A psychiatric emergency is any situation in which a person may be a threat to themselves or others. Examples are suicidal behavior, threat of violence, psychosis or any other acute change in behavior. There are few options for receiving care during a psychiatric emergency. Unfortunately, most of them are rubbish. Psychiatrists are rarely reachable outside office hours and crisis management-trained mental health social workers are not widely available. Relying on friends or family puts an undue burden on those who are not trained in emergency psychiatric care. That leaves most people with one choice, their local hospital emergency department.
Hospital emergency departments are usually the best option in psychiatric emergency cases. The problem is, they may also be the worst option.
Despite the fact that almost 10% of cases are related to mental health, most ED’s are not well-equipped to handle psychiatric emergencies and there are no standards of care. Staff are often uncomfortable handling mental health cases, having never received adequate education or training.
Once seen, patients can expect to be held in the emergency department for a minimum of seven hours and up to several days in a situation called “boarding.” This is because the general practice for handling psychiatric cases is to admit most patients to a psychiatric hospital. There are, obviously, problems with this idea.
First, an emergency department is far from the best environment for someone in psychiatric distress. It’s loud; it’s bright. Clearly in distress, patients are often restrained and their needs left unmet because the people charged with caring for them do not know how to do so. Add to this the fact that more and more hospital psychiatric units are employing armed security and police who have the same or less training than the medical staff. Imagine a scenario in which a patient is experiencing paranoid psychosis and is confronted with a gun.
Second, there are only 50,000 in-patient beds available in psychiatric hospitals in the U.S. with over 12 million visits to the ED related to mental health or substance abuse each year. You do the math. When the practice is to admit every psychiatric patient, the bottleneck is unavoidable and patient care is lost in the process.
Not only is admitting all mental health patients impractical and unnecessary, boarding them can also be illegal. Washington state has declared boarding patients against their will due to inadequate resources unconstitutional. Patients have the right to “adequate care and individualized treatment.”
So how is this avoidable?
One solution is the Alameda Model. This is a procedure first adopted by the East Bay area near San Francisco, California. In this model, once a patient is medically cleared by an ED (meaning no injuries or other physical ailments), they are automatically accepted at a nearby psychiatric hospital, regardless of whether or not a bed is available. Walk-in patients are also accepted at psychiatric hospitals regardless of bed availability. Patients receive immediate care to promote stabilization and reduce the need for admittance as an inpatient. Studies on this model showed ED waiting times reduced to under two hours and an inpatient admittance of only 25%.
Another option is the implementation of comprehensive psychiatric emergency programs. Many of these already exist across the country. The program is implemented in at least one of three ways:
- The psychiatric consultant to the ED is called when needed;
- A self-contained PES within the main ED; and/or
- A separate psychiatric ED in the general hospital or the ED of a freestanding psychiatric hospital.
While larger hospitals in metropolitan areas may be able to implement all of these, having a separate ED or clinic in the hospital may not be financially feasible in rural areas. However, smaller hospitals should still provide psychiatric consultations and the ability of immediate transfer to a regional psychiatric hospital. These processes are vital to keeping patients safe and well-cared for.
Photo credit: Dan McCarthy