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 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.
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. Occasionally he awakens 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 ED physician to 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.
As this case illustrates, boarding of psychiatry patients in the ED while they await an inpatient bed somewhere else 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. Other 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.
A recent EMTALA investigation in South Carolina found that a hospital cannot hold psychiatric patients 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 admitting patients to its hospital, the patients stayed anywhere from 6 to 38 days in the ED. During this time, there was no evaluation by psychiatry. The hospital contended that it could 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.
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.
This case illustrates risk issues in caring for psychiatric patients in the emergency department. The physical area is usually ill-equipped and the staff are 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 emergency department.