Management of Boarding Psychiatric Patients in the ED

Author: Summer Chavez, DO, MPH (EM Resident Physician, Virginia Tech-Carilion) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

No matter what kind of emergency department (ED) you work in, chances are a good number of patient visits are related to psychiatric diseases. In fact, 99% of emergency physicians admit at least one psychiatric patient daily¹. The ED acts as a safety net for these patients, bridging the gap between outpatient and inpatient treatment with 1 in 8 patients having either a substance abuse or psychiatric illness¹. Studies show the number of inpatient beds are severely limited and that the patient’s insurance status greatly affects their placement. In 2005, the number of public psychiatric beds was 50,509, decreasing to 43,318 in 2010, merely 14 per 100,000 people². This is the same number per capita that was available in 1850². The current number of beds is estimated to be 38,847².

The Joint Commission reports that psychiatric patients board in the ED on average six hours, sometimes longer depending on patient demographics¹. In rural Oregon, some hospitals reported boarding patients for as long as 18 days¹. Compared to non-psychiatric patients, those with psychiatric illnesses were twice as likely to be boarded in the ED—11% to 21.5% respectively³. A 2012 survey performed by the National Association of State Mental Health Directors concluded that 70% of EDs surveyed boarded patients for at least hours or days, while 10% reported boarding patients for weeks on end². This is not a problem that can be easily fixed.

Many times a patient may have an exacerbation of their underlying psychiatric illness due to medication non-compliance. A survey of 1,625 Medicaid patients found that 46% of patients reported difficulty accessing their medications within the last year⁴. ED visits were estimated to be 73.8% higher among those Medicaid patients who reported medication access difficulties and 71.7% higher among inpatients⁴. Furthermore, those patients who had medication access problems were more likely to have a psychiatric hospitalization than those without⁴. Another study from Zun et al. found the #1 reason psychiatric patients reported non-compliance with their medications was cost⁵. Let’s go over the approach to the psychiatric patient who shows up to your emergency department.

Patient Assessment

The first step in evaluating a psychiatric patient in the ED is ensuring the safety of you, your staff, and the patient. Stabilize the patient while paying attention to the A’s, B’s, and C’s. If the patient identifies with any suicidal or homicidal behavior, they may need to be detained. Ensure there are no underlying medical conditions that could be exacerbating or contributing to the patient’s behavior by doing a medical evaluation⁶.

When interviewing the patient and focusing on their mental status, observe the patient’s behavior, language, and appearance⁶. Affect is the outward feelings the patient displays, while mood is considered to be more internal. Some examples of affect are anxiety and sadness. Consider asking questions about orientation, ensuring the patient comprehends the situation, and evaluate their memory of events⁶. Thought content, or the patient’s beliefs, are another way to gain more insight into the patient’s condition. For instance, a patient with a disordered thought process may have fixed false beliefs. Also ask about any auditory or visual hallucinations the patient may be experiencing. Finally, look attentively at the patient’s ability to make decisions—their judgment. Patients that have poor insight into their illness may not understand the gravity of their situation.

Medical Evaluation

Next, evaluate your patient for medical stability throughout your shift. Listen to your nurses and pay attention to any changes in vital signs. You can never be faulted for reassessing the patient.  One study found that 34% of cases had missed severe alcohol or other drug intoxication in patients admitted to psychiatric units⁷. Additionally, 12.5% of either withdrawal or delirium tremens were missed⁷. Similarly, only 87.5% of prescription drug overdoses were identified⁷. In approximately 8% of patients, abnormal vital signs were not investigated further⁷. Another study found that adults older than 55 are four times more likely to have a missed medical diagnosis⁷.

Obtaining laboratory tests has been an issue of debate in the past. Always be sure to obtain a good history and physical exam, review of systems, and mental status exam. Positive findings may help to direct you down a certain pathway. One study found that laboratory testing may be of higher utility in the elderly, patients without a prior psychiatric history, substance abuse disorders, and those with medical complaints⁷. Patients with prior psychiatric history have additional information you need to obtain.

