The length of stay for psychiatric patients held in emergency departments (EDs) is growing longer, according to an analysis.1

“Any clinician working in an ED already knows that patients who require admission or transfer for a mental health diagnosis generally have long lengths of stay,” says Genevieve Santillanes, MD, the study’s lead author. Some key findings of the study, which included an analysis of ED visits from 2009 to 2015:

  • Mental-health related visits increased by 56.4% for pediatric patients and 40.8% for adults;
  • Median length of stay in the ED for patients who needed an inpatient bed increased from 6.5 hours to nine hours;
  • For patients who needed a transfer to a psychiatric hospital, average length of stay increased from eight hours to 11.4 hours.

“The magnitude of the increase over such a short time was surprising,” says Santillanes, an associate professor of clinical emergency medicine at Keck School of Medicine at the University of Southern California.

EDs often lack the appropriate resources to provide ongoing mental health treatment. “Patients with non-mental health diagnoses generally receive treatment for their underlying conditions while boarding in the emergency department,” Santillanes notes.

Patients with infections are treated with antibiotics; patients with asthma receive breathing treatments and steroids. Patients with mental health emergencies “frequently do not receive specific mental health treatment. Boarding in the ED waiting for a bed ultimately delays their care,” Santillanes says. The vast majority of patients held involuntarily present with psychiatric emergencies, according to the results of another study.2 Of 251 patients on involuntary holds in the ED of a tertiary care center between 2013 and 2015:

  • 51% presented with a psychiatric disorder;
  • 9% presented with a substance use disorder;
  • 34% presented with both psychiatric and substance use disorders;
  • 5% of patients on involuntary holds presented with neither psychiatric nor substance use disorders.

Meanwhile, the number of hospitals with adequate psychiatric services continues declining. “Every year, you have more and more hospitals that are just getting out of the psychiatric business,” says Todd B. Taylor, MD, FACEP, a Phoenix-based Emergency Medical Treatment and Labor Act (EMTALA) compliance consultant.3,4

Patients still visit EDs with acute psychiatric illnesses that need to be addressed. The problem is that hospitals are not providing those services on an outpatient or inpatient basis. At some facilities, there are no medical staff available to consult. “Emergency physicians, in that circumstance, become the de facto onsite psychiatrist that has to deal with that situation,” Taylor notes.

If the ED psychiatric patient requires inpatient services, there may be nowhere available to send the patient locally — or even regionally. Hospitals are not obligated to accept the patient if all beds are full.

“You end up boarding psychiatric patients in a facility that has no psychiatric services,” Taylor says. “It doesn’t take a rocket scientist to figure out that’s a problem.” Taylor is aware of one patient who was boarded in an ED for six weeks. “What happens then is an opportunity for failure,” Taylor notes.

The patient needs the services, but the hospital does not offer the services, and the ED has no place to send the patient. “You do the best you can. Sometimes, the best you can doesn’t meet the standards CMS [Centers for Medicare & Medicaid Services] says you should meet,” Taylor laments.

Nevertheless, complaints can trigger an investigation. “Anytime CMS comes in, they’re going to find all kinds of stuff you did wrong. They’re going to find something they don’t like,” Taylor observes.

EDs also face potential legal exposure under tort law related to malpractice, informed consent, battery, false imprisonment, and commitment law. “These vary tremendously from state to state. The patient’s status as voluntary or involuntary matters a great deal in many of these state-based claims,” notes Susan Stefan, JD, a visiting professor of law at the University of Miami.

Stefan is former senior staff attorney at the Center for Public Representation in Newton, MA, where she directed the Emergency Department Project, focused on improving the treatment of people with mental health issues in EDs. “There are two ways to mistreat people in psychiatric crisis,” Stefan notes. One is to hold people involuntarily for days or weeks without any treatment. The other is to discharge or exclude patients without any treatment.

CMS cited a Maryland hospital for discharging a woman wearing only a hospital gown and socks in freezing weather.5 “The problem there isn’t that we’re holding her and giving her no treatment. The problem is that we’re not holding her, we’re kicking her out,” says Stefan.

Instead of taking in psychiatric patients, two hospitals in Maine were accused of asking law enforcement to arrest these patients, a violation of EMTALA. One of the two facilities simply asked law enforcement not to bring in these patients.6 (Editor’s Note: The two accused facilities worked with state and federal regulators and issued corrective action plans, which can be found at the bottom of the link associated with Reference 6.)

Increasingly, plaintiffs are going to court to challenge the practice of holding patients with psychiatric crises in EDs while waiting for an available bed.7,8 A recent psychiatric boarding case went all the way to Massachusetts’ Supreme Judicial Court.9 When the state’s commitment law was passed in the 1970s, there were many state hospitals to take people in psychiatric crisis, Stefan explains. The commitment law authorized involuntary detention for long enough to transport an individual to a psychiatric facility. “The statute did not include any time limitations for this stage of detention,” Stefan notes.

Once at the facility, the law limits involuntary detention to three business days. After that, the person has to be discharged or a petition must be filed for involuntary commitment. “But the time limits on involuntary detention don’t start until the person arrives at the psychiatric facility,” Stefan explains.

In effect, the Massachusetts law now permits indefinite involuntary detention in EDs. “It wasn’t really anticipated because the statute wasn’t written for that,” Stefan says.

The plaintiff spent five days in the ED. The court ruled the three-day time limit for involuntary detention at a psychiatric facility began when the patient arrived at the ED. The court declined to impose an arbitrary time limit on ED boarding of psychiatric patients in light of indications the state legislature and department of mental health were working to address the problem. However, the court warned that “any unnecessary delay [in finding a facility to evaluate the patient] is unconstitutional.”9

“It’s better in some ways to try to solve ED boarding legislatively because it’s such a complicated issue,” Stefan offers.

