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Emergency Medicine Practice Management & Health Policy

Psychiatric Patients in the Emergency Department

Heather A. Heaton, MD
Chair Elect


Heather HeatonDecreasing resources for mental health continues to challenge emergency physicians caring for an already vulnerable patient population, the psychiatric patients. Widespread budget cuts have increased issues for patients and physicians alike, decreasing acute hospitalization beds and out-patient resources. Often times, the ED serves as a safety net for these patients, where a multitude of issues arise, including medical clearance, boarding, medical management and disposition. The members of the ACEP Emergency Medicine Practice Committee reviewed literature regarding care of the psychiatric patient in the ED and published their findings in October 2014. Below follows a brief summary of their recommendations based on the most recent literature:

Evaluation of Psychiatric Patients in the ED

An assessment algorithm, proposed by the American Association of Emergency Psychiatry, outlines procedures that should be performed prior to the initial evaluation of the psychiatric patient. The initial assessment should focus on identifying patients with delirium versus those with a psychiatric issue.1 Additionally, when treating those under involuntary emergency hospitalization for a psychiatric evaluation, whether that determination is made by law enforcement or a medical professional, regulations and provisions should be reviewed if the emergency provider is uncertain of the laws of his or her state. The Treatment Advocacy Center has compiled regulations and admissions standards for each state.2

Medical Clearance of Psychiatric Patients in the ED

ACEP published a clinical policy in 2006, “Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department,” based on a literature review prior to 2005 and expert consensus, regarding medical clearance of psychiatric patients in the ED. Several studies have been published since its inception and continue to support the 2006 guidelines. The three summary recommendations are:

  • Diagnostic evaluation should be directed by the patient’s history and physical examination. Routine laboratory testing of all adult patients is of very little benefit and need not be performed as a part of the ED assessment. (Level B recommendation)
  • Routine urine toxicology screens for drugs of abuse in patients who are awake, alert and cooperative do not affect ED management and should not be performed as a part of the ED assessment. Further, toxicology screens obtained in the ED for use by the receiving psychiatric facility or service should not delay patient evaluation or transfer. (Level C recommendation)
  • For patients with alcohol intoxication, the psychiatric assessment of the patient should be based on the patient’s cognitive abilities, rather than a specific blood alcohol level. ACEP suggests that clinicians consider using a period of observation to determine if psychiatric symptoms resolve as the patient sobers. (Level C recommendation)


Boarding of Psychiatric Patients in the ED
Boarding in the ED remains a national issue, both for medical and psychiatric patients. Research shows psychiatric patients’ length of stay in the ED is much longer than that of medical patients; further, psychiatric boarding negatively impacts the patient’s quality of care, as well as hospital operations and finances. Boarding issues stem from multiple sources, including lack of inpatient beds, decreased outpatient services, and reductions in reimbursement. 3, 4, 5

Best Practices for Reducing ED Boarding of Psychiatric Patients
Several best practices, listed below, have been identified to minimize psychiatric inpatient admission, and thereby patient boarding:

  • Psychiatric consultations, in-person or via telemedicine has been shown to decrease inpatient hospitalizations and allows initiation of a treatment regimen.6
  • Psychiatric ED observation unit—keeping psychiatric patients in a quiet environment away from the chaos of the ED helps manage acute psychiatric crises.7
  • ED based case managers can assist with both outpatient resources and inpatient hospitalization, greatly reducing hours spent by ED nursing staff and physicians on disposition.5,7
  • Mobile crisis intervention teams/crisis management teams can collaborate with ED staff and public mental health resources to facilitate quicker dispositions for psychiatric patients.7
  • Statewide patient dashboards allow EDs to quickly assess inpatient bed availability, rather than calling individual facilities.8
  • Change billing and reimbursement for psychiatric services to decrease the closure trend.


Medical Management of Psychiatric Patients in the ED
There are several aspects to the ED management of the psychiatric patient, both medical and physical. Most therapy deals with the agitated patient. First, rule out an underlying organic cause with a detailed history, physical and mental status evaluation.

Medications and diagnoses guide medical therapy in calming agitated patients. The preferred route of administration is PO, followed by IM and then IV, although the onset of effect is the opposite. Many providers use a first generation antipsychotic, such as haloperidol, plus or minus a benzodiazepine, as first line therapy. Second generation antipsychotics are becoming more popular given the more favorable side effect profile. Providers should be aware that antipsychotics such as haloperidol and droperidol have been associated with QT prolongation, although the clinical significance is debated.9

Fundamental to the management of the agitated patient prior to the use of restraints or seclusion are de-escalation measures including verbal, decreasing physical stimuli, and negotiating with the patient. The Centers for Medicare & Medicaid Services and The Joint Commission both provide guidelines regarding the use of restraints.10

Disposition of Psychiatric Patients from the ED

If the emergency provider, using reasonable judgement, is concerned about a patient’s imminent risk to him/herself or others, the patient should be held for psychiatric evaluation and treatment. If the patient does not voluntarily consent to such evaluation, the patient may be held involuntarily.