What’s different if they have a known psychiatric condition?

An integral part of the history is your patient’s prior psychiatric history. Have they ever had a psychiatric diagnosis? Do they have a psychiatrist that they currently see or have seen in the past? Be sure to ask about prior inpatient hospitalizations, any substance abuse, and prior suicide attempts⁸. Be mindful about how you word your questions, as sometimes there is stigma. Inquire about any psychiatric medications and their compliance with their medications. Although it can be difficult in a busy ED, review the patient’s chart and compare this presentation to the past. Another useful source of information may be accompanying family members or associates. Speaking with the patient’s counselor or psychiatrist can also be helpful.

If possible, take a detailed history regarding their medications, and restart their home medications⁶. For instance, in one study of medication errors requiring pharmacist intervention, 89% of the time an error of omission occurred⁹. Patients in this study were not given their normal medication, resulting in error⁹. It is difficult to obtain reliable history from these patients⁹. Tele-psychiatry is another option for some hospitals. Patients may receive medication changes, community referrals, or transfer to another facility¹⁰. Researchers at the University of South Carolina reported cost savings of more than $1700 for patients who had a tele-psychiatry consultation while in the ED¹⁰.  After doing the history and physical exam, it’s time to make a decision.

Who needs admission?

At the end of the day, you have to decide—does this patient require admission, or are they safe to go home? How dangerous is this person to themselves or to others? Are they able to take care of themselves and perform activities of daily living? What available support does the patient have? Knowing these answers can help you determine disposition. The five most important factors predicting admission to inpatient psychiatry from the ED are danger to self, psychosis severity, ability to care for oneself, impulse control, and depression severity⁶. Unfortunately, there is no validated tool to help determine who needs admission. For those patients that you are not sure which way to go or could use a bit more help, a psychiatric consult or evaluation from a psychiatric social worker is beneficial⁶. Remember, telepsychiatry is an option as well. When interviewing these patients, look for signs of depression, substance abuse, or other triggers.

If they need to be admitted but no psych beds, should you admit to a medical bed?

As discussed earlier, the shortage of psychiatric beds makes it difficult to appropriately disposition patients. A study from Claudius et. al determined that approximately 50% of involuntary pediatric patients were admitted to the pediatric medical unit¹¹. 94% were admitted for boarding because there was no bed available¹¹. The researchers came to the conclusion that patients who were admitted to a psychiatric hospital were more likely to receive medications and counseling¹¹. Making the decision to admit a patient to a medical bed while waiting for psychiatric placement is not ideal and will depend on your institution’s procedures.

It’s not uncommon to get sign out regarding boarding psychiatric patients in the Emergency Departments—“Bed #57 was a 24-year-old female, Benadryl overdose, medically clear, awaiting placement. Bed #59 was a 44-year-old male, here for alcohol detox again. On the CIWA protocol. Awaiting placement.” Although it may be tempting to forget about these patients and it’s easy to get caught up with the other patients in the ED, reassess during your shift. A patient that is pending placement for detoxification may have already detoxed. Some patients may no longer require inpatient admission. Here’s another scenario —a patient that was acutely intoxicated that says they want to hurt themselves. The large majority of psychiatric facilities will not accept acutely intoxicated patients. Now the patient is sober and says they no longer have suicidal ideation. This presents a diagnostic dilemma for the physician¹². Let’s dive a little deeper into the acutely suicidal patient scenario.

Assessing suicidal patients: static and dynamic factors

Assessing danger to one’s self can be difficult. Try to establish rapport with the patient. Once you’ve determined that they are suicidal, see if the patient has a plan and means to carry it out. Underlying factors may be playing a role. Patients that have no underlying mental health disorder and are deemed safe to go home should be offered a safety plan and strict return precautions before leaving the ED⁶. Offering problem-solving strategies may be helpful for this type of patient as well as those undergoing severe interpersonal issues. A psychosocial referral could also be of use⁶.  Make sure that follow-up has been arranged before the patient leaves the ED⁶. Let’s look at some factors that contribute to someone’s overall suicidality.

