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).

As with all of our patients, it is vital to treat and address those who suffer from acute psychiatric illness with compassion and respect.

Multidisciplinary Approach

Although this project was a quality/operations program in a high-volume emergency department with a large number of psychiatric patients, given the relative rarity of self-harm in the ED setting, the study may not have been sufficiently powered (ie, large enough to detect a statistical change) for us to reach definitive conclusions about the efficacy of the specific intervention that was evaluated. Also, many emergency departments may not have access to 24-hour in-house psychiatric consultation or an on-site liaison. Therefore, some of the proposed interventions might not be feasible in all practice settings.

However, the study does represent an important contribution to our understanding of management strategies for the boarding psychiatric patient, and some of its broad takeaways might be applicable to a wide breadth of practice settings. First, similar to the approach to scene safety in field assessment for EMS workers, emergency physicians should consider and mitigate any potential opportunities for self-harm or harm to others for patients with acute psychiatric illness. Second, early coordination and conversation with mental health specialists are important, particularly when the search for placement for psychiatric patients requiring inpatient psychiatric hospitalization may be a prolonged process. Lastly, as with all of our patients, it is vital to treat and address those who suffer from acute psychiatric illness with compassion and respect.

Although patient satisfaction data were not collected in this study, future work involving all key stakeholders, including the patients themselves, may shed light on which aspects of the acute care experience most minimize adverse behavioral effects and improve outcomes in the emergent setting. Behavioral and psychiatric emergencies continue to represent some of the most challenging clinical cases. A multidisciplinary approach focused on patient safety and harm reduction represents a promising and innovative approach that can lead to improved patient care and positive health outcomes, ensuring the safety of this vulnerable group of patients.

Dr. Chang is vice chair of research and associate professor of emergency medicine in the department of emergency medicine at Columbia University in New York City.

References

1. Weiss AJ, Barrett ML, Heslin KC, et al. Stocks C. Trends in emergency department visits involving mental and substance use disorders, 2006–2013: Statistical Brief #216. 2016 Dec. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville, MD: Agency for Healthcare Research and Quality (US); 2006.
2. Owens PL, Mutter R, Stocks C. Mental health and substance abuse-related emergency department visits among adults, 2007: Statistical Brief #92. 2010 Jul. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville, MD: Agency for Healthcare Research and Quality (US); 2006.
3. Pearlmutter MD, Dwyer KH, Burke LG, et al. Analysis of emergency department length of stay for mental health patients at ten Massachusetts emergency departments. Ann Emerg Med. 2017;70(2):193-202.e16.
4. Donovan AL, Aaronson EL, Black L, et al. Keeping patients at risk for self-harm safe in the emergency department: a protocolized approach [published online ahead of print Aug. 28, 2020]. Jt Comm J Qual Patient Saf. doi:10.1016/j.jcjq.2020.08.013.