Simply imposing time limits will not solve the problems that result in boarding. “Yet with extended ED boarding, there’s also clearly a constitutional violation,” Stefan notes. “You can’t have indefinite involuntary detention without judicial oversight.” If people could receive decent community-based mental health services, they might avoid crisis, Stefan says. If they receive community-based crisis services, people might avoid going to the ED. “EDs are scapegoats for diminishing social services,” Stefan says.

ED providers believe if a patient is in psychiatric crisis, that person needs an inpatient bed. “It is in fact easier, although it takes much longer, to allow them to fester in the ED waiting for a bed than it is to actually work on creating a good community discharge plan,” Stefan says. She recommends EDs use these approaches to reduce risks when holding psychiatric patients:

Provide all staff with good training in de-escalation techniques, and consistently evaluate whether security guards are appropriate. “This needs to be reinforced by the culture in the ED and the hospital, and often it’s not,” Stefan laments.

Certain times, security guards are the source of problems. This is because behavior due to a person’s mental health condition is interpreted as a security problem. “If security guards are called often in an ED because of psychiatric patients, that’s a bad sign,” Stefan cautions.

Identify the sources of escalations that take place in the ED. If patients in psychiatric crisis are calm enough to answer questions at triage, yet end up in restraints, “that’s a good way to figure out if the ED is having problems,” Stefan offers.

Frequent checks during long waits is one way to avoid needless escalation. Psychiatric patients often are left to guess why they are waiting so long. “If there’s nothing to report, they don’t check in with the person. Their idea is ‘well, we’re waiting for a bed. We don’t know anything,’” Stefan says.

ED staff still can ask if it is too warm, too cold, if the patient wants something to eat, wants lights dimmed, or if they are worried about their kids, their job, or their pets. Frequent checks send the message, “We haven’t forgotten you.”

“Just paying attention to that kind of stuff can help. Those things are relatively easy to do,” Stefan adds.

Examine the spaces in which psychiatric patients are boarded. EDs should conduct an environmental assessment for safety. “Do this in all the spaces where patients will be held, including bathrooms,” Stefan says.

Staying safe does not have to mean depressing and prison-like. In one ED, most treatment areas included artwork on the walls and were relatively bright and cheerful. In contrast, the room for psychiatric patients included a concrete floor with a drain and leather restraints on the bed — and no windows. “It looked like a solitary confinement cell,” Stefan says. “What kind of message did that convey to the patient?”

Identify staff who are good at de-escalating psychiatric patients. Some ED staff are not fazed by people with psychiatric disorders, and have a talent for de-escalating tension. “It’s a particular skill, and you have to find and reward those people,” Stefan says. A reserved parking space for a month or a shout out at a staff meeting are two possible ways to recognize these employees, according to Stefan.

Intervene if the chemistry is not good between a particular ED team member and the patient. If a patient is not getting along with a certain ED team member, it is worthwhile to send someone else in instead.

“The idea is to try to figure out the chemistry that works here,” Stefan says.

Reassess patients carefully at least once a shift. “Maybe you saw them in the first hour, and they really needed a bed, but now they’re ready to go home,” Stefan says.

Without frequent reassessment, the patient is just left to wait indefinitely, even if they no longer require inpatient care.

Ask family members for more information, when possible. Some ED staff misunderstand confidentiality requirements, Stefan observes.

Patients may insist, “I don’t want you talking to my family.” Patients can make that request, but there is nothing to stop ED staff from listening to the family. “Sometimes, families lie. Sometimes, they are the source of the problem,” Stefan acknowledges. “But the more sides of the story you hear, the better.”

Document the thought process behind the decision to discharge. “The biggest mistake is people documenting as though they are advocating for their own decision, rather than explaining how they got to that decision,” Stefan says.

ED providers may only document information that supports discharge, and leave out anything that argues against it. For example, during an assessment, an ED nurse may have discovered the patient had access to lethal weapons at home. Providers can work with the patient and family members to ensure the weapons are removed.

Good charting should show the ED providers carefully considered all the available information. “You are not liable for bad outcomes. You are liable for not weighing the options carefully and using good professional judgment,” Stefan says.

REFERENCES

  1. Santillanes G, Axeen S, Lam CN, Menchine M. National trends in mental health-related emergency department visits by children and adults 2009-2015. Am J Emerg Med 2019; Dec 20:S0735-6757(19)30842-3. doi: 10.1016/j.ajem.2019.12.035. [Online ahead of print].
  2. Lachner C, Maniaci MJ, Vadeboncoeur TF, et al. Are pre-existing psychiatric disorders the only reason for involuntary holds in the emergency department? Int J Emerg Med 2020;13:4.
  3. Kinney J. Advocates decry effort to close psychiatric beds at Providence Behavioral Health Hospital in Holyoke during coronavirus crisis. Mass Live, April 30, 2020.
  4. Huffman J. Napa County to lose remaining inpatient beds for mental health patients. Napa Valley Register, Jan. 23, 2020.
  5. Kennedy M. Federal regulator cites Baltimore hospital after patient left at bus stop in gown. National Public Radio, March 21, 2018.
  6. Stone M. Lewiston hospitals turned away mentally ill patients, had them arrested. Bangor Daily News, Aug. 31, 2018.
  7. Moon J. Arguments heard in lawsuit alleging lack of due process for N.H. mental health patients. New Hampshire Public Radio, April 2, 2020.
  8. Doe v. NH Department of Health and Human Services, Commissioner et al. U.S. District Court for the District of New Hampshire. Civil No. 18-cv -1039-JD. May 1, 2020. https://bit.ly/3i2B735
  9. Massachusetts General Hospital v. CR. Massachusetts Supreme Judicial Court. 484 Mass. 472 (2020).