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[5 MIN READ]

In recent years, emergency department providers have regularly faced an expanding volume of patients with mental health needs. Then COVID-19 happened, dramatically taxing the healthcare system and increasing demands on providers while also challenging patients’ mental health across the board. In response, it is essential that ED providers increase their knowledge and comfort with the assessment, treatment, and disposition of mental health patients in order to improve timely care for these patients, many of whom require behavioral healthcare in the ED.

EDs Need Tools and Resources for Assessment and Treatment

Psychiatric and substance abuse issues had already more than doubled prior to COVID-19 disrupting our lives more than doubled, rising from 6% to 15% 1. And while traditional visits to the emergency department decreased during the pandemic, visits requiring care for adult psychiatric and substance abuse issues increased substantially. This often presented as anxiety or depression diagnoses, trauma, and stress-related disorders, and increased substance use. Some of these problems manifested as an increase in suicide ideation and attempts.

Recent studies demonstrate that about 10% of all emergency department patients present with psychiatric illness. Because of the unique risks associated with psychiatric patients, coordinating their care and admission has proven to be a challenge for emergency physicians. Here we present a case that highlights the risks of boarding patients in the emergency department.

There seems to be a widespread misperception among freestanding psychiatric facilities that the Emergency Medical Treatment and Labor Act, 42 U.S.C. § 1395dd (EMTALA), does not apply to them. This may or may not be true depending upon the licensure and the configuration of the facility. It is not as simple as a yes/no calculation.

There are three criteria that must be met before a facility can be held liable for a violation of EMTALA:

Providing care to psychiatric patients in the emergency department is a challenge for many reasons.

• Emergency physicians often receive insufficient training in behavioral emergencies.
• ED personnel are uncomfortable evaluating and treating these patients.
• ED staff may harbor negative attitudes toward behavioral health patients.
• Resources such as consultants and inpatient beds are lacking.
• The hectic ED environment can lead to iatrogenic escalation of psychiatric crises.

For the ED, however, the greatest risk and safety issue related to behavioral health is the appropriate evaluation and protection of the suicidal patient in the ED. We present 2 case studies to illuminate the uncommon but preventable catastrophe of suicide in the ED.

Patients with mental health complaints are visiting emergency departments and urgent care centers at an increasing rate. It is imperative that triage staff are able to make rapid and safe decisions for these patients.

Rule #1: Make No Assumptions

Making assumptions in triage is dangerous. Our subconscious biases can lead to cognitive errors in the assessment of patients, particularly those who are agitated.

There are approximately 21 million living U.S. military veterans, and the Veterans Health Administration (VHA) is the largest health care system in the country. Despite its size, the VHA is overwhelmed by the need to provide healthcare to the huge number of eligible veterans.

As a consequence of this high demand for care, Congress enacted the Veterans Access, Choice, and Accountability Act of 2014, which allows veterans to seek government-funded care in the private sector under certain circumstances. This act may cause an influx of veterans into private physician practices.