By Debra Anscombe Wood, RN
Psychiatric emergencies can be as serious as a medical condition, but in traditional EDs, mental health patients may wait for treatment. Specialized psychiatric EDs serve that population quickly and efficiently. “They come in with everything from the need for prescription refills to being actively suicidal,” said Brian Miluszusky, RN, BSN, director of nursing in the emergency medicine department at NewYork-Presbyterian Hospital/Weill Cornell Medical Center in New York. “A suicidal person is as much at risk of dying as someone having an MI (myocardial infarction).”
As demand for emergency care has increased, so has the number of mental health patients seeking services. A study from the Carolina Center for Health Informatics at the University of North Carolina at Chapel Hill reported in 2013 that nearly 10% of ED visits in North Carolina from 2008-2010 were for mental health diagnoses, and the rate of mental health related visits increased seven times more than overall ED visits. Mental health related ED visits increased by 17.7%, from 347,806 to 409,276 from 2008-2010. Stress, anxiety and depressive disorders were most common.
A January 2012 American Hospital Association Trendwatch report said, “In 2009, more than 2 million discharges from community hospitals were for a primary diagnosis of mental illness or substance abuse disorder. ... Among children, mental health conditions were the fourth most common reason for admission to the hospital in 2009.”
The report said there were more than 5 million visits to EDs in 2009 by patients who had a primary diagnosis of mental illness or a substance abuse disorder. “Access to [psychiatric] care is not easily found [in the community], but if you are having a mental health crisis, you can walk into our emergency department 24/7 and be seen by a psychiatrist within a couple of hours,” said Jennifer Ziccardi-Colson, RN, MSN, BSW, MHA, vice president for nursing services at Carolinas Medical Center-Randolph, a behavioral health center with a psych ED and 66 inpatient beds in Charlotte, N.C.
Psych EDs serve patients with acute episodes of behavioral health diagnoses, including feeling suicidal, anxious or depressed or abusing substances. “When patients come to us, they are assessed and seen promptly,” Ziccardi-Colson said. “People can feel comfortable coming to our environment to receive care.”
Not all patients with mental illnesses receive care in a psych ED. Even at those hospitals with a dedicated psych emergency unit or a stand-alone psychiatric emergency services facility, patients with acute medical conditions, such as an MI or a broken hip, are treated in the regular ED. The ED provider must determine if a medical problem is contributing to mental status changes or if the problem is solely psychiatric in origin.
Some psych EDs, such as San Francisco General Hospital and Carolinas Medical Center care for children as well as adults. Children and teens receive emergency psych services at Carolinas Medical Center-Randolph. Younger children, ages 3 to 6, come in with situational stress related to family dynamics, such as divorce or custody battles; depression or anxiety, often related to bullying at school or at home; suicidal ideation; conduct disorders; and behavioral issues related to autism or developmental delays. “In the emergency room, it’s crisis stabilization,” said Tez Bertiaux, RN, MSN, nurse manager for the ED at Carolinas Medical. “A lot of these children are followed in the community by a mental healthcare provider.”
The hospital’s social worker will arrange outpatient care for children who do not have a current therapist. Many are admitted to inpatient care. The psych emergency services program treats about 700 children and adolescents monthly, and the hospital admits about an equal number to its inpatient units, said Bertiaux.
Pediatric ED visits tend to increase during the school year, with school staff workers referring students for care. Some of the children are in foster care or are homeless or living in shelters. Some parents and guardians will stay during the stabilization and others do not. “It’s a very complex dynamic, because you are not just treating the patient — the family is involved,” Bertiaux said.
Bertiaux said many of the mental health issues that bring children into the ED are related to their environment. “And that can be challenging,” she said.
Patients seeking care at a psych ED may be treated and discharged, but others require admission to a psychiatric bed for stabilization. Physicians at NewYork-Presbyterian and San Francisco General admit about 30% of their psych ED patients to the hospital. But treatment begins in the psych ED. “It’s amazing how much we can help people,” said Andrea Crowley, RN-BC, interim nurse manager in psychiatric emergency services at San Francisco General. “Some just need someone to talk to and bring them down from the crisis they are in. It makes you feel you are making a difference, and it’s a visible, tangible thing.”
Psych care a growing need
Carolinas Medical has seen a steady increase in psych ED volume during the past several years. It treats about 18,500 patients annually with a variety of psych disorders and continuously operates at 100% occupancy. Construction is under way to double the psychiatric hospital’s inpatient beds to 132.
