Lack of training on patients presenting with behavioral health emergencies exposes EDs to significant liability risks, according to Leslie Zun, MD, MBA, system chair of the department of emergency medicine at Sinai Health System in Chicago.

“How can an ED say they provided a patient-safe environment when no one’s been trained in how to keep the patient safe?” he asks.

EDs are obligated to provide a safe, protective environment for all patients, Zun stresses. This includes those with behavioral health emergencies.

“The key to do this appropriately, professionally, and patient-centered is to have proper training in how to handle behavioral health patients,” Zun says.

Most EDs mandate training in verbal de-escalation or crisis intervention. Zun says training also is needed in preventing self-harm in the ED, and stopping elopement if patients are determined to be a risk to themselves or others.

“It doesn’t have to be a formal course. It just has to be appropriate training in how to assess and manage patients with behavioral health emergencies,” Zun explains. This should include prevention of harm, de-escalation, and prevention of elopement. “Those, to me, are the basics — prevention of harm instead of escalation,” Zun adds.

Same Standard of Care

All EDs, whether in small, critical access hospitals or large, urban, academic medical centers, must adequately train staff to handle behavioral health emergencies. “It all goes back to the standard of care,” Zun says. “It doesn’t matter if your ED sees 6,000 or 100,000 patients a year. It’s still the same standard of care.”

Almost 10% of all ED patients present to the ED with a behavioral health emergency.1 “That’s a really important statistic. It used to be 6%, and that number has actually increased,” Zun notes.

A recent study found that 45% of adults and 40% of children who come to ED with a non-psychiatric complaint tested positive for an undiagnosed mental illness.2

“You put those numbers together, and we’re looking at somewhere between 50% and 55% of patients who are either coming in with a psychiatric problem or have a psychiatric overlay,” says Zun, one of the study’s authors.

ED policies on training staff to deal with behavioral health patients, including those who are agitated and potentially violent, should include these key elements, Zun says:

  • How to manage agitated patients using verbal de-escalation and other techniques;
  • How to protect patients who want to hurt themselves or others;
  • Proper assessment and treatment of suicidal patients.

“We need to do an appropriate risk assessment and determine if the patient needs to be hospitalized or if psychiatry needs to be consulted,” Zun says, noting the same is true for patients with homicidal ideation. “It puts us at risk if we don’t treat those patients, because they can harm someone else.”


  1. Centers for Disease Control and Prevention. Emergency department visits by patients with mental health disorders — North Carolina, 2008-2010. MMWR Morb Mortal Wkly Rep 2013;62:469-472.
  2. Downey LV, Zun LS, Burke T. Undiagnosed mental illness in the emergency department. J Emerg Med 2012;43:876-882.


  • Leslie Zun, MD, MBA, System Chair, Department of Emergency Medicine, Sinai Health System, Chicago. Phone: (773) 257-6957. Fax: (773) 257-1770. Email: