Managing Behavioral Health Patients in the Emergency Department

Laura M. Cascella, MA, CPHRM

Behavioral health issues have escalated in recent years and pose serious public health and patient safety concerns. About 23 percent of adults in the United States have a behavioral health condition; 20 percent of adolescents report having a major depressive episode in the last year; and only half of people who have mental illnesses receive treatment.¹

A significant and ongoing concern for healthcare organizations is managing behavioral health patients in emergency departments (EDs). The convergence of multiple factors has exacerbated this problem, including lack of insurance coverage, an uptick in suicide attempts, mental health workforce shortages, and dwindling behavioral health services.²

Because of these issues, EDs have become a safety net for many individuals who experience mental health or substance abuse episodes or crises, which has cascaded into problems associated with overcrowding, lack of appropriate treatment, and potential violence. Additionally, EDs are “poorly equipped to address these individuals’ needs because of a variety of issues, including regulations, policies, training, culture, stigma, and the lack of integration and connectivity to other settings in the community.”³

Various strategies have been proposed to improve the care and management of behavioral health patients in emergency care settings. Although no single set of strategies offers a perfect solution for all facilities, the following recommendations may help enhance healthcare organizations’ efforts to provide high-quality care to these patients:

• Thoroughly evaluate current policies and procedures for managing behavioral health patients to determine how well they are working and how to improve them. Solicit feedback from healthcare providers, staff members, patients, family members, and community partners.
• Provide clinicians and staff members with ongoing behavioral health education to raise awareness about the situations they might encounter and their potential seriousness. A Health Affairs article explains that “When behavioral health needs are viewed as ‘other’ and ‘not my job,’ the quality of care and the patient and family experience of care suffer.”⁴
• Foster an ED environment that supports the principles of a trauma-informed culture, such as safety, transparency, and collaboration. Offer training to providers and staff members on trauma-informed care.
• Educate healthcare providers and staff members about available mental health and substance abuse recovery services in the community, and forge collaborative relationships with organizations providing these services to improve care and streamline referral processes for behavioral health patients.
• Use evidence-based guidelines to develop standardized protocols for managing different types of behavioral health conditions and crises. Develop policies related to triage, patient assessment, screening, monitoring, diagnosis, medications and other treatments, referrals, patient and staff safety, etc. Make sure clinicians and staff members are aware that patients might present with both behavioral health and medical issues that need attention.
• When possible, include patients and families in discussions about assessment, diagnosis, care planning, and follow-up. Involving patients and families can help reduce agitation and alleviate feelings of helplessness. An article in American Nurse Today advises “when possible, give patients choices so they have a sense of security and control. Respect personal space and speak calmly.”⁵
• Implement periodic huddles or rounds to allow emergency medicine providers and staff members to share important information and discuss care for all behavioral health patients in the ED.
• Consider the value of using telehealth services (e.g., telepsychiatry) to provide specialty consultation for patients who have complex behavioral health issues for which resources and expertise are not available onsite.
• Designate a safe observation area for behavioral health patients. Have a trained staff member assess the area for potential environmental risks, such as items that patients might use as weapons or to inflict self-harm.
• Determine the feasibility and value of having a separate wing or area of the ED that is designed for behavioral health patients and minimizes visual, auditory, and other sensory stimuli that might agitate patients (e.g., sirens, crowds, and extensive medical equipment). If resources permit, have trained behavioral health specialists oversee care in this specialized area.
• Consider using trained peer specialists who can draw on their own lived experiences with behavioral health conditions or substance abuse struggles to support patients and direct them to appropriate resources in the community.
• Implement safeguards to prevent patient wandering and elopement from the ED. Examples of safeguards might include door alarms and locks, electronic monitoring, designated gown/sock color for at-risk patients, and diversion activities. Additionally, have comprehensive elopement procedures in place to quickly respond to missing patients.
• Train healthcare providers and staff members on strategies for de-escalating aggressive behavior. Consider implementing an emergency response team that can quickly respond if a patient becomes volatile.
• Conduct drills and simulation trainings to prepare emergency medicine providers and staff members for managing various behavioral health scenarios (e.g., violent patients, suicidal patients, patients who are paranoid or who hallucinate, patients who have overdosed, etc.).
• Develop organizational policies related to transferring behavioral health patients to inpatient units, other facilities, or home. Policies should include guidance for handoff communication, coordinating patient care prior to discharge, and following up with patients after they are discharged.
• Identify ways to provide emotional and mental health support to ED providers and staff members. These individuals may experience burnout, anxiety, stress, and emotional trauma from caring for behavioral health patients. Examples of support include wellness programs, peer mentoring, debriefing sessions, and flexible schedules and breaks.⁶

