Emergency psychiatric care is extremely limited and getting worse, says the American College of Emergency Physicians (ACEP). The tragic death of a 49-year-old woman with schizophrenia who died waiting for care in a metro-NY psychiatric ED exemplifies what a 2008 ACEP survey found that many psychiatric patients are left hanging in limbo in the ED with no psychiatric services involved prior to admission or transfer.What are the standards of care for patients with mental health issues who seek emergency care in New York?
Numbers speak the problem
Of the 328 ED directors across the country who responded to the ACEP survey, the majority from general hospital EDs, almost 80% said their hospitals board psychiatric patients in the ED, with 30% acknowledging boarding them between eight and 24 hours. “The environment of a busy ED may function to exacerbate symptoms, often requiring patients to be sedated, rather than providing the specific care they need,” says David Mendelson, MD, principal study author.
Psychiatric patients in the ED require more nursing and other resources than nonpsychiatric patients, according to the majority of ED medical directors who responded to the survey. Mendelson says patients who have severe mental illness and have experienced trauma, for example, may require one-to-one care that taps into nursing as well as security and other personnel.
When asked “What is the most common reason(s) for extended stays of psychiatric patients in your ED,” some respondents said decreased inpatient psychatric beds without a corresponding increase in outpatient psychiatric resources, pre-authorization of insurance carrier prior to admit from the ED, lack of insurance, and unwilling psychiatrist to evaluate patients between 1 pm and 10 am, despite being on-call. Sixty percent of respondents said that their ED does not have a dedicated area for these patients.
The CPEP answer
“Patients with mental illness experiencing a medical emergency are assessed, stabilized, and triaged from a general hospital ED to the less stimulating environment of an existing psychiatric ED,” says Robin Krajewski, MSN, NPP, RNC, director, Office of Mental Health, Long Island Field Office, Brentwood, N.Y.
In several community hospitals across NYS, patients receive care in Comprehensive Psychiatric Emergency Programs (CPEPs) that provide psychiatric patients with emergency observation, comprehensive physical and psychiatric assessments, evaluation, and treatment in a safe and comfortable environment. The New York State Office of Mental Health licenses CPEPs as designated entry points into the mental health system for individuals experiencing a psychiatric crisis.
Krajewski describes the CPEP environment as located apart from the main ED to separate patients with mental health problems, those acting out, and those potentially dangerous to themselves or others. Here patients are evaluated and triaged and can be held for up to 72 hours for observation.
Patient supervision and safety monitoring vary according to assessed levels of risk from suicide/harm, with constant staff supervision and observation through a glass observation area and/or video monitoring; one-to-one for seriously suicidal/homicidal patients who require arm’s length, direct eye contact; and police attendance for patients they brought in, Krajewski says. There are two time frames set in statute regarding CPEPs, she notes. A patient must be seen by a clinician within six hours, and if he or she is to be retained for more than 24 hours, the patient must be admitted to a holding bed.
EDs that do not have CPEPs are licensed by the NYS Department of Health and must meet its standards for care of patients with mental health problems. These EDs may serve as entry points of admission for patients to psychiatric EDs or as triage points to other facilities.
“When patients enter EDs [without CPEPS], it is required that they receive a medical screening to assess for emergency medical conditions and receive the appropriate level of care referral to outpatient treatment or inpatient stay,” says Jeffrey Hammond, spokesman, Public Affairs Group, NYSDOH, Albany. “Psychiatric patients receive medical screenings to rule out potentially life-threatening conditions, and then decisions are made about the disposition of careinpatient psych treatment, discharge home with follow-up, outpatient treatment, etc.,” he says.
The Joint Commission standards
Both psychiatric and general hospital EDs must meet specific standards of care and safety to be accredited by The Joint Commission. These standards address safety from three perspectives: assessing for a safe physical environment free of risk, assessing the quality of initial and ongoing patient assessments and monitoring; and assessing the quality of staff communication. Analysis of sentinel events data has shown that a breakdown in these areas can lead to a sentinel event.”When we’re talking about safety [in the ED for psychiatric patients]we’re talking mainly about preventing patient suicide, self-harm, and harm to staff if a patient attacks them,” says The Joint Commission’s David Wadner, PhD, field director, Survey Management and Development, Oak Brook Terrace, Illinois.
The Joint Commission requires accredited organizations to be focused on the health and safety of these patients specifically because this group has a high rate of self-injurious behavior during short-term ED admissions, he says. According to Wadner, psychiatric EDs are specifically equipped to handle individuals with long-standing and short-term behavioral disorders, because they are staffed with trained behavioral health professionals who closely monitor patients in a safe environment.