Quality Plus Solutions, LLC

EDs have rapidly become the primary care providers for persons with behavioral health or substance abuse disorders. The 2011 Healthcare Cost and Utilization Project (HCUP) Nationwide Emergency Department Sample (NEDS), recently published by the Agency for Healthcare Research and Quality (AHRQ), reports that 5.5 million, or 4%, of all ED visits were for a behavioral health/substance abuse diagnosis.1

Even more significantly, 43 million, or 33%, of all ED patients presented with either a primary or secondary behavioral health/substance abuse diagnosis. This indicates that one in three ED visits involve a patient with a significant behavioral health condition. Because of dwindling community resources and fewer inpatient treatment settings, the ED has become the “de facto” care provider for the mentally ill.

Caring for behavioral health patients often affects timely throughput of all patients in the ED and they present many other risks in the emergency care setting. The future of rapid improvement in access to appropriate treatment settings and care providers is uncertain. Therefore, organizations must identify and implement strategies to mitigate risk and improve patient safety.

The major high-risk conditions for EDs caring for behavioral health patients include suicidality, aggression, and elopement. Adverse outcomes involving behavioral conditions have led to legal claims, with the most frequent allegations including inadequate risk assessments, lack of a safe treatment environment, and lack of staff competencies. These deficiencies can lead to a variety of exposures such as regulatory risk, healthcare professional liability risk, and reputational risk from adverse media attention — none of which will fare well for organizations.

It is not an impossible challenge for EDs to provide safe care to the behavioral health patient population. The first step in identifying risk is to assess of the treatment setting. Once completed, this assessment can yield valuable information to set priorities for improvements and develop strategies to improve safe care and prevent adverse events.

The following are three common risk assessment findings that are high liability areas ripe for risk mitigation strategies.

1. Insufficient initial and routine assessment for patients that demonstrate high-risk behaviors. The lack of screening, assessment, reassessment, and documentation of such opens the door to liability for the facility.

Risk management strategies include the following:

  • Identify patients at risk during the initial triage assessment to be followed by a comprehensive assessment by a behavioral health clinician. The identification of individual risk factors and protective factors is an important part of the assessment.
  • Implement frequent assessment (every one to two hours) and document patient contact by care providers. Note: Anxiety/agitation are usually the first signs of increasing risk, and regular contact with staff helps to minimize this symptom.
  • Perform reassessment at critical junctures and transitions in care: change in level of functioning, change in observation level, and at discharge.
  • Assign the appropriate level of observation to the patient based on the risk assessment. Staff providing the monitoring should have documented competencies to provide this monitoring.
  • Based on the risk assessment, medication management should be instituted promptly to manage symptoms. The Substance Abuse and Mental Health Services Administration (SAMHSA) has developed the Suicide Assessment Five-step Evaluation and Triage — SAFE-T — assessment, as well. This tool could be used by professionals with limited competencies in suicide risk assessment. There also are many tools that are widely used to both screen and assess behavioral patients. While these tools can be helpful, it must be remembered that it is not possible to predict suicide.2,3

2. The lack of a safe treatment setting. Given the high rate of behavioral health patients presenting to EDs, it is essential that there are safely designed treatment areas to minimize the risk of suicide, aggression, and elopement. Agencies and accreditation bodies have provided recommendations for safe treatment environments, such as The Joint Commission Sentinel Event Alert Issue 56, which provides recommendations for the assessment and management of behavioral health patients in non-behavioral health settings and is a useful reference.4

Risk management strategies include the following:

  • Staff should escort patients presenting with a behavioral health complaint directly into the ED or other safe location where they can be observed. High-risk patients should not be left in the waiting room, as this can increase anxiety and can lead to agitation and/or elopement.
  • Conduct an initial search of the patient for any items of potential harm. These items should be secured in a locked cabinet in the room or another safe location.
  • Establish “safe” rooms close to the central nursing station and not near exits or areas that provide for easy egress, such as ambulance bays. These rooms can be a permanent design, or used for other purposes and able to be converted for use as needed. The Facilities Guideline Institute published the Behavioral Health Design Guide, which is currently considered the standard in the industry for a safe environment of care.5
  • Design a large room for two or more patients and provide recliners instead of beds for patient comfort. This can optimize staff resources for observation of patients as well.
  • Provide diversions such as a television, magazines, music, food, and drinks. Doing so can decrease the patient’s anxiety, and decrease risk.
  • Conduct routine surveillance and searches of the designated treatment area for potentially dangerous items, such as plastic bags, sharps, ropes, and strings.
  • Ensure that the bathroom used by patients is safely designed or provides for constant supervision of high-risk patients. Patients that are high risk should be constantly monitored, even when using the restroom.
  • Consider the use of a different color gown, scrubs, or footies for easy identification of behavioral health patients or those at risk for elopement.

3. Insufficient staff competencies. Considering that the ED often is the first stop for patients experiencing a behavioral health crisis, it is imperative that the staff treating them know how to manage patients’ behaviors and symptoms in a safe, therapeutic manner.

Risk management strategies include the following:

  • Provide education/training in assessment, de-escalation, and nonviolent management of aggressive behaviors. Minimally, the staff that should be trained include security personnel, ED nursing staff, behavioral health staff, and nurse supervisors.
  • Ensure that all staff involved in restraint and seclusion procedures have firm knowledge of the federal guidelines surrounding the use of these restrictive interventions.
  • Provide adequate behavioral health professional support to allow for timely and comprehensive assessment. Crisis counselors, social workers, or advanced practice nurses are invaluable to assist in assessment and discharge planning. Psychiatrist consultation also should be available for evaluation if necessary.
  • Hire trained behavioral health technicians to provide routine monitoring and management of behavioral patients in the ED or on units where there is a significant number of patients at any time. These staff members can be cross-trained to function as ED technicians or assistants should the volume of behavioral health patients diminish.
  • Provide patient companions, or “sitters,” that function as observers. These staff should have documented competencies to perform this role. The use of safety companions is widespread in acute care settings. While it is considered to be the highest level of monitoring for an at-risk behavioral patient, there is no evidence to suggest that they prevent adverse events.
  • Telepsychiatry can be useful in providing timely assessment and disposition of patients. Currently, there are barriers that exist for the widespread use of telepsychiatry, including reimbursement, clinician licensing, and credentialing.

Safer care is possible for behavioral health patients in the ED. While there are many additional risk mitigation strategies that have proved to be beneficial, an organizational focus on these three high-risk areas in the management of this population can greatly assist in reducing organizational risk and improving patient safety.


  1. Healthcare Cost and Utilization Project. Overview of the Nationwide Emergency Department Sample (NEDS). Agency for Healthcare Research and Quality. Available at:
  2. Jayaram G, Herzog A. SAFE-MD: Practical Applications and Approaches to Safe Psychiatric Practice. Committee on Patient Safety, June 2008.
  3. Substance Abuse and Mental Health Services Administration. SAFE-T: Suicide Assessment Five-step Evaluation and Triage. Available at:
  4. The Joint Commission. Sentinel Event Alert 56: Detecting and treating suicide ideation in all settings. Available at:
  5. Hunt J, Sine D. Design Guide for the Built Environment of Behavioral Health Facilities, 7.2 edition, March 2017. Available at: