Mental health complaints comprise a significant and growing portion of ED visits nationwide. A recent governmental report found that ED visits related to psychiatric complaints increased more than 15 percent from 2007 to 2011.¹ Many of these psychiatric complaints, such as suicidal ideation or severe depressive/anxiety episodes, may necessitate inpatient psychiatric hospitalization for further specialized care and treatment. In fact, patients with psychiatric chief complaints are two times more likely to require inpatient admission and also experience significant lengths of stay.

Like many patients, those with psychiatric complaints may encounter prolonged stays in the emergency department while awaiting inpatient beds. One study found that patients with psychiatric complaints had mean lengths of stay in the emergency department of 16.5 hours (more than 21.5 hours for those who requiring transfer to another institution for inpatient care).^2,3 This is an issue of concern, as psychiatric patients face several unique challenges in the ED setting that may expose them to elevated risk for adverse outcomes during their acute care. For example, patients with severe depression or other mood disorders may be at an increased risk for self-injury or harm in the emergency department while they await further psychiatric care.

What can the practicing emergency physician, who is already tasked with managing multiple critically ill patients simultaneously, do to help support these patients and ensure smooth transitions of care?

Establishing a Protocol

Interdisciplinary approaches among emergency physicians and mental health specialists may help improve safety outcomes and enhance the ED experience for psychiatric patients. Recently, a multispecialty team composed of emergency physicians, psychiatrists, security, hospital administration, and nurses, crafted a comprehensive safety program aimed at reducing the incidence of adverse events, such as those involving attempted self-harm.⁴ The protocol was an iterative process involving a diverse group of stakeholders from clinicians to security staff and hospital legal counsel. Prior to implementation of the program, the interdisciplinary group reviewed all reported historical incidents of self-harm in their emergency departments. A series of potential interventions were identified including bathroom safety, number and training of patient observers, management of personal belongings and clothing search/removal, and the need for enhanced protocols for high-risk patients.

Based on these initial qualitative approaches, a comprehensive, multilevel care approach designed to balance patient safety with a recognition of and focus on patient experience was implemented. Details such as the use of shatterproof fixtures and the removal of wastebasket liners (to minimize ligature risks) lowered the potential for self-injury, while additional training for patient observers helped strike a balance between patient visualization in the bathroom while being minimally intrusive. Some of the highest-risk patients (identified by factors such as repeated episodes of self-harm) required enhanced protocols, including 1:1 observation, additional search of the patient and/or belongings, and expedited psychiatric consultation. Following implementation of the protocol, the authors reported a reduction in episodes of attempted self-harm, with half the number of cases reported when compared to the year prior (1.33 per 1,000 at-risk patients versus 2.95 per 1,000 at-risk patients).