Emergency Departments and Mental Health: A Crisis for Rural Communities

There is a growing mental health crisis in the United States with more people, including those with severe mental health issues, needing professional care. The Kaiser Family Foundation (KFF) stated that before the COVID-19 pandemic, nearly one in five U.S. adults (47 million) reported having a mental illness in the past year, and over 11 million had a severe mental illness. Mental illness frequently results in functional impairment and limits life activities. Still, access to care is a significant problem.

A report from the Journal of Health Affairs in 2016 found that more than half of U.S. counties have zero psychiatrists. The same report found that two-thirds of primary care physicians report difficulty referring patients for mental health care, twice the number reported for any other specialty.

“Unfortunately, one of the consequences of a lack of mental health resources is the use of the emergency department as a safety net,” says Roger Barnhart, a consultant and interim CEO for rural hospitals and skilled nursing facilities providing C-suite leadership.

The Healthcare Cost and Utilization Project (H-CUP) reports that one in every eight emergency department (ED) visits in the U.S. is related to a mental disorder and/or substance use issue. According to H-CUP, the rate of mental health/substance abuse-related ED visits increased 44.1 percent from 2006 to 2014, with suicidal ideation growing the most (414.6 percent increase in number of visits). 

Emergency Department Care

“Many emergency departments — especially in rural settings with limited resources — struggle to adequately address the needs of an individual with severe mental health issues,” says Barnhart. “There are various logistical challenges, proper training and understanding of mental health, stigmas about mental health and — perhaps most of all — a lack of integration or access to proper mental health services in the region.”

Barnhart noted that patients might spend extended periods in the emergency department, sometimes multiple days, waiting for a mental health evaluation or outcome of court proceedings before a transfer or discharge can occur.

Barnhart went on to say that this can put a significant amount of stress on the patient and the patient’s family as well as emergency department providers and staff. Although larger organizations may have a dedicated mental health unit attached to the emergency department with trained staff who provide care for patients with serious mental health needs, many smaller and rural emergency departments do not.

Barnhart recommends that emergency departments embrace a comprehensive systems-based approach to develop sustainable strategies, including the six outlined below.

  1. Make ongoing coordination and communication with first responders a priority. This collaboration should include working together to develop protocols and processes and regular meetings to analyze and develop strategies for improvement.
  2. Work with crisis responders and those who can authorize an involuntary hold to establish response times to the emergency department. Promote regular communication and problem-solving.
  3. Incorporate telehealth options both in the community as well as in the emergency department. Tele-psychiatry can provide needed resources and support for patients in the community but also for the treatment and care of patients once they arrive in the emergency department.
  4. Provide education and training for staff and providers. All staff in the emergency department need appropriate competencies to care for behavioral health patients, including those experiencing a severe mental health crisis. Staff education and training must include everyone who interacts with the patient, including laboratory, medical imaging, security, contract staff, or staff who float from other areas of the hospital.
  5. Implement a trauma-informed care approach that recognizes the impact of trauma and promotes a safe and caring environment. This approach may involve providing a calming environment for the patient that is not in the middle of an emergency department, more involvement of the family if appropriate, and training emergency department staff to utilize de-escalation techniques. Trauma-informed care also includes helping staff overcome potential biases about mental illness. it is important to reinforce that the patient is someone’s loved one and to always treat him or her with respect, kindness, and an empathetic professional approach.
  6. Provide a safe environment. Always put safety first to prevent injury to both patients and staff. In addition to providing a ligature safe room and training staff regarding de-escalation techniques, the team should receive ongoing training on how to restrain a patient if needed and how to do so safely.

Mary Fuller-Fougerousse, MSN, RN, PMHNP-BC, a psychiatric nurse practitioner in Arizona, recommends a few additional strategies, including:

  1. Training: Develop a collaborative relationship with the facilities likely to receive transfers. Set up opportunities for staff to shadow or learn from a tertiary care emergency department.
  2. Education: Provide “Nonviolent Crisis Intervention” (NCI) for all emergency department staff, including providers, and annually after that.
  3. Social Work: If at all possible, assign a mental health social worker to the emergency department.
  4. De-escalation: Among the many de-escalation techniques, don’t forget food. Ask the patient when he or she last ate, and if longer than 5 to 6 hours, offer something (granola bar, sandwich). Eating is a noninvasive intervention and can begin the de-escalation process.
  5. Poly Substance: Always be mindful of substance abuse (frequently poly substance). Provide staff with chart/written resources for those ingested substances that DO NOT show up on urine toxicology (the list changes often and differs by region).
  6. Critical Stress Debriefing: After a stressful emergency department encounter, schedule a critical stress debriefing. This debriefing can be very useful for care improvement, staff development, and growth.

Barnhart cited two resources to assist hospitals with improving mental health care in the emergency department: