The emergency care of behavioral health clients in emergency departments (EDs) is not as well developed as other types of emergency care. Most hospitals, even those, which have worked to improve ED flow overall, have not adequately tackled the behavioral health area. However, the behavioral health cohort in EDs is a significant subset of all patients, appears to be growing, and is often a source of concern and even embarrassment for hospitals and staffs. The behavioral health field has the same basic objectives and stages of care as the rest of medicine. The requirements are to
National statistics on ED visits are a poor indicator of the actual number of people with behavioral health problems who utilize the ED. Further, these statistics do not account for the impact of their presentations or the number of people whose problems have a secondary relation to behavioral health. The number and percent distribution of ED visits by the 20 leading principal hospital discharge diagnosis groups indicates about 2.4% of discharges have a diagnosis of psychosis excluding other major depressive disorders.1 Individual hospital data suggests about 8% of ED patients carry a behavioral health diagnosis, but the stigma of these diagnoses still causes many clinicians to hesitate identifying them as a primary diagnosis. Recently Pam Hyde, SAMHSAS Administrator, estimated that a quarter of all ED visits have a behavioral health component.
Psychiatric Illnesses Treated Differently during ED Visits
People with mental illness spend an average of 75 minutes longer waiting for, or receiving, treatment in EDs than do people with other illnesses. This may be due to perceptions that their conditions are less serious.2 There are many stories of people with a behavioral health problem waiting several days in a hospital ED for treatment or discharge. The Report of the Council on Medical Service of the AMA found the influx of patients with psychiatric illnesses seeking care in EDs has been identified as a trigger, exacerbating medical personnel shortages and causing ED overcrowding.3
One significant issue adding to the difficulty of serving behavioral health patients is that a high proportion of these patients arrive with previous thoughts of suicide. In a study published in General Hospital Psychiatry, Boudreaux and others found that over half of those who presented with behavioral health problems indicated they had at least thought about suicide.4 The extended boarding of psychiatric patients in EDs not only results in delayed and inadequate care for the mentally ill, but also increases the backlog of patients in the ED. Sixty percent of emergency physicians in the American Association of Emergency Psychiatry survey reported that the increase in psychiatric patients negatively affected access to emergency medical care for all patients.
Additionally, these physicians reported that ED staff spends more than twice as long obtaining inpatient beds for psychiatric patients as for nonpsychiatric patients. Such inefficiencies deplete emergency medical resources and lead to poorer emergency care.
The Emergency Care Environment and Its Impact
The atmosphere and culture of the commonly designed ED can actually, and inadvertently, add to the destabilization of many patients who present with behavioral health problems. ED staffs are trained to be professional, efficient, effective, and unemotional. In many cases, the patients and their families can interpret this behavior as uncaring, distant, and brusque. Many ED staff members, from physicians to aides, see behavioral health clients as requiring a significant investment of time and resources, that could be better invested in patients with “true” medical or surgical emergencies.
Behavioral health issues are complex, and yet often not recognized as real emergencies. While a diabetic reaction brought on by excess sugar consumption is an emergency, a wish to rid one's head of voices demanding antisocial actions can often be perceived as just a waste of time. Behavioral health problems can be as life threatening and debilitating as many more traditional general health issues. Serious depression kills people. Drug abuse kills people. Unchecked schizophrenia gets people killed. These psychiatric illnesses can be life-threatening conditions just as heart disease or carcinoma can be life threatening. Suicide is the 10th leading cause of death in the United States, ahead of colorectal cancer, breast cancer, and prostate cancer (http://www.nimh.nih.gov/health/publications/suicide-in-the-us-statistics-and-prevention/index.shtml).
Frequently, ED staffs have inadequate resources to address behavioral health emergencies. Whether adequately resourced or not, untrained staff members are often uncomfortable with these patients. Prior poor experience, inadequate resources, and perhaps unrealistic expectations may lead these staff members to maintain a distance both emotionally and physically from patients with psychiatric illnesses. In some cases, the lack of ability to manage these patients may lead to outright hostility. This is especially true when the ED staff members are stressed out by a large volume of demanding psychiatric patients. For patients presenting with serious behavioral health issues, this combination of distance, emotional pain, and inadvertent neglect are likely to exacerbate an already difficult existence. Even staffs in psychiatric emergency units specifically designed for the behavioral health client have a tendency to fall victim to these tendencies toward patient depersonalization. It is useful to recognize that everyone is “put off” by depersonalizing behavior, and those with behavioral health problems are especially likely to react negatively.
ED staff members are often unaware of their negative biases. Rather, the attitudes toward psychiatric patients are often born out of unfortunate experience, lack of training and understanding of the etiology of mental illnesses. Developing a positive, caring, attentive, and “can-do” approach can often reduce the patient's agitation and disorientation. To understand the nature and impact of the ED from the psychiatric patient's perspective, it may be helpful to actually become a patient and go through the process. When developing new initiatives to improve the system of care, it is important to involve the local consumer community in the process. Contra Costa Regional Medical Center took this approach and improved care as well as outcomes and financial results.5