and self-harm to talk with ED staff about his experiences, helping to mitigate staff burnout and increase understanding and compassion for patients.

5. Creating safe and supportive spaces

Respondents universally described the ED as ill-equipped to care for people experiencing a mental health crisis and detailed the importance of creating safe, quiet spaces in the ED for patients being treated after self-harm; often referred to as ‘safe rooms’ or ‘ligature-limited’ spaces. One nursing director from a low performing, high availability site described how they created two make-shift safe rooms in the ED by removing most of the furniture and placing the mattress on the floor of the room. A social worker at a low performance, low availability ED noted how several rooms had been retrofitted with metal screens that rolled down from the ceiling to cover exposed pipes and sinks to make the room safer for patients.

Respondents at a few sites talked about efforts to provide access to on-site therapeutic services for patients being treated after self-harm, allowing therapeutic treatment to begin in the ED. Examples mentioned included psychotherapy, yoga, and music therapy. A nursing director from a low performing, low availability ED elaborated on a program that brought in ‘guest’ yoga instructors or music therapists who volunteered their time with patients.

Discussion

Most respondents said they lacked the resources to fully implement evidence-based practices in an environment designed to address acute general medical emergencies. Despite these challenges, respondents provided examples of strategies and facilitators to support quality care for patients treated for intentional self-harm in the ED.

The first strategy involved efficiencies in care using technology. Specifically, respondents suggested the use of telehealth, virtual sitters, risk stratification, and medication management technologies to improve care and address organizational barriers to providing mental health care in the ED, including lack of timely access to mental health specialists.^23,31 However, these strategies should be cautiously pursued as research has demonstrated that reliance on technology instead of live staff can contribute to moral distress and burnout among ED nurses²¹. Therefore, strategies using technology should augment rather than substitute for sufficient on-site mental health providers, particularly as the number of patients being treated after an episode of self-harm continues to increase.³²

Second, providers identified post-discharge strategies that help patients from falling through the cracks once they leave the ED, including partnerships with community-based supports, peer mentorship and follow-up – all with the same goal of reducing subsequent ED visits and hospitalizations. When asked about post-discharge follow-up for patients being treated after self-harm, ED staff responded by sharing examples of programs focused on patients who arrive at the ED after an unintentional overdose. Respondents viewed patients being treated in the ED after intentional self-harm and patients being treated after an unintentional overdose as having similar mental health needs and being at similar risk for repeat ED visits, as well as increased morbidity and mortality. Furthermore, they clearly viewed the post-discharge intervention needs of patients treated after self-harm and patients treated after an unintentional overdose as similar. This thinking is consistent with recent research demonstrating that ED patients with nonfatal overdose are at high-risk of death from suicide in the year following discharge, calling for more widespread implementation of interventions such as warm handoffs to mental health care and post-discharge follow-up to reduce risk of subsequent overdose or suicide.³³

The third strategy identified supporting staff through use of alternative (i.e. compressed/flexible) schedules, training and debriefing. These strategies align with studies highlighting ED nursing leaders’ desire for additional training, resources, and policies to more effectively and comprehensively assess and treat patients with mental health needs, including patients being treated after self-harm. ^34,35 Providing staff with the tools to effectively care for these patients along with the opportunity to debrief can serve the dual purpose of improving patient care and mitigating staff burnout.

The fourth strategy suggested by participants was finding creative ways to manage space and include on-site therapeutic treatment to ensure that the ED is a safe environment. Few EDs in our sample had capacity to build dedicated spaces or provide therapeutic programming to meet patients’ mental health needs. More commonly, respondents described low-cost initiatives to make existing spaces safer, such as removing furniture, or providing mental health programming through volunteer staff or community organizations. Although recent work has focused on redesigning the ED environment to improve patient experience³⁶ and mitigate the risk of adverse events,³⁷ our findings indicate that ED environments should also focus on ways to meet the needs of an increasing number of patients with mental health needs, including patients treated after self-harm.

ED staff identified several facilitators that supported mental health care and services, including efforts of local champions within the ED and partnerships with local non-profit and governmental organizations. Respondents who worked in an ED affiliated with an academic institution shared that these services were only possible through collaborations with colleagues in research and quality improvement, confirming previous research that EDs associated with teaching hospitals are more likely to provide evidence-based safety planning.¹⁸ Finding ways to incentivize teaching hospital teams to consult with and provide resources to EDs that are without an affiliation could help bridge this gap in care.

Limitations

Although we interviewed ED staff from across the country, respondents were from sites that had responded to our initial survey. In addition, some ED staff declined to participate or were unable to be interviewed due to busy schedules, which may have introduced unknown bias into our sample. Respondents were diverse in terms of role in the ED (i.e., nursing directors, medical directors, social workers), hospital size, availability of mental health staffing, and performance; still, the small number of participants may limit generalizability of study results. Although this paper reports findings from the ED sites within our sample who had innovations and facilitators to share, some sites solely discussed challenges and barriers, indicating that there are disparities across EDs. In a future paper, we plan to report findings about the multiple barriers that many EDs face when trying to meet patients’ mental health needs.

Implications for Emergency Clinical Practice

Although study respondents described many challenges to caring for patients being treated after self-harm, they also identified the key role that local champions within the ED and partnerships with community-based organizations can play in addressing existing shortcomings. Emergency nursing leadership should consider developing diaglogues with hospital leadership and local organizations to identify ways to establish relationships with potential mental health champions and community-based partners. These types of partnerships not only establish a link between the ED and outpatient care, but also provide a stronger safety net for patients through connected and comprehensive care. Finally, these linkages address the needs of patients being treated after self-harm and patients being treated after an unintentional overdose, both of whom are at heightened risk of subsequent self-harm or suicide attempts. Further, EDs should consider the thoughtful integration of technology and ongoing clinical education and training in mental health care skills for ED staff nurses and nursing leaders. The fact that our findings align with existing research, as well as across hospital types within our study, suggests that many of these suggestions may be applicable in a wide range of ED settings.

Conclusions

Our interviews with a national sample of ED staff confirmed that, due to lack of resources, many nurses and other staff are unable to fully implement evidence-based practices such as safety planning and post-discharge follow-up that have been found to reduce suicidal behaviors and increase engagement in treatment after discharge.³⁸ Some EDs sought out partnerships with community organizations to bring services to the ED as well as to provide aftercare connections to mental health resources for patients. Although ED providers often feel ill-equipped to meet the mental health needs of patients, they also identified programs and policies with the potential to improve the care of this patients being treated after self-harm. EDs should consider programs that encourage the thoughtful use of technology and training to promote evidence-based care for patients being treated after self-harm. Finally, policies at the local and state level should leverage resources to promote community-based partners, as ED staff seem willing to provide their expertise and a warm contact to enhance the care that patients who have experienced an episode of self-harm receive in all settings.

Contribution to Emergency Nursing Practice:

• Emergency departments (EDs) are known to vary in their implementation of evidence-based practices to support a patient’s mental health needs following an episode of self-harm.

• The main finding of this paper is that, despite challenges to meeting patients’ mental health needs, many ED staff identify opportunities to provide care and leverage community resources to support patients presenting to the ED after an episode of self-harm.

• Recommendations for translating the findings of this paper into emergency clincal practice include: thoughtfully integrating technology to enhance access to mental health specialists; increasing mental health training to support ED staff; incentivizing academic researchers to collaborate with under-resourced EDs; and leveraging community resources to improve access to mental health resources following discharge.