Challenges Associated with Caring for Behavioral Health Patients in Emergency Departments Lessons Learned from the CHPSO Database
It is estimated that 20% of patients presenting at emergency
departments have a psychiatric diagnosis. This is not surprising
considering that, in 2014, over 43 million (18%) adults in the
United States experienced a mental, emotional, or behavioral
health related disorder.
CHPSO recently hosted a safe table discussion on
difficult-to-place psychiatric patients, during which
participants discussed several categories of patients. These
patient types —are also found in safety event reports submitted
to the CHPSO database — include:
Pediatric and adolescent patients
Developmentally disabled adult patients
Patients with co-morbidities
All too often the complexity of the care required by these and
other patient, combined with a shortage of psychiatric beds,
results in extended stays in emergency departments. In a study of
psychiatric boarding in United States emergency departments,
researchers found that the odds of emergency department boarding
may be as much as five times higher for psychiatric patients when
compared with their non-psychiatric patient counterparts. The
authors also noted that, in addition to being more likely to be
boarded in the emergency department, psychiatric patients are
boarded for longer periods of time than non-psychiatric patients.
Along with the increased incidence of behavioral health disorders
and the dwindling number of appropriate beds, challenges
associated with finding appropriate placement are often
compounded by care coordination factors such as:
Significant variation in rules from county to county
Communication breakdowns among team members
Insurance and eligibility issues
Consider the following examples from the CHPSO database:
Insurance Coverage Issues and Communication
Breakdowns: A 43-year-old male patient with a history of
bipolar disorder had been boarded in the emergency department
waiting for placement for several days. He had been stabilized
and medically cleared for two days when a bed was obtained for
the patient. During the transfer of information between the
sending and receiving facilities, it was discovered that the
patient had both private insurance and Medi-Cal coverage.
In this case, the protocol for obtaining placement for
behavioral health patients varies based on insurance type. If the
patient has private insurance then a transfer center places the
patient. However, if the patient has Medi-Cal, then the county
mental health department handles the placement.
Because the staff were unaware that the patient had private
insurance, the mental health worker spent the better part of two
days working on his transfer and placement. The delay was due in
part to the fact that the patient’s Medi-Cal was from a different
county, which the receiving facility could not accept. So, the
mental health worker needed to wait for a
Short Doyle contract to be written before the patient could
be transferred. The writer of this particular event report felt
that if the staff had been aware that the patient had private
insurance, then the transfer could have occurred sooner. This
would have improved the quality of care, freed up a much needed
emergency department bed, and reduced the workload of both the
hospital and county mental health department staff.
Transgender Adolescent: A 15-year-old
transgender male patient with suicidal ideation was brought in to
the emergency department by his parents. The patient had a
detailed suicide plan, however, he was calm, cooperative, and
open to intervention. Both his age and gender identification made
finding placement challenging. After nearly two days in the
emergency department, the patient was discharged to home with his
parents with plans to follow up with outpatient psychiatry. The
patient’s parents remained calm and cooperative. However, they
were upset that the facility was unable to meet their child’s
Pregnant Patient: A 36-year-old homeless
woman with a history of paranoid schizophrenia was brought into
the emergency department by the local police department for
evaluation. She was disheveled, and her speech was disorganized.
Upon examination, the patient was found to be approximately 30
weeks pregnant, but it was unclear if she had received any
prenatal care. The patient was placed on a 5150 hold and remained
in the emergency department for nearly a week before an
appropriate bed was secured for her. During her emergency
department stay she was convinced that the staff were trying to
harm her, and she attempted to leave against medical advice
multiple times. A sitter had to be at the bedside at all times,
and she had several episodes involving incoherent ranting and
violent outbursts, during which staff members reported feeling
These cases illustrate that caring for behavioral health patients
is challenging, particularly those with unique needs.
Organizations should be sure that they understand what their
county requires and provides with respect to care and placement
options for behavioral health patients. Facilities should work
toward developing collegial relationships with the Public Health
Department, the Mental Health Department, the Social Services
Department, and the Department of Veteran’s Affairs.
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