Author: Amy O'Neil, MD

A commentary on Behavioral Health Boarding in Community Emergency Departments by O'Neil et al. (open access)

The challenges of caring for behavioral health patients in the emergency department (ED) are great.  Clinical decision making is difficult with limited histories and underlying disease that places the patient at high risk for harmful behavior.  Aside from the clinical challenges, the limited resources for behavioral health patients contribute to even greater frustrations when trying to provide care.  In academic centers we are fortunate to have the expertise of behavioral health staff readily available to develop care plans and make recommendations on medication management.  Unfortunately, this is not the case in the community.  This article surveyed 21 community hospitals within the Mayo Clinic Health System to better identify what resources are in fact available to provide care to behavioral health patients.  We found that logistical, staffing and systems based resources are all limited.

Caring for behavioral health patients appropriately requires a team approach.  Psychiatrists, psychologists, social works and case workers who know the patient well provide invaluable information when trying to determine the potential risk of self-harm and develop a care plan for the patient.  Portions of the health system surveyed have developed a behavioral health team that is on-call and assists with assessing and developing the best plan of care.  Survey responders from these sites reported very positive experiences when using this team to care for patients.  Unfortunately, over 20% of the health care system does not have psychiatric consulting services available.  The potential for telemedicine or a more expansive multi-disciplinary psychiatric care team in these settings is great.

When it is determined that a patient does need inpatient psychiatric care and one-to-one observation for safety, the personnel to provide this level of observation is frequently not available.  As a consequence, 40% of EDs report that patients are transferred to a medical unit or ICU to await bed placement in an inpatient psychiatric unit in order to provide the level of observation needed to ensure patient safety.  The availability of this practice is declining in part due to inpatient beds frequently being at capacity.  Fortunately, the practice is also decreasing as EDs develop new systems to provide the closer observation needed for one to one care.

Patient and staff safety must always be at the forefront of providing care.  However, we have found that due to limited resources, safety may be at risk.  In half of community EDs, there are no rooms in the ED designed to care for high risk behavioral health patients who may be actively suicidal, homicidal or violent.  This places both the staff and the patient at substantial risk.  In addition, only five of the EDs have 24-hour security personnel available.  This is a significant resource for the hospital to provide and the utilization of local police departments or other hospital personnel has filled this need.  As the rate of behavioral health visits continues to rise in addition to the increased reports of violent and threatening behavior occurring in the workplace, this is a resource that hospitals may need to consider moving forward.

The resources to provide safe and timely care for behavioral health patients in the community are limited.  Community EDs have developed innovative strategies to care for behavioral health patients including on-call multi-disciplinary teams and enhanced technology to provide safe patient observation.  As the number of behavioral health patients continue to rise, innovations in care will be vital to meet the health care needs of this growing population.

Image by Ryan Melaugh via flickr under CC BY 2.0

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