Johns Hopkins Hospital in Baltimore’s psych ED census has experienced a 30% jump this year. “People are sicker, and there are fewer resources in the community,” said Kate Pontone, RN, MSN, nurse clinician 3 and nursing service line leader for Psychiatric Emergency Services at Johns Hopkins. “Outpatient programs that had space available are no longer options. People are running out of medications or cannot afford transportation. Many of the same reasons emergency departments are crowded.”
A March 2012 Congressional briefing by the National Association of State Mental Health Program Directors reported, “the economic downturn has forced state budgets to cut approximately $4.35 billion in public mental health spending over the 2009-2012 period,” a trend it expects will continue. While at the same time, there was a 10% increase in consumers receiving state-supported mental health services.
In July 2012, the Treatment Advocacy Center released the paper “No Room at the Inn: Trends and Consequences of Closing Public Psychiatric Hospitals,” which found nationwide, closures of such hospitals “reduced the number of beds available in the combined 50 states to 28% of the number considered necessary for minimally adequate inpatient psychiatric services.” And “in the absence of needed treatment and care, individuals in acute or chronic disabling psychiatric crisis increasingly gravitate to hospital emergency departments, jails and prisons.”
Volume at San Francisco General’s psych ED has jumped from 500 per month to 600 per month. “It could be due to closures in programs,” Crowley said. “We are starting to see a fallout from lack of services in the community.”
Volume also has increased at NewYork-Presbyterian where, typically, a dozen or more psych patients are waiting in the regular ED for a bed in the psych ED, Miluszusky said. Difficulty transferring patients to an inpatient bed clogs up the EDs. A lack of insurance complicates transfers, and patients may end up boarding in a regular or psych ED.
Patients may walk in, arrive by ambulance or with a petition for involuntary commitment, because they are deemed dangerous to themselves or others. First responders may take a mental health patient to a psych ED rather than to a community hospital without such specialized services. “This is a growing population, and emergency rooms will have to evolve,” Miluszusky said. “The population is getting so big; we are going to have to think of new ways to handle it.”
Benefits of a separate psych ED
Psychiatric emergency services programs typically are staffed with behavioral health professionals, allowing mental health interventions to begin quickly, and often the onsite team can stabilize the patient, avoiding a hospitalization, according to the article “Treatment of Psychiatric Patients in Emergency Settings” in the journal Primary Psychiatry. “You don’t have agitated psych patients in the emergency room with all of the sick people,” Crowley said. “It’s a specialized environment where you can begin treatment better.”
Nurses and other members of the psych ED team have a solid understanding about different mental health conditions and their treatment. They can begin therapeutically talking with patients immediately. “Our patients appreciate being cared for by someone who is familiar with their medications and their symptoms and can intervene when they begin to decompensate,” Pontone said. “You get specialized care and the rooms are safe,” said Miluszusky, who adds that improves outcomes.
Psych EDs often are locked units and feature specially outfitted rooms, with no sharp corners, no cords, nonexposed plumbing and a calm atmosphere. The safety features prevent patients from harming themselves or creating tools to harm others. “Our main priority is patient safety,” Ziccardi-Colson said. “There’s no potential for suicide or other negative outcomes.”
Ziccardi-Colson reported Carolinas Medical’s psych ED operates cost effectively, in part because of its ability to begin treatment and stabilize. “We’re able to process people more quickly than a medical ED,” Ziccardi-Colson said.
Miluszusky said having a psych ED can be cost effective, because it reduces overtime pay necessitated by providing one-on-one oversight of a psych patient in the medical ED.
Nurse staffing varies by institution, often with psychiatric nurses providing care, such as at San Francisco General’s psych ED. “It’s an exciting job, where you see a wide variety of people,” Crowley said. “You have a profound effect on people’s lives.”
Emergency nurses, who have received specialized training in the care of mental health patients and de-escalating situations, staff the psych ED at NewYork-Presbyterian. Nurses from a Johns Hopkins inpatient psych unit covers the emergency room, and Pontone describes significant interest from the inpatient staff. The hospital also cross-trains the ED nurses, so they can step in during an emergency. Pontone says nurses who love psychiatric nursing are interested in the management of the acutely ill patient, who needs as much care and support as they can get in a safe environment. “We like to be there when patients are in crisis and need help,” she said. “And we are good in a crisis.”
Ziccardi-Colson said every day presents challenges, but the reward of helping patients to wellness is inspiring and keeps nurses motivated. “Those who like it, love it,” Crowley said. “And for those who are not into it, we are happy to do it for them.”