Recent studies demonstrate that about 7% of all emergency department (ED) patients present with a mental health condition. Because of the unique risks associated with psychiatric patients, coordinating their care and admission has proven to be a challenge for emergency practitioners. Here we present a case that highlights the risks of boarding patients in the ED.
Case Presentation
A 37-year-old chronic schizophrenic male patient was brought to the ED by police because he was directing traffic without any clothes on. The patient is homeless and is known to the ED staff for non-compliance with his medication. He has a history of hypertension and drinks alcohol.
The physical exam reveals a blood pressure of 162/94, pulse of 96, respiratory rate of 20, and normal temperature. The heart, lung and abdomen exams are normal. The physician orders screening lab tests and contacts the outside community mental health service to perform the psychiatric evaluation.
The outside psychiatric service evaluates the patient and recommends admission; the emergency service concurs. Since the patient has no funding, he is to be transferred to the state psychiatric hospital. The state facility is full, cannot accept the patient at this time, and requests additional laboratory tests; they request to be contacted again the next day. Even though the hospital has an inpatient psychiatric unit with beds available, it is an unwritten policy of the hospital not to admit unfunded patients to this unit.
Since the patient is not actively suicidal and the ED is already overwhelmed with psychiatric patients, the staff places the patient in a hallway of the mental health area in the ED and administers haloperidol for his agitation. The patient thinks the male nurse is the devil and strikes him in the face, inflicting a nasal bone fracture. The nurse later goes on to develop PTSD and files a workers’ compensation claim against the hospital.
The patient is sedated and falls asleep in the ED. He awakens occasionally and screams at the nursing staff, who respond with an additional dose of haloperidol.
The ED contacts the state facility again the next day; they are full but think they will have a bed in another day or two. The emergency staff keeps the patient sedated and feeds him but does little else. The sign-out from the ED physician states that the patient is waiting for a state hospital bed. After 5 days of boarding in the ED, the state psychiatric hospital accepts the patient in transfer.
Risk Concerns
Inadequate Treatment
The patient spent five days in the ED with little or no treatment. In these frequent instances of ED boarding, the risk of iatrogenic and symptom escalation due to non-treatment is high. These patients can have worsening of their psychosis, depression, or mania while waiting for a bed. It is rare that a chest pain, trauma or stroke patient would go untreated in the ED, but for some reason emergency physicians are reluctant to treat psychiatric patients. In cases of medication non-compliance, it is appropriate and well within the standard of care to restart the patient’s psychotropic medication while they wait in the ED for admission or transfer.
The risk of medications used to treat cardiac or stroke patients has a significant risk profile, including death, as compared to psychotropic medications. The major risk of providing patients with their psychiatric medication is medication side effects or an inadvertent overdose. The risk of overdose is highly unlikely in this environment, and the concern about medication side effects is minimal since the patient had been on the medication on a long-term basis. If the emergency practitioner is uncomfortable prescribing these medications, a psychiatrist can be contacted from the consultation liaison service or even via telepsychiatry.
As this case illustrates, boarding psychiatry patients in the ED while they await an inpatient bed at another facility is risky, both for the patient and staff. There are many options to decrease boarding and reduce the cost of services for these patients. Providing treatment early in their ED visit may result in effective stabilization and reduce the need for admission. These patients can also be referred to other, perhaps more appropriate, resources in the community. Alternative options to reduce the influx of patients to the ED include referring patients to such services as mobile crisis care, crisis phone services, walk-in psychiatric clinics, and living room models of care.
Mental Health Patients and EMTALA
An EMTALA investigation in South Carolina found that a hospital cannot hold patients with unstable psychiatric emergency medical conditions in its ED while waiting for an inpatient bed in a state facility when beds are available in its own institution. State policies, customs or practices do not trump the federal mandate.
The federal government fined ANMed $1.2 million for this EMTALA violation of boarding psychiatric patients in its ED for days. The hospital held 36 psychiatric patients in its ED without appropriate treatment. Instead of being examined and treated by an on-call psychiatrist, and despite empty beds in its psychiatric unit to which the patients could have been admitted for stabilizing treatment, the patients were involuntarily committed and kept in AnMed's ED for between 6 and 38 days each.
The hospital contended that it could not admit involuntarily committed patients because their unit only accepted voluntary patients. It was hospital policy to transfer all involuntary patients to the state hospital. This was thought to be the equivalent of sending unfunded patients to the state hospital. In its plan to correct the EMTALA violation, the hospital changed its policy to accept involuntary patients and added 19 beds to its inpatient unit.
In recent years, there has been increased CMS scrutiny at multiple acute care hospitals in different CMS regions, specifically addressing mental health patients in EDs. CMS allegations have included inadequate medical screening examinations (MSE) for mental health; failure of the MSE to be ongoing, especially when the patient remained in the ED beyond shift change; mental health patients “holding” in EDs for extended time periods; elopement of mental health patients from EDs; the need for increased safety measures for suicidal and homicidal patients; improper use of psychoactive medications as chemical restraints; and inadequate documentation of MSEs, psychiatric interventions, and justification for psychiatric interventions.
Many of these allegations result from the increasing difficulty EDs have in finding an appropriate inpatient bed for patients with mental health emergencies, meaning the hospital has to keep the patient in its ED for extended periods of time. Most general acute care hospitals do not have their own inpatient psychiatric units, and the number of inpatient psychiatric beds has decreased nationwide. Demand, however, has not decreased, and EDs sometimes spend hours over several days trying to find an appropriate facility with an available bed for a patient with a psychiatric emergency. This often involves ED personnel contacting facilities that are increasingly geographically distant from the patient’s home just to get the patient admitted to an appropriate setting.
Unsafe Work Environment
Psychiatric patients are at high risk for violence towards staff, other patients and visitors. Psychiatry patients and their clothing must be properly searched prior to placement in a room, not only for weapons, but also for contraband that could be used to harm themselves. It is recommended that all psychiatric patients have their clothes removed and that they be placed in a gown. Most institutions give the patient a specific gown color or ID band that signifies they are a psychiatric patient and should not be allowed to elope. The routine use of restraints, seclusion and sedation to prevent elopement is not an acceptable reason to perform these interventions.
Psychiatric patients are also at risk for completing suicide or performing self-harm while in the ED and must be properly monitored to prevent these acts. Psychiatric areas in the ED must conform to all the standards of safety found on the psychiatric floor.
Conclusion
This case illustrates risk issues in caring for psychiatric patients in the ED. The physical area is usually ill-equipped, and the staff is reluctant to care for these patients. The care environment, staffing, and treatment protocols and processes need to be enhanced to reduce the risks associated with psychiatric patients in the ED.
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References
Nordstrom K, Berlin JS, et al. Boarding of Mentally Ill Patients in Emergency Departments: American Psychiatric Association Resource Document. West J Emerg Med. 2019 Jul 22;20(5):690-695. doi: 10.5811/westjem.2019.6.42422. PMID: 31539324; PMCID: PMC6754202.
Villas-Boas S, Kaplan S, et al. Patterns of US Mental Health-Related Emergency Department Visits During the COVID-19 Pandemic. JAMA Netw Open. 2023 Jul 3;6(7):e2322720. doi: 10.1001/jamanetworkopen.2023.22720. PMID: 37432688; PMCID: PMC10336606.
