The Case

A 25-year-old female was sent by ambulance to the emergency department (ED) by a mental health clinic for suicidal ideation. Upon arrival to the ED at 1645, the patient was evaluated by the triage nurse and determined to be awake, alert, calm, and cooperative. She denied current suicidal thoughts. The department was extremely busy with a census of 97 patients, including 29 admissions being held awaiting inpatient beds; the National Emergency Department Overcrowding Scale (NEDOCS) score was 200 (scores > 180 indicate disaster-level crowding).¹ After completing triage, the patient was placed on a gurney in the hallway next to the triage station at 1650. A Posey restraint was applied, as no qualified sitter was available to stay with the patient. Psychiatric Emergency Services (PES) (a group of licensed clinical social workers who provide ED services) was contacted for psychiatric social work assessment. The PES staff member stated that other patients needed to be seen first and that the patient would be evaluated as soon as possible.

Approximately 40 minutes later (1730), the triage nurse noted the patient was missing from the gurney, the Posey belt on the bed still buckled and in place. Hospital police were called immediately, and the elopement of the patient and her description was reported. PES was also paged and made aware of the patient’s elopement. Eight minutes later the patient was found by an Environmental Services staff member in a bathroom in the radiology department adjacent to the ED. The patient was on the floor with her shoestrings tied around her neck. She was awake with discoloration to her face (purple) and neck (red), but she was breathing and able to follow the nurse with her eyes. She was returned to the ED resuscitation room where she was evaluated by the physician. Redness was noted to her neck, but abrasions, swelling, and bleeding were absent. There was adequate breathing and air exchange, adequate oxygen saturation, and no respiratory distress. The patient underwent PES evaluation and was eventually transferred to an inpatient psychiatric facility for further care.

The Commentary

by James A. Bourgeois, OD, MD, Glen Xiong, MD, David K. Barnes, MD and Rupinder Sandhu, RN, MBA

This case illustrates several challenges facing the medical care delivery system. As is so often seen, the emergency department (ED) becomes the urgent care site of default when other systems of care do not provide adequate coverage or offer necessary resources for urgent clinical situations. This case involves a suicidal psychiatric patient who was sent to the ED from a psychiatric clinic, when direct referral to an inpatient psychiatric facility could have been the more efficient, simpler, and safer disposition. Overcrowding in the ED, with boarding of admitted patients, led to inability to room and appropriately treat this suicidal patient promptly. The situation was aggravated by the unavailability of sitters for psychiatric patients in this ED.

Triage and Medical Screening of Psychiatric Emergencies

The case narrative, arguably incomplete, does not suggest systemic illness as the cause of the patient’s decompensated behavior. It is a routine practice for psychiatric hospitals to obtain a urine drug screen for psychoactive substances, and an admission history and physical examination at the psychiatric facility would typically be adequate to discern a previously unsuspected systemic illness or medication-related effect (e.g., delirium and/or mania from high dose corticosteroids) that could impact the patient’s mood state and suicidal behavior. Notwithstanding these capabilities, the ED experience in many communities is that psychiatric inpatient facilities resist admitting any new patient who “may have” underlying medical condition(s), an occult ingestion, or a systemic medical etiology for their psychiatric presentation. Rather than address these concerns through the admission history, physical examination, and laboratory assessment at the psychiatric facility, directors of these facilities often perceive a need to “medically clear” every new inpatient in the ED before accepting the transfer. As a result, pre-hospital personnel learn to transport these patients with acute psychiatric illnesses to the nearest ED for “medical clearance” examinations.

All patients who present to the ED, even if directly referred from a psychiatry clinic, must go through ED triage. Triage is necessary when ED resources are limited, which they typically are, given the excess demands on modern emergency services. Patients must therefore be sorted and prioritized by their chief complaint, vital signs, appearance, and anticipated resource need. Sicker and more complex patients receive higher priority. To triage effectively, nurses must have strong critical thinking skills, the ability to identify high-risk presentations, clinical experience and expertise, and institutional knowledge. Physicians can also perform this triage function, but they are a more limited and expensive resource and need to focus on patient evaluation and management.

