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Emergency Medicine

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Emergency departments vary in their approach to psychiatric emergencies, underscoring the need for standards

With the lack of State psychiatric facilities and community support, persons in psychiatric crisis, who are suicidal, suffering from hallucinations, or having severe anxiety attacks, often end up at the hospital emergency department (ED). Yet, there are no established best practices for managing these ED patients. In fact, hospital EDs vary tremendously in their approach and resources for management of these patients, according to a new study. Psychiatric emergency patients can be stressful for ED staff who often don't know how to handle them, and there are often insufficient ED on-site or on-call psychiatric personnel to manage them.

Improper triage, lengthy reviews with third-party payers to request preauthorization of care, inaccessible outpatient services, and lack of inpatient behavioral health beds further hinder emergency providers from obtaining the appropriate level of treatment for these vulnerable patients, explains Jennifer Field Brown, A.P.R.N., P.M.H., Ph.D., of Virginia Commonwealth University. Her survey of ED administrators at 71 hospitals in 2 States found that 45 percent of hospitals used an in-house psychiatric service, 41 percent had a contractual structure, and 14 percent had no psychiatric services.

A hospital's approach to ED psychiatric emergencies tended to be largely influenced by its available resources and circumstances. For example, hospitals with an ED psychiatric emergency service (EDPES) had more inpatient psychiatric beds and a larger share of the market and served a greater volume of psychiatric patients. Those without an EDPES had a low volume of ED psychiatric visits and/or availability of other psychiatric emergency services in the area. Hospitals that used a contractual EDPES had the slowest response time and were more likely to contract for other clinical services as well. The study was supported by the Agency for Healthcare Research and Quality (HS13859).

See "A survey of emergency department psychiatric services," by Dr. Brown, in the November/December 2007 General Hospital Psychiatry 29, pp. 475-480.

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