Creating a place of safety

Treating patients who come to the ER with behavioural health issues brings its own set of risks. HRMR investigates.

“For patients with suicidal ideations, we need rooms that are safe and secure." Richelle Heldwein

What happens when a patient presents in the ER with behavioral health issues? Clearly there are special risks surrounding this type of situation—risks that, if not properly addressed, can have serious consequences for the patient, and possibly for the staff, hospital visitors and other patients. Yet a number of risk managers interviewed by HRMR say they are seeing an increase in patients with behavioral health issues arriving for ER treatment.

Richelle Heldwein, a clinical risk manager for Western Litigation who has developed risk assessment tools and identified best practices concerning management of the behavioral health patient, says there are a number of contributing factors to this increase.

“First of all, the overall numbers in most emergency departments are increasing, so that will result in an increase in patients with behavioral health problems,” she says. 

“Second, the resources available for patients with behavioral health problems are becoming even more limited. There has always, to some extent, been a shortage of these types of services, but as populations increase, and as reimbursement decreases, this shortage of treatment options is becoming even more pronounced.” 

Heldwein says the shortages begin at that provider level: according to the Department of Health and Human Services Health Resources and Services Administration, there are 4,000 designated health professional shortage areas (HPSAs) in the US and it would take 2,800 additional psychiatrists to fill this shortage. 

“Psychiatry is not a highly paid, or highly reimbursed service, and those positions have some of the highest turnover rates for the medical professions, so there is not a lot of incentive to choose psychiatry as your medical specialty,” she says.

She adds that some of the recent legislative changes have made the problem more pronounced by providing better insurance coverage for behavioral health diagnosis. This has helped to remove or lower financial barriers to care, by requiring medical plans to provide insurance coverage for care and treatment of mental health disorders. 

“However, while this has helped the patient pay for care, it has actually opened the gates for additional people to seek care, and with the continued provider shortage, those patients are flooding into the healthcare system, and end up in emergency departments and non-behavioral health units because of the inability to get into outpatient treatment or inpatient treatment facilities,” she says.

Kevin Kuhn, a partner with law firm Wheeler Trig O’Donnell who has extensive experience in the defense of medical malpractice lawsuits, agrees that provider shortage—driven by under-funding—is pushing more people with  behavioral issues into the ER.

“Mental health is woefully underfunded, which means that emergency rooms become the ‘basket’ for these kinds of patients. And with US laws such as the Emergency Medical Treatment and Active Labor Act (EMTALA) against turning patients away from emergency departments, hospital emergency rooms become the default mental hospital. We all end up paying for that, on many different levels,” he says.

Another factor that may be exacerbating the problem is the fact that many symptoms of behavioral health disorders may present as physical problems, which may lead people with such issues to seek help in settings that primarily deal with physical health. 

Furthermore, John Nicoletti, a co-founder of Nicoletti-Flater Associates, who specialises in police and public safety psychology, says seeking mental health treatment is still a taboo for some people, while current problems relating to socioeconomic status, family issues, job loss and divorce, may be exacerbating the severity of mental illness and increasing the number of people who need help.

Heldwein adds that a lack of appropriate medical support can drive behavioral health patients to the ER. “Their medications need ongoing and follow-up care that is best provided in an outpatient and clinic setting. When these providers are not available, patients can get into crisis and their only recourse can be the hospital.”

Protecting the patient

Whatever the contributing factors, there is no doubt that risk managers are regularly having to plan for, and to deal with, issues related to the needs of the behavioral health patient in the ER. 

“Seldom a day goes by that our hospital emergency rooms and medical floors don’t have an issue that needs to be addressed,” says Heldwein. “The most common of these are patients who have a medical condition that needs to be treated, and also a mental health diagnosis that needs to be addressed. 

“One example would be a patient who is brought in to the emergency department following a suicide attempt. These patients can have harm to their bodies, whether that be lacerations or an overdose of medication, that need to be medically treated. They need to be in a safe place, not only for their medical condition, but for their mental health as well.”

In this type of situation, hospital staff work to get patients the help that will prevent further suicide attempts, and to make the environment safe to prevent them harming themselves with the equipment and supplies that are needed to treat their medical condition. All sharp instruments, cords, medication, and anything that could be used for harm are removed from the room. 

