Safety and Security in the Emergency Room

Presenter: Neal Howard
Guest: Dr. Cary Gutbezahl
Guest Bio: Dr. Cary Gutbezahl is president and CEO of Compass Clinical Consulting. He has worked as interim CMO for several hospitals and health systems, where he led major change initiatives in case management, leading to reductions in length of stay and introducing a culture of safety and professional accountability. He has also served as a physician mock surveyor to prepare hospitals for regulatory surveys. While Dr. Gutbezahl was on active duty in the U.S. Navy, he was Head of the Quality Assurance Department of the Navy Medical Command, National Capital Region, in Bethesda, Md. He is board certified and completed a laboratory medicine residency and an immunohematology fellowship at Washington University in St. Louis.

Segment Overview: Dr. Cary Gutbezahl discusses safety in the Emergency Room and how Mental Health patient’s needs should be addressed, focusing on creating and committing to a plan for positive patient safety change.


Health Professional Radio

Neal: Hello and welcome to Health Professional Radio. I’m your host Neal Howard. Glad that you could join us today. Many of us have experiences with the emergency room or the emergency department. Either someone that we care about has been admitted, you’ve gotten a call saying there’s been an accident or someone’s fallen out of a tree, if you got kids, things to that nature. Our guest in studio today is here to offer some insight into a specific population of the ER patients. Those that are suffering from mental health issues, maybe not suffering from mental health issues at the time but having them nevertheless and they manifest while undergoing the stress of the ER. Dr. Cary Gutbezahl is here today. He is the President and CEO of Compass Clinical Consulting with a diverse background in hospital, medical group and manage care settings. And also, working as a physician mock surveyor to prepare hospital for regulatory surveys. He’s also in active duty US Navy where he was head of the Quality Assurance Department of the Navy Medical Command National Capital Region in Bethesda Maryland. How are you doing today Doctor?

Dr. Gutbezahl: Very well Neal. Thank you.

N: Thank you so much for returning with us. You were here in another segment and we were talking about some of the issues facing patients admitted to the ER with not only a physical trauma, but who have an ongoing mental health situation as well. When you were here with us before, we talked about some of those issues as being not only related to the patient but to the staff members as well. When it comes to the staff members, we touched on maybe some of the larger facilities having the ability to have someone there as a specialist that can identify mental health issues. But what about some of the attitudes toward mental health patients once they’re recognized in the ER – such a fast phased stressful triage type of setting?

G: Well it’s very important that the staff and the entire emergency department be prepared to handle these patients. They do show up unexpectedly at different times of the day just as any other patient would but they are a bit different and their needs are different. It’s interesting that we spend a lot of time planning how we’re gonna care for patients who had strokes. We have spent a lot of time thinking about how we care for patients who had heart attacks and we deliver very timely and efficient care to them. But we don’t spend the time in most emergency departments thinking about how we’re gonna care for patients who have behavioral health issues and they do require some care and planning.

N: Now when we’re talking about caring for patients that has behavioral issues, they’re under stress, they’re in pain, the behavioral issue is exaggerated or exacerbated by the trauma – are you suggesting maybe some type of psychological treatment in conjunction with the pain killers or the stiches or having, you know, that person there by their side? How would you address such as intricate problem in that type of a situation? In that type of setting?

G: Behavioral health patients present to the emergency room with two types of problems. One is they have a medical problem such as injury as you’ve described on top of their existing mental health problems. But the other times, they have acute psychiatric issues. They may have tried attempted suicide. They maybe acutely psychotic and threatening to harm themselves or others and the emergency department’s got to be prepared to deal with both of those situations. In some cases, the first thing you have to do is just have to assess the patient and reassure the patient and see how the patient responds to the interaction between the staff and the patient. If the patient can be handled by calming the patient down, by helping, reassure them, by engaging them and showing respect to their opinions and what they’re saying. If you can keep them calm that way, that’s the best way to handle the problem. There are times, however, when the patients do need to be medicated. In either case, however, if the patient’s showing acute psychotic symptoms, then the patient’s gonna have to be evaluated and assessed in terms of the needs for whether they need to be hospitalized or cared for an outpatient basis.

N: Well in most emergency room settings, there is a security guard there or in some cases a police officer, or an MP in military settings. Maybe some of that type of negotiation training, situation resolution training, on the part of the safety staff that’s already employed by the hospital. Maybe the training should go come fall on their shoulders as opposed to the busy hospital staff.