Pursuant to EMTALA—the Emergency Medical Treatment and Active Labor Act—federal law requires every patient who “comes to an emergency department,” regardless of their mode of arrival (e.g., on foot, by car, via ambulance, voluntarily, involuntarily), to be evaluated for an emergency medical condition (EMC). An EMC is “a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the lack of immediate medical attention could reasonably be expected to result in placing the health of the patient, or (in case of pregnancy, the unborn child) in serious jeopardy, the significant impairment to bodily functions, or serious dysfunction of any bodily organ or part."² A previous WebM&M commentary extensively addresses EMS crowding, including EMTALA and the role of ED triage.

The process used to screen for an EMC after triage is known as the medical screening exam (MSE). The MSE includes any history, examination, testing, treatment, and consultation necessary and sufficient to determine if an EMC exists. The MSE must be performed and documented by a qualified medical provider (QMP), usually a physician. In most EDs, APPs (Advanced Practice Providers, including Nurse Practitioners and Physician Assistants) are designated as QMPs. However, patients still need to be triaged before they see a QMP.

It is conceivable that a hospital could designate an LCSW as a “qualified medical provider,” thereby accelerating definitive care of psychiatric emergencies. A CMS bulletin discussing EMTALA compliance states: “A hospital must formally determine who is qualified to perform the initial medical screening examinations, i.e., qualified medical person. While it is permissible for a hospital to designate a non-physician practitioner as the qualified medical person, the designated non-physician practitioners must be set forth in a document that is approved by the governing body of the hospital. Those health practitioners designated to perform medical screening examinations are to be identified in the hospital by-laws or in the rules and regulations governing the medical staff following governing body approval.”² However, as LCSWs are not medically trained or licensed, they are not able to address systemic comorbidities implicated in psychiatric presentations, so a physician or APP would need to co-manage the patient. A theoretical benefit to having ED-based LCSWs perform mental health assessments in the ED is that they can more effectively assess psychosocial problems that lead to crisis presentations but are not manifestations of major psychiatric illness. This process can allow for social interventions in lieu of psychiatric inpatient admission to manage “crisis” presentations.^3-5

The Emergency Severity Index (ESI) is the system that US hospitals use to categorize and prioritize care for emergency patients who have been triaged: ESI-1 is reserved for those patients with immediately life-threatening conditions like cardiac arrest, blunt trauma, seizure, and choking, while ESI-5 represents low (or no) risk complaints like requests for medication refills. In our ED at the University of California, Davis Medical Center (UCDMC), most patients with a psychiatric complaint (and all those likely to be eventually placed on a psychiatric commitment order) are triaged as ESI-2. We implemented the C-SSRS (Columbia Suicide Severity Rating Scale) at ED triage for a subset of patients who present with a chief complaint of suicidal ideation, other behavioral health related complaints, or specific observable behaviors.⁶ Any patient screened “high risk” is seen quickly by our PES team, licensed clinical social workers (LCSW) who are empowered by Sacramento County to write initial psychiatric commitment applications for patients who meet legal criteria for involuntary psychiatric commitment. Patients ascertained to be high suicide risk are placed on suicide precautions. They are also assigned to 1:1 continuous observation, often in the ED-affiliated behavioral health unit (BHU), with psychiatric nursing and psychiatric consultation and co-management.

Observation and Restraint of Suicidal Patients

It is not clear why the patient was restrained after triage, with or without a designated sitter. Suicidal patients should not be restrained unless they are actively harming themselves or physically agitated and dangerous at the time. Suicidal and/or depressed patients are not typically agitated when they present to the ED. While suicidal patients (especially those on commitment orders) must be constantly observed and not permitted to leave, securing the perimeter of an enclosed space and providing 1:1 watch are preferable to physical restraint. Parenthetically, when restraints are clinically indicated, ED staff need to be made aware because restrained patients are vulnerable to assault. For safety purposes, restrained patients must have constant 1:1 watch; therefore, “q15min” checks are not enough. Increasing the frequency of nursing assessment of acute psychiatric patients may decrease the duration of episodes of physical restraint.⁷ Curtains and doors should be kept open so that additional assistance is readily available, if needed.