“At the same time, we need to provide them with oxygen which has to come through a tube that can be a hanging risk. They need to have utensils to eat meals, but these can also be used for self-harm. It is difficult to provide the level of care that is needed to keep these patients safe and still operate as a hospital,” she says.

The risks are very real: Andrew Efaw, a partner with Wheeler Trig O’Donnell, says his firm has dealt with a number of cases that have had tragic consequences, including a patient who committed suicide in a treatment room after triage, and another who committed suicide by leaping from a moving ambulance.

The problems with adequately addressing the needs of patients with  behavioral health issues in the ER are compounded by the fact that the medications used to manage their health conditions can be difficult to regulate and need close monitoring and periodic adjustments. 

“This is difficult to do in a setting that is designed for acute care and episodic visits such as a hospital,” says Heldwein. 

Staff experience

One of the primary risks linked to treating behavioral health patients in the ER is the potential for violence—either self-directed or directed towards others.

A related issue, says Efaw, is the staff’s potential lack of experience in treating and handling mental health patients. 

“Obtaining a meaningful history from a patient with serious behavioral health issues can be a daunting task,” he says. “Additionally, many ER doctors are not comfortable with the use of physical and chemical restraints.”

Nicoletti agrees, highlighting the main risk issues as harm to self, harm to others, and medication compliance. He adds that many physicians, as well as psychologists and psychiatrists, are not well trained in risk of harm to self and others.

“Generally, the only questions are ‘are you thinking of hurting yourself?’ or ‘are you thinking of hurting someone else?’. This is often due to lack of training or time constraints, where there is not enough time to conduct a proper risk assessment,” he says.

Medication compliance is a problem seen more in severely mentally ill populations: people with a bipolar disorder may enjoy their manic episodes and may not want to come down from that high. People with schizophrenia may truly believe that their hallucinations are real, making them believe that they do not need to take medication. 

“In summary, conducting a risk assessment by utilizing only self-report data can potentially create a concerning situation because of false negatives,” Nicoletti says. 

An important issue that can create liability relates to the items and equipment typically found in emergency department rooms.

“For patients with suicidal ideations, we need rooms that are safe and secure, and hospital rooms are designed to have lots of equipment and supplies to provide efficient, quality care. The same items that are necessary to care for medical patients are potentially deadly for patients in a mental health crisis, so making a hospital room safe for those patients is difficult,” says Heldwein.

Liability for harm caused by a patient to him/herself or others is a significant exposure, agrees Roger Hillman, a partner in the Health Care Practice Group at Garvey Schubert Barer, who adds that plaintiffs may point to the short duration or lack of frequency of treatment as a cause of any harm and/or injuries they may suffer associated with their care. 

“Patients may be seen for shorter periods and less frequently simply due to the increased patient load that many providers are facing,” he says.` “Also, this becomes exacerbated when it involves a patient whom the provider believes should undergo in-patient treatment, but is treated as an out-patient due to lack of available facilities.

“Balancing the duty to the patient under the Health Insurance Portability and Accountability Act (HIPAA) and the perceived duty to others in harm’s way is particularly challenging.”

Risk mitigation

Heldwein and her colleagues encourage their hospitals to implement several measures that help to mitigate these types of risk. The first is to provide a safe environment, such as a lockdown unit, so that patient access is controlled by the staff. They also advise providing ‘safe rooms’ that allow staff to quickly take all hazardous items out of a room. 

“There is some great technology for accomplishing this, for example by installing a safe wall that can be pulled down to block access to all supplies and equipment in the patient room,” she says.

“Next is to assure staff training and competency in assessing, treating, and protecting the patient and themselves. There are good standardized de-escalation training programs out there that help staff to properly address behavioral issues and to help the patient to a calmer, better place.”

Nicoletti agrees that all medical staff should have basic training in behavioral health, risk assessment, and have a list of providers, if none is available within their setting, with whom to consult and refer. “In conducting risk assessments, medical staff should utilize collateral data including social media broadcasts in addition to self-report for determining risk levels,” he adds. 

Efaw says that emergency rooms should have written policies with a multi-disciplinary approach regarding how to deal with behavioral health patients. 

“For example, many hospitals have a designated staff member to conduct suicide evaluations in ERs,” he says.

Communication is also vital—particularly with those who might be responsible for getting the patient on the correct care pathway.

