Created by members of the ACEP Emergency Medicine Practice Committee, September 2013

Psychiatric patients, perhaps more than any other patient group, seeking emergency mental health evaluation face one of the most complex, and at times, labyrinthine processes for treatment and management in the US health care system. Not only is the system complex and at times incomprehensible, secondary to varying state, insurance and hospital regulations, patients are left with an ever shrinking system to meet their needs.

Over the past 40 years, services for mental health patients have become increasingly deinstitutionalized, shifting away from inpatient facilities. As a result, inpatient beds have dwindled to less than 50,000 nationwide, forcing patients to seek other avenues for treatment that has included outpatient facilities, outpatient medical management groups, and community resources. Unfortunately, those resources have also become increasingly constrained by widespread budget cuts, leaving patients with the health care system’s last remaining safety net—the ED. 

Because EDs are seeing growing number of patients, government agencies and hospital administrators have recognized the importance of improving throughput and the quality of care delivered in EDs. For example, the Centers for Medicare and Medicaid Services (CMS) has included several measures that evaluate operational metrics, patient length of stay, and boarding times within the ED. Of those metrics mentioned, psychiatric patient boarding times represent a significant concern for health care professionals, administrators and regulators. 

While many academic researchers and even governmental regulatory agencies such as the Department of Health and Human Services (DHHS) have looked at the issue of boarding, all have come to a relatively common culprit-- a supply and demand mismatch. This simple, yet doomed equation of shrinking psychiatric patient resources with an ever-expanding psychiatric patient population represents the main cause for reduced psychiatric patient capacity in the ED. Not only has the operational capacity within the mental health system decreased, medical clearance and patient disposition have become significantly more complex with disparate state-by-state regulatory requirements, insurance verifications, and institutional requirements for the management, medical clearance, evaluation and disposition of patients seeking psychiatric services. As a result, hospital systems, clinicians, and administrators have begun to evaluate ways to improve the evaluation of psychiatric patients including streamlining the intake process, reducing variances in care, and improving outpatient services. 

In an effort to develop a reference tool and guide for ACEP members, the Emergency Medicine Practice Committee summarized relevant, recent literature that addresses the evaluation, medical management and treatment, boarding, best practices, and ultimate disposition of psychiatric patients. The following subjects are summarized within this document: