C O L L A B O R A T I V E C A S E M A N A G E M E N T

Managing the Challenges of Psychiatric Patients in an Urban Hospital

Emergency Department
By David Sobel, MSW, LCSW; and Lisa Grace, RN, MSN, CNS

A clear delineation exists between acute care hospitals and psychiatric facilities – acute care facilities are set up for the treatment and medical
stabilization of ill or injured patients, while psychiatric hospitals are designed and staffed to treat patients with psychiatric or behavioral
problems. What happens, however, when the line between these two types of facilities becomes blurred? More specifically, what challenges
do psychiatric patients present to acute care facilities responsible to provide quality care to these patients in an efficient and cost-effective
manner, and how can acute care hospitals manage these challenges?

Pomona Valley Hospital Medical Center (PVHMC) is a 443 bed the high number of psychiatric patients treated at PVHMC, the mental
acute care facility located on the outskirts of Los Angeles County, health center maintained staff in PVHMC’s ED. The mental health
California. The hospital does not have a psychiatric unit. Prior to 2004, center also provided a discharge facility for psychiatric patients once
PVHMC had a contractual relationship with a local mental health they had been medically stabilized.
center, which was effective in managing the psychiatric patients that In 2004, however, several events disrupted this effective
presented to the hospital, almost entirely in the Emergency collaboration. The mental health center declared bankruptcy and
Department (ED). To assess these patients upon arrival and because of abruptly closed. Simultaneously, there was also a rapid decrease of
available psychiatric beds in Los Angeles
County – over 200 such beds were
�������������������������������������������������� permanently closed.
����������������������������������� Regardless of these infrastructure
changes, PVHMC continued to receive

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eight to 10 psychiatric patients per
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��� ����������������������������� week presenting to the ED for various
������������������������ reasons. Psychiatric patients typically
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��� ����������������������� fall into one of three categories when
��������������������������� they present to the ED: psychiatric
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them for psychiatric admission; some
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����������������������������� treatment who face psychiatric illnesses,
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����������������������� those brought to the hospital by
������������������������������ local law enforcement in relation to
�
������� ������������ ��������� �������������� ��������� a “5150” involuntary psychiatric
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assessment that they pose a threat to
themselves or others.
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CHALLENGES POSED BY PSYCHIATRIC
PATIENTS IN THE ED
PVHMC faced several
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��������� ��������������������������� specific challenges in managing
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��������������������������������� 4 Legal status regarding involuntary
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����� 4 Reliance upon county services for
psychiatric assessments
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4 Discharge barriers and a scarcity of
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psychiatric beds
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4 Safe and effective management of
psychiatric patients in the ED

6
 w w w . a c m a w e b . o r g

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Source: Data is based on 2004 data – the latest
�� ��������� currently available – from the Agency for
��������� Healthcare Research and Quality’s (AHRQ)
Healthcare Cost and Utilization Project Nationwide
���� ����
���� ���� Inpatient Sample, a database of hospital inpatient
�� ���� �������� ���� stays that is nationally representative of all short-
�������� ����� ��������
����� term, non-federal hospitals.
����� ����� ����� ����� �����
����� ����� Owens P, Myers M, Elixhauser A, Brach C. Care of
� Adults With Mental and Substance Abuse
Disorders in U.S. Community Hospitals, 2004.
2004
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Agency for Healthcare Research and Quality, 2007.
HCUP Fact Book No. 10. AHRQ Publication
���������������������������������������������������������������������������� No. 07-0008. ISBN 1-58763-229-2.

Principal MHSA Only: Principal reason for hospitalization Principal and Secondary MHSA: The principal reason for Secondary MHSA Only: One or more MHSA diagnoses were
was a MHSA disorder and no additional MHSA diagnoses hospitalization was a MHSA disorder and at least one additional listed as secondary or complicating conditions, but the principal
were indicated on the discharge record. MHSA diagnosis was indicated on the discharge record. reason for the hospital stay was not a MHSA disorder.