“If treating an individual, ensure continuing communication among all providers, of whatever discipline, involved in the care,” says Hillman. “If the facility is not equipped to treat and a referral is made, follow up with the entity receiving the referral. Document in detail all encounters with the patient.”

Staff need to be able to handle patients with  behavioral health issues sensitively as well as safely—and for this, training and simulation can reap huge dividends.

Western Litigation helps hospitals by providing simulations so staff can practice for the situation and improve their ability to provide improved care, says Heldwein. 

“We have hospitals that have developed best practices and are sharing those best practices,” she adds. “Ongoing education programs, either live or virtual, for staff are important components to keeping staff trained and current with the best practice standards.”

Besides training the ER staff, the ideal situation is that behavioral health specialists are on hand to assist troubled patients.

“The stigma of mental illness needs to be taken away, so that people feel comfortable getting the services they need,” says Nicoletti. “Having psychologists or other mental health providers available in hospital settings to consult with both staff and patients is one way to do this.

“Proper risk assessment is also necessary. If a hospital does a thorough risk assessment and learns that a patient is suicidal or homicidal, there should be a plan in place that can be executed efficiently and calmly. The last thing patients need to hear is that no-one knows what to do with them because their issue is so rare or scary.”

The future

What can be done to decrease risks relating to  behavioral health patients in the future—and what looks likely to happen?

“Mental illness will always be around,” says Nicoletti. “Our job is to decrease the stigma around it so people are comfortable with seeking treatment.”

He says this can be done through education of the public, primary care providers and ER physicians, who are often the first to see patients. Funding and access to crisis centers and community mental health centers will also take the burden off the hospitals, putting patients in a place where they are more likely to receive effective treatment. 

“With the implementation of the Affordable Care Act, there will be an increase of psychologists in primary care (medical) settings,” he says. 

“These settings will become known to be ‘integrative primary care’. Psychologists, or other mental health providers, in these settings will be available to consult with physicians on mental illness, as well as meet briefly with patients showing symptoms to provide psychoeducation, brief interventions, and resources.”

It’s a promising prospect, but Heldwein suspects things are probably going to get worse before they get better. 

“There does not appear to be much change in the numbers of providers being trained in psychiatry, and so there is not a light at the end of the tunnel for provider availability,” she says. 

In terms of the number of people presenting in the ER with  behavioral health issues, she notes that there are many factors that can complicate and contribute to a mental health disorder: they include co-morbidities with medical conditions, and substance abuse problems.

“Until we see better resources on the outpatient side of the care, we will not see improvement on the hospital side of the care,” she says.

However, she notes that some success has been seen with aggressive case management of patients with a known mental health diagnosis and with the use of advance practice clinicians (APCs). 

“Physician extenders (APCs) can help to manage patients between psychiatric visits, and can help to maintain patients in the outpatient setting. There is also great new technology that is allowing care and treatment through tele-health programs. 

“This can allow psychiatrists in larger population centers to see patients located in underserved areas through closed circuit video technology. These programs can be very successful for small communities that are not able to recruit psychiatrists to their healthcare systems.”

Hillman echoes Heldwein’s view that expanding insurance is leading to a demand for treatment that is putting strain on the treatment system. In addition to this, he says there is the propensity for plaintiffs’ attorneys to widen the spectrum of potential sources of recovery to include those providing such treatment to an individual allegedly liable for harm to another. 

“The number of providers of such treatment who do not accept Medicaid as a source of payment, will cause an increasing number of potential patients to seek treatment in the ER if they are unable to obtain outpatient mental health treatment,” he says.

Whatever happens in the future, it is clear that there are a number of gaps in care provision and access that need plugging if behavioral health patients are going to get the care they need, and the ER is to be a safe place for them and for others. In part, the current situation is a result of the decades-long move away from long-term residential care for patients with behavioral health issues. If this is move is handled correctly, with adequate support in the community, Efaw believes this situation has some positives.

“There was a time when once you were institutionalized you might never leave the hospital. Think of the movie One Flew Over the Cuckoo’s Nest. The pendulum needs to swing back in the other direction, but there is a huge issue with who pays—and the issue won’t go away until there is a recognition that not providing long-term treatment to our most seriously ill mental health patients ends up costing society more in the long run.”