Research is ongoing to identify upstream solutions to society’s burgeoning behavioral health needs and to determine how best to integrate behavioral health services into the ED and other care settings. Although new methods and solutions will come to light, healthcare organizations can take steps now to improve their approaches for managing behavioral health patients.

Assessing current protocols to identify improvement opportunities and considering new frameworks and strategies for addressing behavioral health needs can improve the quality of care; help protect patients, staff members, and others; and strengthen organizational culture.

To learn more about issues and strategies associated with behavioral health, see MedPro’s Risk Resources: Behavioral Health.

Endnotes

¹ Reinert, M., Fritze, D., & Nguyen, T. (2024). The state of mental health in America. Retrieved from https://mhanational.org/the-state-of-mental-health-in-america/#Key; Mental Health America. (n.d.). Quick facts and statistics about mental health. Retrieved from https://mhanational.org/resources/quick-facts-and-statistics-about-mental-health/; National Institute of Mental Health. (n.d.). Mental health information: Statistics. Retrieved from www.nimh.nih.gov/health/statistics/index.shtml

² Zeller, S. (2018, July 25). Transforming behavioral healthcare in the emergency department. HealthLeaders Media. Retrieved from www.healthleadersmedia.com/clinical-care/transforming-behavioral-healthcare-emergency-department; Kalter, L. (2019, September 3). Treating mental illness in the ED. Association of American Medical Colleges. Retrieved from www.aamc.org/news/treating-mental-illness-ed

³ Laderman, M., Dasgupta, A., Henderson, R., & Waghray, A. (2018, January 26). Tackling the mental health crisis in emergency departments: Look upstream for solutions. Health Affairs Blog. Retrieved from www.healthaffairs.org/do/10.1377/hblog20180123.22248/full/

⁴ Ibid.

⁵ Dzubak, J. L. (2017, November). Managing mental health emergencies in the ED. American Nurse Today, 12(11). Retrieved from www.americannursetoday.com/managing-mental-health-emergencies-ed/

⁶ Zeller, Transforming behavioral healthcare in the emergency department; Eng, J. (2018, July 26). 3 ways to improve behavioral health in the emergency department. Institute for Healthcare Improvement. Retrieved from www.ihi.org/insights/3-ways-improve-behavioral-health-emergency-department; Dzubak, Managing mental health emergencies in the ED; The Joint Commission. (2021). Quick Safety 19: ED boarding of psychiatric patients – a continuing problem. Retrieved from www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety--issue-19-alleviating-ed-boarding-of-psychiatric-patients/alleviating-ed-boarding-of-psychiatric-patients/; Institute for Healthcare Improvement. (2020). Improvement stories: improving behavioral health care in the emergency department and upstream. Boston, MA: Author; True, G., Pollock, M., Bowden, C. F., Cullen, S. W., Ross, A. M., Doupnik, . . . Marcus, S. C. (2021). Strategies to care for patients being treated in the emergency department after self-harm: Perspectives of frontline staff. Journal of Emergency Nursing, 47(3), 426–436.e5. doi: https://doi.org/10.1016/j.jen.2020.12.016

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