Posted on June 15, 2018 in: Patient Safety
By Steven Zhang, Pharm.D., PGY-1 pharmacy resident, Sparrow Hospital, Lansing
A major emerging issue in emergency medicine practice is the boarding of psychiatric patients awaiting placement. Boarding is defined as a patient remaining in the emergency department after admission to the facility, but has not been transferred to an inpatient unit. The American College of Emergency Physicians considers the boarding of patients to be a failure of inpatient bed management that contributes to decreased patient safety and lower quality of care.1 While boarding may occur with any patient, psychiatric patients are frequently affected because of dwindling availability of inpatient psychiatric beds.2 For psychiatric patients that present with psychotic, aggressive or violent behavior, the emergency department may not be able to provide the specialized psychiatric care necessary.
In 1955, over 500,000 inpatient psychiatric beds existed nationwide. By 2012, that number decreased to just over 50,000 beds.3 During that same time frame, the national population nearly doubled, from 165 million to 325 million. The reason for this decline in beds is in part due to reports of patient abuse at psychiatric facilities, which prompted the president of the American Psychiatric Association in 1958 to describe psychiatric hospitals as “morally bankrupt beyond remedy” and advocated for their closure “as rapidly as can be done.” This, along with reduced funding and the emergence of antipsychotics which allowed for more outpatient management of previously hospitalized patients, contributed to the deficiency of psychiatric bed availability. In Michigan, 47 percent of inpatient psychiatric beds were closed between 2005 and 2010, leaving a total of 5.4 beds per 100,000 people, fourth fewest among states in the country.3 The impact of this trend has been widespread, but has presented significant problems for emergency departments in particular. A nationwide survey of 6,000 hospitals in 2012 found 70 percent of emergency departments reported boarding psychiatric patients for “hours to days,” with 10 percent reporting boarding of individuals in psychiatric crisis for one week or longer.3
The medical management of patients presenting with psychotic, aggressive or violent behavior in the emergency department is challenging. There are few studies or guidelines that offer conclusive evidence on how these patients should be treated. Chemical restraints such as antipsychotics, benzodiazepines and ketamine can be given as needed; in severe cases, physical restraints may be used.4,5 While rescue doses are effective for an acute escalation in patient behavior, the relatively short duration of action of these agents leaves open the possibility of re-emergence of the psychotic, aggressive or violent behavior once effects of the medication have worn off. Emergency physicians may be less likely to start scheduled antipsychotics in boarded patients, as they anticipate a psychiatrist will take over care upon inpatient admission. However, with more of these patients remaining boarded in the emergency department for longer periods of time, a stronger emphasis should be placed on not allowing the patient’s behavior to escalate to the point of requiring stat or IV injections. Every instance where a rescue dose of an antipsychotic, benzodiazepine or ketamine is required is an indication of an unsafe situation that poses a risk to the patient and hospital staff. The prevention of these situations should be a priority in boarded psychiatric patients exhibiting behavioral issues that may escalate. Pharmacists can make an impact by identifying and intervening on appropriate patients to recommend scheduling an antipsychotic regimen. The agent, dose and frequency chosen will vary based on patient factors, adverse drug reactions and the clinical judgment of the pharmacist and physician, but the overall objective is to avoid resorting to rescue injections to restrain a patient, thereby indicating a decrease in the number of risky situations. More studies are needed moving forward to give more conclusive evidence on the clinical impact of these interventions.
Psychiatric patients presenting with psychotic, aggressive or violent behavior while boarded in emergency departments present a major challenge for health-systems and healthcare professionals. Because the trend of declining inpatient psychiatric beds shows no indication of reversing, the medical treatment of these patients in the emergency department should be optimized by pharmacists with the goal of reducing the need for rescue injections of chemical restraints. Using antipsychotics in a scheduled regimen for these patients may be an effective method of reducing the risk of physical injury to patients and staff.
1. American College of Emergency Physicians. Boarding of admitted and intensive care patients in the Emergency Department. Policy statement. ACEP website. https://www.acep.org/patient-care/policy-statements/boarding-of-admitted-and-intensive-care-patients-in-the-emergency-department/#sm.000kxp1n7154messs1i200bq8xdid. Last revised June 2017.
2. Fuller D, Sinclair E, Geller J, et al. Going, going, gone: trends and consequences of eliminating state psychiatric beds. Treatment Advocacy Center. 2012.
3. Torrey E, Fuller D, Geller J, et al. No room at the inn: trends and consequences of closing public psychiatric hospitals. Treatment Advocacy Center website. http://www.treatmentadvocacycenter.org/storage/documents/going-going-gone.pdf.
4. Wiler J, Brown N, Chanmugam A, et al. Care of the psychiatric patient in the emergency department – a review of the literature. American College of Emergency Physicians website. https://www.acep.org/globalassets/uploads/uploaded-files/acep/clinical-and-practice-management/resources/mental-health-and-substance-abuse/psychiatric-patient-care-in-the-ed-2014.pdf.
5. Yildiz A, Sachs G, Turgay A. Pharmacological management of agitation in emergency settings. J Emerg Med. 2003;20:339-46.