G: The security people that you’re referring also participate in training associated with how to ‘de-escalate’ it. It’s the term that we use for the patient’s anxiety so that they’re better under control. But really, everybody who interacts with the patient probably should be educated and then skills developed to help them learn to deescalate the patient’s anxiety and to address the patient’s concerns. The goal is not to identify these patients as different and isolate them to security management. These are patients with real clinical medical issues. Even if they’re just acutely psychotic, that’s an acute medical problem that needs to be addressed by clinical staff.

N: So basically, we’re talking not security so much as the safety of the patient and the staff as well considering some of the severe behavioral problems that a person could manifest in the ER. How do you get everybody, say, security; the nursing staff; the on call surgeon – how do you get everybody on the same page when it comes to once the patient has been identified as having this mental health condition? How do you formulate a plan and to where everyone can work in unison in order to give the safest and best care to the patient?

G: This is where the preparedness comes in. Just like we prepared to handle a stroke so that everybody knows their role and nobody has to figure out what to do. You don’t want to be in a situation with a behavioral health patient and say, “Okay now we have behavioral health patient, how are we gonna handle this? What are we gonna do?” Instead, you got to invest the time in advance to provide the training to the staff so that they know how to evaluate the patient, interact with the patient, deescalate the patient and know when they need help in dealing with the patient. You can’t expect the emergency department to completely deal with an acutely psychotic patient on their own. They’re goanna need help from the behavioral health specialists who have to come in and evaluate the patient and potentially initiate the remainder of the patient’s treatment plan.

N: Now, not only President of Compass Clinical Consulting – in addition to your consulting work, you’ve worked as interim CMO for a number of hospitals and health care systems. And you made major changes, introduced major initiatives where the length of stay was decreased, a culture of safety was introduced and successfully, I might add. Could you give us a little bit of insight, maybe a step-by-step on how you got the staff onboard with your initiatives and ideas as they’re related to mental health care patient?

G: Sure. The first step of course to make sure the people understand what the problem is and can appreciate the significance of the problem. You need supporters on board and as a champion for change, my job is to help build support among other people. Once you get people to understand the significant of the issue and become engaged in the issue, then you can bring them together and start saying, “What kind of things can we do in order to change what we’re doing and get a better outcome?” And usually they’ll say, “What have other people have done? Can we find out what other organizations have done or what published in literature and bring that to the table?” Which we do. Then the next thing is to digest it to get people to understand what that is and hopefully have some innovative changes to what other people have done. And then as you go forward, you construct a plan of multiple different sets of tasks that you have to do in order to get to it implemented. So in a case of a stroke protocol, we have to get the neurologist and the emergency department and the internist all on board as to what we wanted to do. We had to work with the nursing staff in order to make sure the nurses understood their roles. We had to develop a data monitoring system to see how well we were doing it implementing our plan as well as what the clinical outcomes would be.

N: Okay. Could you tell me briefly exactly, how much your consultant firm, Compass Clinical Consulting, is involved in stream lining certain training programs for different ER or ED settings across the country?

G: Our organization is built around helping hospitals and health systems be better at consistently executing their plans. So we work with them to make sure that they’ve got well designed policy and procedures. That they have good training programs that they can correctly coach skills and asses competency and then have the right data monitoring systems to be able to monitor whether they are actually doing what they say they’re gonna be doing in the outcomes that they get. That’s really a very significant part of our business. I mean, we do mock surveys to help hospital prepare to be inspected, if you will, but a big part of our business is about helping hospitals become better at providing consistently safe high quality care.

N: Great and where can our listeners get more information about your organization?

G: Our organization can be found on our website

N: You’ve been listening to Health Professional Radio. I’m your host Neal Howard. And as I said, our guest in studio with us, returning to give us some more insight is Dr. Cary Gutbezahl – President and CEO of Compass Clinical Consulting, with a diverse background on Hospital medical group and manage care settings. Also, having served on active duty the US Navy head of the Quality Assurance Department of the Navy Medical Command, National Capital Region in Bethesda Maryland. Also, board certified and completed a laboratory medicine residency and an immunohematology fellowship at Washington University in St. Louis. It’s been great having you here with us today.

G: Thank you very much Neal.

N: Thank you. Transcript and Audio of this program are available at and also at and you can subscribe to our podcast on iTunes.

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