Lessons Learned

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
  • Geriatric patients
  • Pregnant 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 needs.

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 unsafe.

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.

For those interested in learning more about this topic, the Hospital Quality Institute (HQI)/CHPSO will host a webinar June 27 from 11a.m. to noon titled Barriers to Discharges and Admissions to Community Placements for Behavioral Health Patients. The webinar will include a discussion of admission criteria for different types of behavioral health facilities, as well as a discussion of different types of conservatorship.

References and Resources:

Beasley, J. B., Kalb, L., & Klein, A. (2018). Improving Mental Health Outcomes for Individuals With Intellectual Disability Through the Iowa START (I-START) Program. Journal of Mental Health Research in Intellectual Disabilities, 11(4), 287-300. Available here.

Nolan, J. M., Fee, C., Cooper, B. A., Rankin, S. H., & Blegen, M. A. (2015). Psychiatric boarding incidence, duration, and associated factors in United States emergency departments. Journal of Emergency Nursing, 41(1), 57-64. Abstract only available here.

Schroeder, S. M., & Peterson, M. L. (2018). Identifying variability in patient characteristics and prevalence of emergency department utilization for mental health diagnoses in rural and urban communities. The Journal of Rural Health, 34(4), 369-376. Abstract only available here.

Weiss, A. J., Barrett, M. L., Heslin, K. C., & Stocks, C. (2006). Trends in Emergency Department visits involving mental and substance use disorders, 2006–2013: statistical brief# 216. Available here.