For patients requiring inpatient psychiatric hospitalization for stabilization, several barriers exist to disposition. Chief among these barriers is bed availability and whether or not the treating facility accepts the patient. Uninsured, publically insured, and homeless patients tend to be more difficult to place.11,12 For those patients that are discharged, follow up plans prior to leaving the department reduces hospitalization and return visits.13

Community Resources for Emergency Psychiatric Patients
Several states have taken it upon themselves to work through the psychiatric service crisis, ranging from regionalizing services to developing comprehensive crisis systems to appropriating money to redesign current systems to match the needs of the state.14,15

EDs continue to play a vital role in suicide prevention with structured screening and assessments for those at risk. 16

We appreciate the time put into developing this reference guide for ACEP by the Practice Committee (Jennifer L. Wiler, MD, MBA, FACEP, Committee Chair, N. Adam Brown, MD, MBA, FACEP, Subcommittee Chair , Arjun S. Chanmugam, MD, FACEP, Enrique R. Enguidanos, MD, FACEP, Heather L. Farley, MD, FACEP, Robert D. Greenberg, MD, FACEP, Anthony Mazzeo, MD, FACEP, Laura N. Medford-Davis, MD (EMRA), Howard K. Mell, MD, MPH, FACEP, Michael J. Pace, MD, FAAFP, FACEP, Claire Pearson, MD, MPH, FACEP, Thomas Sugarman, MD, FACEP, Gerad A. Troutman, MD, Michael A. Turturro, MD, FACEP, Patrick Um, MD, FACEP and Leslie Zun, MD, FACEP). Please see the guide for additional information and sources.

REFERENCES

  1. Stowell KR, Florence P, Harman HJ. Psychiatric evaluation of the agitated patient: Consensus Statement of the American Association for Emergency Psychiatry Project Beta Psychiatric Evaluation Workgroup. West J Emerg Med. 2012;13:11-16.
  2. Treatment Advocacy Center. Emergency Hospitalization for Evaluation.
  3. Park JM, Park LT, Siefert CJ, et al. Factors associated with extended length of stay for patients presenting to an urban psychiatric emergency service: a case-control study. J Behav Health Serv Res. 2009;36(3):200-208.
  4. Treatment Advocacy Center. No room at the inn: trends and consequences of closing public psychiatric hospitals. 2012.
  5. Bender D, Pande N, Ludwig M. A literature review: Psychiatric boarding. US Department of Health and Human Services, 2008.
  6. Bender D, Pande N, Ludwig M. Psychiatric boarding interview summary. US Department of Health and Human Services, 2009.
  7. Alakeson V, Pande N, Ludwig M. A plan to reduce emergency room ‘boarding’ of psychiatric patients. Health Aff. 2010;29(9):1637-1642.
  8. Virginia Department of Behavioral Health and Developmental Services. Online Psychiatric Bed Registry.
  9. Wilson MP, Pepper D, Currier GW, et al. The psychopharmacology of agitation: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup. West J Emerg Med. 2012;13(1):26–34.
  10. Centers for Medicare and Medicaid Services, HHS. Conditions of participation: Patient’s rights; restraint or seclusion. 42 CFR §482.13(e)(1)(i)(B).
  11. Weiss AP, Chang G, Rauch SL, et al. Patient-and practice-related determinants of emergency department length of stay for patients with psychiatric illness. Ann Emerg Med. 2012;60(2):162-171.
  12. Chang G, Weiss A, Kosowsky JM, et al. Characteristics of adult psychiatric patients with stays of 24 hours or more in the emergency department. Psychiatr Serv. 2012;63(3):283-286.
  13. Boudreaux ED, Niro K, Sullivan A, et al. Current practices for mental health follow-up after psychiatric emergency department/psychiatric emergency service visits: a national survey of academic emergency departments. Gen Hosp Psychiatry. 2011;33(6):631-633.
  14. Zeller S, Calma N, Stone A. Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments. West J Emerg Med. 2014;15(1):1-6.
  15. Colorado Division of Behavioral Health. Behavioral Health Crisis Study - Crisis System Overview and Exemplary Models.
  16. Suicide Prevention Resource Center. Continuity of care for suicide prevention: The role of emergency departments.



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