LEGAL STATUS MANAGEMENT
Section 5150 of California’s Welfare and Institutions Code
allows a law officer or qualified clinician to confine involuntarily a
person meeting any of the following criteria:
4 Danger to self – an immediate threat to themselves,
usually by being suicidal
4 Danger to others - an immediate threat to someone else
4 Mental disorder - behavioral symptoms of a mental disorder
must be articulated in the 5150 request document
4 Gravely disabled - unable to provide for their food,
clothing, and/or shelter
Confinement is requested through a written document and
lasts for up to 72 hours, during which time an evaluation must take
place to determine if a psychiatric admission is warranted.
The legal status management of 5150 patients at PVHMC was
severely limiting the ED social workers’ ability to manage these
patients. After the closure of the local mental health facility in 2004,
local law enforcement adopted the standard practice of automatically
writing involuntary holds on all individuals they dropped off at the ED.
Often the hold – and its 72-hour duration – proved unnecessary.
Psychiatric patients who had not taken their medications, or
individuals whose psychiatric symptoms were the result of drugs or
alcohol, were often able to be stabilized – medically and
psychologically cleared – in six to eight hours, but were unable to be
discharged until the hold expired. While the ED Social Workers were
clinically trained, the law requires involuntary psychiatric holds to be
written or lifted only by qualified employees of a psychiatric facility.
Assessment Team (ACCESS) for patient psychiatric assessments. This
agency, however, was responsible to cover all of Los Angeles County
with limited resources, leading to lengthy response times. Waiting six
hours for them to arrive was common.
Similar to law enforcement, ACCESS also commonly wrote
involuntary holds on patients who could be stabilized in a much
shorter period of time than the hold required. Further, this agency’s
authority included the ability to write involuntary holds but not the
legal authority to remove them, which required a psychiatric
professional. ACCESS could not be called once a patient was
psychologically cleared to remove a hold they had written. Effectively,
holds on patients who could be stabilized in less than 72 hours resulted
in unnecessary LOS.
DISCHARGE BARRIERS
In addition to the scarcity of psychiatric beds available in LA County,
a patient’s admission status could also create discharge complications.
Three factors contributed to discharge difficulties for inpatients:
4 Inpatient admission to a medical facility legally voids an
involuntary psychiatric hold
4 Psychiatric facilities are very reluctant to accept a patient
without an involuntary hold (5150)
4 County assessment teams are unwilling to go on units to
assess inpatients
The result was very difficult placements for patients whose
medical severity required treatment as an inpatient.

RELIANCE UPON COUNTY SERVICES MANAGEMENT OF PSYCHIATRIC PATIENTS

The closure of the contracted mental health facility removed from Because ED staff members had previously relied on the mental
PVHMC’s ED the primary tool for assessing psychiatric patients. This health facility’s onsite staff person, the process for handling these
forced the hospital to rely on the Los Angeles County Psychiatric patients in the hospital became problematic without experts onsite

continued on page 8
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 C O L L A B O R A T I V E
Managing the Challenges of Psychiatric Patients in an Urban Hospital Emergency Department (continued from page 7)
to provide guidance. Training for ED staff in safety and suicide
precautions, psychiatric medication needs, and proper use of
restraints became a high priority.
PVHMC had only limited areas suitable to hold psychiatric
patients. Therefore, barriers to the efficient discharge of psychiatric
patients contributed to difficulties in safely holding them. When
backups occurred in the ED or psychiatric patients became too
disruptive they had to be kept in an ICU room with an attendant,
which was a costly stopgap solution.
PROCESS IMPROVEMENTS ADDRESS PATIENT
MANAGEMENT CHALLENGES
These factors combined to drive ALOS for psychiatric patients,
those without co-presenting medical conditions, to 36 to 48 hours.
In response, PVHMC implemented a program led by the ED social
workers to manage this patient population. The program focused on
three process improvements:
4 Process modification of legal status assignment using
social worker screenings
4 Development of interventions to begin psychiatric treatment
of these patients in the hospital
4 Development and implementation of a comprehensive algorithm
for management of psychiatric patents in the ED
ED SOCIAL WORKER SCREENING PROGRAM
ED social workers at PVHMC began to modify the hospital’s
interactions with ACCESS regarding psychiatric patients and writing of
involuntary psychiatric holds. They arranged a modified process with
ACCESS to allow the ED social workers to screen patients for ACCESS
intervention. Under this new process, when a patient with obvious or
suspected psychiatric illness arrives at the ED they are first medically
stabilized, and then evaluated by an ED social worker to determine if
they meet the legal criteria for involuntary hold.
Because of their hospital experience and clinical social work
training, the ED social workers are able to effectively identify those
patients who are dangerous to themselves or others – and therefore
meet involuntary hold criteria – from those who can be quickly
stabilized with psychiatric medication or whose psychiatric episode is
a temporary result of substance abuse. When a patient meets
involuntary hold criteria, the ED social worker who screened the
patient places a call to ACCESS to arrange an assessment and a
psychiatric hold if that assessment is confirmed. For other patients the
ED social workers’ screening allows a psychiatric hold to be avoided.
The patient can be treated and cleared medically and psychologically,
and discharge can be arranged without the constraint of having to keep
the patient in-house for the entire length of the hold or calling in a
psychiatrist to reassess the patient for hold removal.
The process improvement also included training ED staff to call
social services when psychiatric patients arrive rather than
immediately placing a call for county assessment. ACCESS is now
called only when patients legitimately need to be held for psychiatric
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C A S E M A N A G E M E N T
illness and placement or hospitalization, resulting in an overall
decrease in ACCESS calls.
An unforeseen benefit of the new process is the ACCESS workers’
appreciation of the additional screening prior to their involvement.
Their response time has also improved, since they know that calls from
PVHMC are for patients who have been assessed and will definitely
need psychiatric services.
To address holds placed by law enforcement, ED social workers,
Hospital Security and Nursing arranged a meeting with local law
enforcement leaders. Officers had no training to distinguish those
MEDICALLY VS. PSYCHOLOGICALLY CLEAR
MEDICALLY CLEAR
• All diagnostic studies are within normal limits
PSYCHOLOGICALLY CLEAR
• All diagnostic studies are within normal limits
• Psychological evaluation by PVHMC Social Worker ACCESS/
Psychiatric Evaluation Team (PET) determines that the patient
is NOT a danger to himself/others or gravely disabled
• Note: The patient could still be experiencing a psychological
crisis, however, he/she appears to have effective coping
mechanisms and/or resources available to assist them with
dealing with the crisis.
patients who needed to be held from those who would regain sobriety
or could be stabilized in a much shorter period. The ED social workers
discussed with law enforcement the current police practice and
educated the officers about the new screening process and the clinical
training of the ED social workers. The police department agreed to
change the practice and rely on the new ED screening process. If a
patient who is not on an involuntary hold wants to leave the hospital
before they are stable and safe, the attending physician has the
authority to write an eight-hour hold order, if needed.
PSYCHIATRIC TREATMENT INTERVENTIONS
With the lack of available psychiatric beds in Los Angeles County,
the ED social workers at PVHMC identified the need to begin
psychiatric treatments while patients are in-house. The objectives of
developing this ability are to facilitate the discharge of patients to
psychiatric facilities, assist in the management of psychiatric patients
in the hospital and, when possible, stabilize patients during their
medical treatments in the hospital so that they can be discharged to
home with resources for follow-up care – eliminating the need for
placement in a psychiatric facility.
PVHMC contracted with two licensed psychiatrists to provide
treatment in the hospital as needed. The psychiatrists remain in private
practice in the community, and respond promptly to calls from the hospital.
continued on page 12
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Psychiatric Management Algorithm

