Hospital emergency departments are a destination for all types of health issues, from minor injuries and illnesses to emergent medical crises and psychiatric episodes.
And though emergency department teams are trained to provide medical stabilization to all patients, they often lack the specialized resources needed for psychiatric care. Combine that with a lack of mental health resources in many communities, and emergency departments can be forced to "board" psychiatric patients until a mental healthcare provider is available to provide a psychiatric evaluation –and sometimes much longer while waiting for an available inpatient bed or treatment program slot.
In 2014, 84 percent of emergency physicians responding to a survey by the American College of Emergency Physicians said psychiatric patients were being boarded in their ED.
The practice of psychiatric boarding is associated with a variety of problems for hospitals and patients, including exacerbated symptoms and patient elopements, longer wait times for patients experiencing medical emergencies, and an increased risk of violence. Facing these challenges, emergency departments are exploring many strategies to reduce boarding and help all patients get the care they need.
Telepsychiatry
Among the most common strategies is the introduction of a telemedicine program in psychiatry, or a telepsychiatry program. These programs use technology such as videoconferencing to make psychiatrists available "on-demand." Through this model, hospitals without a staff psychiatrist can get fast access to a specialist for evaluating a patient, assessing his or her risk factors, discussing disposition and treatment plans or dispensing medications. The latter can be especially critical so patients who must wait for an available bed don't have to wait to begin treatment.
Literature has shown hospitals with telepsychiatry programs for emergency department patients can experience positive results such as reduced wait times, decreased staff burden and patient monitoring responsibilities, and lowered risk of patient elopement and staff injury, among others.
Specialized Units
Some hospitals find success in reducing psychiatric boarding by segmenting and designating an area of the ED specifically for mental health patients, creating an environment that is more conducive to psychiatric well-being and allowing the department to better manage internal resources.
For example, several years ago Nash General Hospital in Rocky Mount, North Carolina, created a six-bed psychiatric unit within the emergency department to help manage patients who presented to the ED with psychiatric symptoms. The locked unit provides a separate, quieter area for healthcare providers to begin evaluating, treating and finding the appropriate care setting for these patients.
Using a psychiatric screening tool, the emergency department staff at Nash General quickly determines whether patients have issues such as hallucinations or aggression, and a psychiatric nurse sees patients to begin therapeutic intervention – as opposed to "warehousing" these patients without treatment while trying to find them a bed. The result has been an improvement in the care and experience for patients in both the psychiatric unit and the main emergency department.
Management Strategies
For hospitals where tele-psychiatry or specialized units are not feasible, there are a few management strategies that can help alleviate the challenges associated with psychiatric cases in the emergency department. For example, opening a dialogue among hospital departments – administration, risk management, human resources, etc. – and with outside groups such as law enforcement, mental health organizations and community members to collectively identify solutions. This collective problem solving collaboratively identifies community resources which could be helpful to the hospital. Also, this type of "crowd sourcing" communicates to the community that the hospital recognizes a population health issue and wants to partner to address it.
At an internal level, hospitals can take steps such as conducting a security assessment to identify ways to increase safety for all patients, enhancing data reviewing and reporting to better understand the cause and number of incidents of violence, and conducting targeted staff training on issues such as de-escalation and basic self-defense.
When it comes to psychiatric boarding, though, there is no one-size-fits-all strategy. Every hospital and every community are different. But with some effort internally, and in working with community, hospitals can improve the way they manage psychiatric patients in the emergency department to help enhance care and the patient experience for everyone.
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