Attempts with intricate planning, particularly lethal methods, or suicide notes, suggest high risk. The population with the highest risk to complete suicide are older, white, recently widowed males with access to lethal weapons⁶. Ask the patient how they felt after the attempt, such as any remorse for their actions, as this has been shown to have a lower risk of future suicidal behavior than those who do not⁶. Secondary gain may also play a role in some suicide attempts, but all attempts should be taken seriously.

Another way to think about suicide risk is the lethality of the patient’s suicide attempt, their likelihood of rescue, and the patient’s perception⁶. A patient that takes a few pills in front of an estranged boyfriend is probably not as high risk as someone that goes off into a remote area with a gun. Additionally, patients with prior suicide attempts are more likely to attempt suicide in the future⁶. Patients whose attempts continue to increase in lethality warrant a much closer look. The table below demonstrates some high-risk factors.

From: Zun, Leslie. “Mental Health Disorders: ED Evaluation and Disposition.” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. Eds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2016, http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=1658&Sectionid=109447969.

Obviously, patients who continue to have strong desire to commit suicide are high risk and should be hospitalized. However, patients with moderate-risk (originally presented in a serious suicidal state but responded well to initial intervention and have good social support) may not need to be admitted⁶. Involve a psychiatrist with this patient population. Ensure that lethal weapons or materials for suicide attempts are no longer accessible, a safety plan is in place, and go over problem-solving strategies. You may want to consider starting a course of psychotropic medication (approximately 2 weeks) with family involvement to ensure compliance⁶. Low-risk patients are considered to be the frequent fliers. They present with minor attempts with a clearly defined crisis and typically have good social support. Low-risk patients who meet the following criteria may be considered for discharge from the ED: “medical treatment not needed, no prior suicidal attempt, not actively suicidal, adult in house with good relationship, adult agrees to monitor, adult will remove guns and medications, contact for deterioration available, follow-up arranged, and patient and support group agreement to plan and recommendations.”⁶. These community resources can be incredibly helpful.

Using community resources

Community resources are an additional way to provide support for your patients. A study from McCullumsmith et. al found that patients who were seen within 3 days from an ED visit at a transitional psychiatry clinic were significantly more likely to stay in the community longer before returning to the ED¹³. Patients that had to wait longer were less likely to attend at all¹³. Another study that looked at a community intervention to improve depression among the elderly also had favorable outcomes¹⁴. Understanding what resources are available at your institution is helpful for patient disposition and optimal management. Before finishing up, let’s briefly touch on possible treatment options.

Treatment options for the ED: depression/suicide, mania, schizophrenia

Depression/Suicide:

Anti-depressants can take weeks or even months to take effect so are typically not started in the Emergency Department unless a psychiatric consultant specifically requests it⁶. For this patient population, non-medical treatments are typically used acutely.

Mania:

Patients that are acutely manic or presenting with hypomania should have their antidepressant discontinued. Mood stabilizers and atypical antipsychotics are first line treatment¹⁵. Mood stabilizers should only be started in association with psychiatry consultation, and patients not on any current medication may be started on lithium (up to 300 mg PO BID with dose adjustments PRN). Some experts suggest starting atypical antipsychotics for patients with mixed features¹⁵. Valproate is another option, but is contraindicated in women of child-bearing age due to its teratogenic effects. Patients that are already on a mood stabilizer but have symptoms may be started on an atypical antipsychotic¹⁵. For those on atypical antipsychotics with symptoms, consider switching to another atypical antipsychotic or adding a mood stabilizer. Do not combine multiple antipsychotics¹⁵. Carbamazepine is a second-line treatment option¹⁵.