Patient arrives with law enforcement on 5150 Patient arrives in the ED and receives assessment at Triage
or in treatment area

Patient undressed and gowned. Possessions removed from patient reach. Patientatient placed in a ““safe” room. If patient refuses and did not
Officers to stand by until achieved if patient arrived with law enforcement. arrive with law enforcement,
call Security for assistance

Notify social worker of patient in ED during daytime hours

If patient becomes aggressive, consider restraints
after alternatives attempted
ED MD examines patient and writes orders

Medically cleared (does not mean psychologically cleared) Nurse obtains lab results, ETOH level and drug screens.
Give meds if ordered. If night hours allow patient to sleep.

Call social services for psychological assessment

Place call to on-call pysch MD to manage patient behavior if needed

Results of ED Social W
Worker Assessment

• Meets 5150 criteria • Meets 5150 criteria • DOES NOT Meet 5150 criteria
• Unfunded • Funded through commercial insurance, • Needs resources for care
Medicare or MediCal

Commercial Insurance Medicare MediCal

Contact private psychiatric
hospitals for placement.
(Many have private PETs for 5150)
Call ACCESS for 5150 (LA County only)
Call ACCESS for 5150 (LA County only)
M-F 8-5: (555) 555-5555
M-F, 8-5: (555) 555-5555
M-F
or private PET

Follow instructions for placement Call MediCal hospitals for placement (not the same as
county hospitals) See phone number list

Call ACCESS for 5150 (LAA County only) / M-F

M-F, 8-5: (555) 555-5555
Call on-call psychiatrist for medication consult & to discharge when stable

ACCESS to place in LA County Bed

Discharge back to
community with
Bed available: Transfer patient No bed available: Patient on 5150 in ED mental health
ED nurse to call Medic Alert Center (MAC) to check on Patient is dangerous and
LA county psych bed availability 2x/day and document must be moved ASAP
Discharge with referral to Long Beach
23-hour program (555) 555-5555
• Patient must agree to go
• Transportation by bus voucher or
patient arranged
• Under NO circumstances
should patient go by taxi

ED nurse to call LAC psych hospitals every 4 hours and document Call social services to reassess Call on-call psychiatrist for consult

