Best practices for the treatment of patients with mental and substance use illnesses in the emergency department.

In recent years, hospitals across the nation have experienced a significant and growing number of patients with mental and substance use illnesses presenting in their emergency departments (EDs). This recent upsurge can be attributed to several factors, including the loss of acute hospital psychiatric capacity in both the public and private sectors; lack of access to primary and other outpatient care; an under funded community mental health system; lack of insurance for mental or substance use illnesses; lack of any health insurance; a rising incidence of drug use; and a large population of persons with mental and substance use illnesses that go untreated until a crisis occurs. The hospital ED has become for many a safety net when other alternatives are unavailable, inaccessible or unaffordable. Recognizing the demands being placed on our EDs by an increasing number of patients with mental and substance use conditions, as well as the need for us to provide high quality care, compassionately and efficiently, the IHA Behavioral Health Steering Committee established a Task Force to consider and document best practices associated with treatment of the patient with mental and substance use illnesses in the emergency department. This multidisciplinary committee of psychiatrists, emergency medicine physicians, psychiatric nurses, psychologists, social workers, counselors and hospital management executives met on several occasions during 2006 and 2007. The document that follows is the result of their work, experience, and expertise. It considers emergency departments in a variety of hospital settings, from the large urban academic medical center to the small rural hospital. It also considers EDs with dedicated psychiatric space and staff as well as those that do not have these resources. It is the Task Force’s goal to provide this information for hospitals in Illinois to use as a resource. As healthcare providers, we exist to serve our patients and believe the use of evidence-based or best practices will support the delivery of better care. Among the practices identified by the Task Force that are provided in this report for your consideration are the following: • Use a predetermined triage system or scale to ensure timely and appropriate evaluation and treatment of psychiatric patients. • The Psychiatric Medical Clearance Checklist developed by Illinois emergency and psychiatric physicians. (See Appendix A) • The Consensus Statement on Medical Clearance from the Massachusetts College of Emergency Physicians and the Massachusetts Psychiatric Society. (See Appendix B) • Routine urine toxicologic screens need not be routinely performed as part of the assessment (in medically stable patients). Drug screens should not delay patient transfers to psychiatric facilities.