Most PES staffing models do not have a process to call in extra social workers for “surges” in clinical demand. EDs typically staff based on predicted patient volume, which can vary wildly, as can acuity. There is not an accepted numerical time standard for when the PES staff member is expected to see a patient. Assigning an additional LCSW to the triage area may shorten the interval to initial patient contact for patients presenting with acute psychiatric symptoms.

In our ED, when a patient in triage is screened as high risk for suicide using the C-SSRS tool, an automated page is sent to the PES LCSW through the electronic health record. These patients are prioritized for mental health assessment by the PES LCSW. If a patient is assessed as high risk for harm to self/others or gravely disabled, a psychiatric commitment application is completed, 1:1 observation is assigned, and the patient is prioritized for the next open bed. Some EDs do not permit immediate “offload” of patients at high risk of suicide who arrive via emergency medical services (EMS). Instead, patients remain under the supervision and care of EMS staff—a practice known as wall time—to maintain constant 1:1 observation if ED staff are unavailable.

When staffed ED beds are unavailable, typically because of hospital crowding and patient acuity, psychiatric patients on involuntary commitment status may be kept in the hallway until a bed becomes available. In our ED, we utilize unlicensed MHWs (mental health workers) on duty 24/7 who perform 1:1 sitting and other tasks to support psychiatric patients. An MHW completes a safety check on each assigned patient every 15-20 minutes. In reality, MHWs are often monitoring multiple patients and may need to help a patient to the bathroom, leaving other patients in the hall unattended. With multiple patients in the hallway at times, any one person’s ability to keep track of a single patient is easily overwhelmed. In addition, hallway care may contribute to the stigmatization, shame, embarrassment, confusion, and even hostility that patients often perceive when they report suicidal ideation or self-harm.⁸

Most large academic and county hospital EDs have physically separate treatment areas for psychiatric patients. This practice helps to concentrate resources for these patients to better manage psychiatric emergencies. In smaller hospitals, psychiatric patients often commingle with other medical and surgical ED patients, leading to unfocused care and possibly misalignment of staff attention and resources, especially at times of crisis. However, a recent survey of a probability sample of ED nursing directors reported no meaningful differences in safety planning (e.g., creating individualized plans to restrict access to lethal means, helping patients to use internal coping strategies, or accessing available social supports/activities) for patients presenting after self-harm across different types of hospitals.⁹

At minimum, all acute psychiatric presentations require screening for physical injuries and alcohol or drug intoxication or withdrawal. While details regarding the medical evaluation after the patient’s attempted strangulation are incomplete, standard ED evaluation for similar patients would consider possibilities such as cervical spine fractures, hypoxic brain injury, vascular injury, stroke, airway trauma, and asystolic cardiac arrest secondary to carotid baroreceptor stimulation, all of which may lead to serious morbidity or death. Additional serious injuries after strangulation include thyroid storm, pneumothorax, pneumomediastinum, pneumopericardium, pulmonary edema and delayed pneumonia. Computed tomography of the brain, cervical spine, and cervical vasculature are routinely ordered, in addition to standard laboratory screening such as a complete blood count, serum chemistries, urine drug screen, and pregnancy testing (for patients of child-bearing age). Evidence of airway trauma, manifesting as stridor, difficulty speaking (dysphonia), or painful swallowing (odynophagia), requires specialty consultation and often necessitates endotracheal intubation for airway protection. Similarly, cervical spine fractures, hypoxic brain injury, and vascular (e.g., carotid artery, vertebral artery, internal jugular vein) injuries require specialty consultation and frequently surgical intervention.¹⁰ These high-risk injuries make medical clearance for psychiatric confinement impossible in the near term; psychiatric facilities may well reject any patients who have had such injuries and intervention.

Opportunities for System Improvement

When a mental health clinic patient is sent to the ED for urgent evaluation of psychiatric symptoms, direct communication to the ED staff could facilitate more efficient care. A useful message would include key information as follows: “This patient with borderline personality disorder is reporting suicidal ideation (SI). We called police at XXXX hour to detain patient and bring to ED for assessment. Here is an excerpt from the last clinician note. Call the clinic for additional background information …” Identifying the treating outpatient physician or other clinician who can be contacted, if necessary, could prove beneficial. With advance notice, the receiving ED may be able to call in a sitter, or to prepare a hospital assistant on duty to assume the role of a sitter.