LEGEND / ED NURSE / ED MD OR SOCIAL SERVICES

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 C O L L A B O R A T I V E
Managing the Challenges of Psychiatric Patients in an Urban Hospital Emergency Department (continued from page 8)
PVHMC commonly utilizes their services in the following situations:
4 Patients on an involuntary hold (written by ACCESS) for whom
the ED social workers expect placement delays or difficulties
that indicate for an LOS of 24 hours or greater. This includes almost
all self-funded or un-funded patients.
4 Patients on an involuntary hold who can be cleared, both
medically and psychologically, and who therefore need to have
the hold removed
4 To help manage difficult patients – those who are overly
aggressive or unruly
4 When an attending physician requests a formal psychiatric
diagnosis or reassessment
PVHMC has found that this early psychological intervention often
allows the hospital to move patients on a path parallel to their medical
treatment toward psychological stability, allowing them to be
psychologically cleared and eliminating the need for a psychiatric
placement at discharge.
Although ACCESS is still the primary service to write psychiatric
holds, the contractual arrangements with these psychiatrists also
affords PVHMC additional flexibility regarding psychiatric holds since
these professionals have that authority to write or remove psychiatric
involuntary holds and are willing to see, assess and treat inpatients. These
professionals treat an average of six to 10 cases at PVHMC per week.
PVHMC pays the contracted psychiatrists a stipend for their on call
responsiveness. For un-insured patients PVHMC is also responsible to
reimburse the psychiatrists for their services. The psychiatrists bill directly
ffor their services to commercially and government-insured patients.
PSYCHIATRIC MANAGEMENT ALGORITHM
ED social workers had existing protocols and resource lists
pertaining to specific issues with psychiatric patients, but recognized
the need for a comprehensive psychiatric management algorithm for
use by the entire ED medical and social services staff. The algorithm
must address current challenges in the management of this patient
population, include all possible psychiatric presentations to the ED,
and include varying management and discharge options based on a
patient’s health insurance status.
Development of the algorithm was led by the ED social workers
and the ED Clinical Nurse Specialist, and involved an interdisciplinary
team including the Director of ED Nursing, the Chief Operations
Officer, Risk Management, and Security. The result is a comprehensive
set of treatment protocols that unifies often-disconnected elements of
the care process, including:
4 Nursing management of psychiatric patients in the ED
4 Legal status assignment
4 Social Work assessment
4 Psychiatric care
4 Identification of payer source and development of the most
appropriate plan of care for various payer sources
4 Community and county resources for assessment and placement
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C A S E M A N A G E M E N T
To implement the algorithm, all ED nursing and social services staff
received mandatory education regarding its use. The training improved
understanding of psychiatric issues, legal status, criteria for clearance,
and management of psychiatric patients in the hospital setting.
Full implementation, however, has required a longer process of
building credibility among the medical staff for the algorithm’s efficacy
and, more importantly, for the social workers’ clinical training and
ability to assess psychiatric patients. Some physicians felt that proper
care of psychiatric patients required that they be seen by ACCESS –
even though these agents typically have less training and education
than the ED social workers. Over time, however, the social workers built
credibility in their ability to screen psychiatric patients and in the
effectiveness of the process and algorithm.
More recently, PVHMC has added case managers to the ED, adding
further expertise to the management of psychiatric patients. The ED
nurse case managers are able to:
4 Facilitate physical assessment, ensuring medical clearance
4 Scrutinize psychiatric patients against medical criteria and level of
care assignment/management (i.e. inpatient or observation status)
4 Facilitate placements and the transfer and communication of
medical information to the receiving facility
The ED nurse case managers have also been trained by social
workers to perform basic screening of psychiatric patients for meeting
5150 criteria during evening hours. Becaues they work 12-hour shifts,
whereas the ED social workers cover eight hours and have minimal
coverage during the evenings, ED case managers can provide back-up
personnel to perform screenings as needed.
OUTCOMES
Together, the initiatives and process improvements relating to the
management of psychiatric patients represent a multi-layered strategy
for managing this challenging patient population. The program shows
the following positive outcomes:
4 70 percent of calls to ACCESS eliminated
4 Psychiatric involuntary holds reduced by 75 percent
4 LOS for psychiatric patients (without medical conditions or need) has
been reduced from 36 to 48 hours to the current four to seven hours
In addition, providing psychiatric treatment in the hospital has
improved patient care. Early implementation of psychiatric treatment
allows patients experiencing psychiatric episodes to regain
psychological stability more rapidly.
David J. Sobel, MSW, LCSW, is the Supervisor of Social Work Services
at Pomona Valley Hospital Medical Center in Pomona, CA. He has held
this position for 13 years. He earned his MSW from Arizona State
University in Tempe, AZ.
Lisa Grace, RN, MSN, CNS, is the Clinical Nurse Specialist for Emergency
Services at Pomona Valley Hospital Medical Center in Pomona, CA. She
earned her RN from Pasadena City College in Pasadena, CA and her MSN
from the University of Phoenix in Phoenix, AZ. She has over 24 years of
healthcare experience.