Schizophrenia:

Haldol 2-5 mg IM and Ativan 1-2 mg IM are two fast-acting options for a schizophrenic patient⁶. Other options include Risperdal 3-6 mg PO daily or Zyprexa 15 mg PO daily⁶. Benzodiazepines combined with Zyprexa can cause some hypotension, so be mindful⁶.

When it comes to managing boarding psychiatric patients, keep these pearls in mind:

• Restart home medications.
• Reassess patients at least once during your shift.
• Make sure the patient remains medically clear.
• Get a good history and physical!
• Use your community and facility resources to help disposition and treat patients.
• For a great review article on psychiatric medications to use in the ED for agitated patients, check out “The Psychopharmacology of Agitation: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup” by Wilson, et al.

References/Further Reading

1. Joint Commission. Alleviating ED boarding of psychiatric patients – Google Search [Internet]. 2015 [cited 2016 Oct 21]; Available from: https://www.google.com/search?client=safari&rls=en&q=Alleviating+ED+boarding+of+psychiatric+patients&ie=UTF-8&oe=UTF-8
2. Kutscher B. Bedding, not boarding. Psychiatric patients boarded in hospital EDs create crisis for patient care and hospital finances. Mod Healthc 2013;43(46):15–7.
3. Nolan JM, Fee C, Cooper BA, Rankin SH, Blegen MA. Psychiatric boarding incidence, duration, and associated factors in United States emergency departments. J Emerg Nurs JEN Off Publ Emerg Dep Nurses Assoc 2015;41(1):57–64.
4. West JC, Rae DS, Huskamp HA, Rubio-Stipec M, Regier DA. Emergency Psychiatry in the General Hospital: Medicaid medication access problems and increased psychiatric hospital and emergency care. Gen Hosp Psychiatry 2010;32:615–22.
5. Zun L, Downey L, Burke T. Article: 0655: Non-compliance in the Emergency Department: Is There a Difference Between the Reasons Medical and Psychiatric Patients Use the Emergency Department? Eur Psychiatry 2015;30(Supplement 1):655.
6. Zun L. Mental Health Disorders: ED Evaluation and Disposition [Internet]. In: Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, editors. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill Education; 2016 [cited 2016 Oct 27]. Available from: http://mhmedical.com/content.aspx?aid=1121518909
7. Tucci V, Siever K, Matorin A, Moukaddam N. Down the Rabbit Hole: Emergency Department Medical Clearance of Patients with Psychiatric or Behavioral Emergencies. Emerg Med Clin North Am 2015;33(4):721–37.
8. Desan PH, Powsner S. Assessment and management of patients with psychiatric disorders: Crit Care Med 2004;32(Supplement):S166–73.
9. Bakhsh HT, Perona SJ, Shields WA, Salek S, Sanders AB, Patanwala AE. Medication errors in psychiatric patients boarded in the emergency department. Int J Risk Saf Med 2014;26(4):191–8.
10. S.C. telepsychiatry ED consultations promoting timely care, cost savings. Ment Health Wkly 2013;23(41):1–7.
11. Claudius I, Donofrio JJ, Lam CN, Santillanes G. Impact of Boarding Pediatric Psychiatric Patients on a Medical Ward. Hosp Pediatr 2014;4(3):125–32.
12. Zun LS. Best Clinical Practice: Pitfalls in the Care of the Psychiatric Patient in the Emergency Department. J Emerg Med 2012;43:829–35.
13. McCullumsmith C, Clark B, Blair C, Cropsey K, Shelton R. Rapid follow-up for patients after psychiatric crisis. Community Ment Health J 2015;51(2):139–44.
14. Joubert L, Lee J, Mckeever U, Holland L. Caring for Depressed Elderly in the Emergency Department: Establishing Links Between Sub-Acute, Primary, and Community Care. Soc Work Health Care 2013;52(2/3):222–38.
15. Zadarenko S. Medications for bipolar mania, hypomania, or mixed features | DynaMed Plus [Internet]. [cited 2016 Oct 27]; Available from: https://www.dynamed.com/topics/dmp~AN~T909584#Overview-and-Recommendations