Equitable Care of Psychiatric Emergency Room Patients: It Does Take a Village

Dr. Zun’s commentary, “An Issue of Equity of Care: Psychiatric Patients Must Be Treated ‘On Par’ With Medical Patients,” illuminates key problems faced in the care of psychiatric patients treated in the emergency department setting (1). However, we would add that even in an emergency department where a successful effort has been made to develop a well-integrated psychiatric service and specialized resources, systemic issues outside the department contribute significant obstacles to the delivery of optimal patient care.

Our perspective is from an academically affiliated urban safety-net hospital emergency department with a level 1 trauma center. The emergency department has more than 68,000 annual patient visits, 6,000 of which are seen in a dedicated psychiatric emergency service that is staffed at all times by a psychiatrist, a psychiatric resident, a nurse practitioner, and nurses, with support from social workers and chemical dependency counselors, working in a designated space with 10 individual patient rooms. The psychiatric emergency service employs a triage function to evaluate and transfer patients for appropriate ongoing care, and it can admit patients to available beds in the hospital’s 61 inpatient psychiatric beds. The service can provide immediate and short-term treatment, including initiation of medications for medical and psychiatric conditions.

Provision of excellent care of the psychiatric patient is well integrated in the entire emergency department. The mission statement for the hospital explicitly identifies mentally ill patients as a priority population. The training program for the emergency medicine residency includes rotations to the psychiatric emergency service. On-site chemical dependency assessments are performed by a chemical dependency counselor using a “screening, brief intervention, and referral for treatment” program. The emergency department has a high-utilizer program, with social-worker case managers and a consultant psychiatrist, focused on engagement and diversion from the emergency department to more appropriate outpatient resources. The hospital supports a community mental health center, and psychiatric emergency service providers can schedule follow-up appointments there to ensure that patients have ready access to outpatient care.

As noted by Zun, emergency departments generally have limited advance notice of the arrival of psychiatric patients. At our facility, patients are seen on arrival by an emergency physician, who may then enlist the assistance of psychiatric colleagues before providing sedating agents. Patients are screened for acute medical conditions that may be causing or exacerbating the presenting psychiatric condition. Our emergency department staff cares for psychiatric patients with the same concern and professionalism as all other patients in the emergency department.

Given the importance of obtaining an adequate history and ensuring continuity and coordination of care, the public mental health system in our county requires on-site assessment by outpatient case managers for psychiatric emergency service patients enrolled in Medicaid-funded mental health programs, and a crisis outreach team is available for the evaluation of pediatric patients. County-funded crisis intervention services are available through next-day mental health and chemical dependency appointments in community mental health centers, and there is a local 10-bed crisis diversion unit where patients can be admitted for up to 3 days.

Yet, with all these resources, the crisis of psychiatric patient boarding threatens our ability to provide high-quality care. Approximately 700 patients boarded in 2013, which represents an increase of 200 over the previous year. On some days, more than half the available psychiatric emergency service rooms are occupied by a boarding patient, making the service a de facto inpatient unit. The boarding of psychiatric patients in the emergency department affects the ability of the entire department to function. During periods of high psychiatric emergency service boarding, key metrics such as door to doctor, emergency department length of stay, and percentage of patients who leave without being seen by a provider, increase. The psychiatric emergency service staff realizes that despite their best efforts, they do not have the full resources of an inpatient psychiatric unit, and they suffer demoralization as they face the prospect of delivering less than optimal care.

As we have explored this boarding trend, we have increasingly found that systemwide issues are at the root of boarding and the “subpar” care it generates. Shrinking inpatient psychiatric bed capacity is a national problem (2). In our state, there has been a 16% decrease in the number of inpatient beds since 2000, while the population has increased by 14% (3, 4). A similar shortage of detoxification beds for substance users, who often present to the psychiatric emergency service intoxicated and with suicidal ideation, contributes to the boarding problem. The vast majority of the boarding patients have been referred for involuntary detention. Our state laws dictate that patients transitioning from 14-day holds to 90-day holds are to be transferred to the state psychiatric hospital—but overcrowding at the state hospital, which has also experienced bed-count shrinkage, often means that there are no available beds there, so these patients must remain in community hospitals, essentially clogging the system. The involuntary commitment laws are enacted by the state legislature, and eight times over the past 15 years, lawmakers have voted to make it easier to commit patients, often in response to high-visibility acts of violence and pleas of families desperately wanting treatment of mentally ill relatives. Consequently, involuntary detentions have increased 27% over the past 2 years (5). Similarly, as law enforcement officers and jails increasingly encounter mentally ill offenders, laws have been implemented to ensure that these patients receive proper evaluation and treatment, creating another stream of patients to the psychiatric emergency service from the jail.

The situation is dire, and we agree with Dr. Zun that it is absolutely vital that all emergency department physicians and staff develop a basic comfort with assessing and managing psychiatric patients. We also agree that critical research in emergency medicine and psychiatry should be directed toward this problem. Yet system improvements will also be necessary, as even departments with a wealth of psychiatric resources cannot provide optimal care in a system that is fundamentally flawed. We applaud our legislature for its recent decision to increase the supply of psychiatric beds. Equally important, there is serious discussion about increasing the reimbursement rate for inpatient psychiatric care. Once again, we are in an era where the involuntary treatment act laws are to be revised, and we would hope that any moves to increase access to involuntary treatment will be funded at the community and state hospital levels.

The emergency department trauma system has taught us much about how a system needs to function regionally to make best use of the skills and resources of multiple stakeholders. A recently formed mental health collaborative of nine hospitals and health systems organized by our state hospital association will hopefully point the way toward a better coordinated and functioning mental health system so that psychiatric patients can receive care “on par” with the medical patients in the emergency department.