In a more effective and integrated health care delivery system, patients in psychiatric crisis would only be sent from the outpatient care setting to the ED when there is a high probability that the patients’ general medical conditions are plausibly causative of the acute psychiatric crisis. Examples could include acute behavioral decompensation in patients with systemic illness such as human immunodeficiency virus (HIV), multiple sclerosis (MS), or cancer; patients with recent exposure to high dose corticosteroids; or patients at risk for physical side effects of psychotropic medication (e.g., lithium, anticonvulsants).

Most patients with decompensated (or new onset) psychiatric illness can be well managed by direct admission to inpatient psychiatric facilities where the admitting physician can oversee the admitting history and physical examination, and laboratory results to guide definitive care. This practice prevents the interposed presentation to the ED, the associated use of precious medical and nursing resources, and the predictable but usually preventable delay in obtaining definitive psychiatric care. In addition, EDs vary widely in their recommendations for subsequent care after an episode of self-harm, even adjusting for all identified features of the patient’s presentation.^11,12 Rarely, as illustrated by this case, the interposed presentation to the ED may lead to harms that delay effective treatment of the patient’s underlying psychiatric condition. Of course, the feasibility of these “best practices” may be limited by the local availability of inpatient psychiatric beds, which are in short supply in many communities."

Take Home Points

• Psychiatric emergencies are common reasons for referral from outpatient care settings to emergency departments (EDs), even when the risk of a contributing medical condition or an alcohol/drug-related problem requiring medical intervention is very low.
• In the United States, federal laws and regulations mandate that every patient presenting to an ED be evaluated for an emergency medical condition through a medical screening exam, which must be performed and documented by a qualified medical provider, usually a physician. This process may lead to delays in the assessment and treatment of a psychiatric patient’s underlying condition.
• Suicidal patients should not be restrained unless they are actively harming themselves or physically agitated and dangerous at the time. Direct 1:1 observation is a safer approach.
• When a mental health clinic patient is sent to the ED for urgent evaluation of psychiatric symptoms, direct communication to the ED staff facilitates more efficient care.

James A. Bourgeois, OD, MD
Clinical Professor, Department of Psychiatry and Behavioral Sciences,
Medical Director, Emergency Psychiatry
UC Davis Health
jbourgeois@ucdavis.edu

Glen Xiong, MD
Clinical Professor, Department of Psychiatry and Behavioral Sciences,
UC Davis Health
gxiong@ucdavis.edu

David K. Barnes, MD
Health Sciences Clinical Professor
Medical Co-Director
Department of Emergency Medicine
UC Davis Health
dbarnes@ucdavis.edu

Rupinder Sandhu, RN, MBA
Nursing Director
Department of Emergency Medicine
UC Davis Health
rupsandhu@ucdavis.edu

References

1. National Emergency Department Overcrowding Score (NEDOCS®). Accessed May 25, 2023. [Available at]
2. Certification and Compliance for the Emergency Medical Treatment and Labor Act (EMTALA). Centers for Medicare & Medicaid Services (CMS). Accessed May 25, 2023. [Free full text]
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8. MacDonald S, Sampson C, Turley R, et al. Patients’ experiences of emergency hospital care following self-harm: systematic review and thematic synthesis of qualitative research. Qual Health Res. 2020;30(3):471-485. [Free full text]
9. Bridge JA, Olfson M, Caterino JM, et al. Emergency department management of deliberate self-harm: a national survey. JAMA Psychiatry. 2019;76(6):652-654. [Free full text]
10. De Boos J. Non-fatal strangulation: hidden injuries, hidden risks. Emerg Med Australas. 2019;31:302–308. [Free full text]
11. Arensman E, Griffin E, Daly C, et al. Recommended next care following hospital-treated self-harm: patterns and trends over time. PLoS One. 2018;13(3):e0193587. [Free full text]
12. Griffin E, Gunnell D, Corcoran P. Factors explaining variation in recommended care pathways following hospital-presenting self-harm: a multilevel national registry study. BJPsych Open. 2020;6(6):e145. [Free full text]