Assessment and general approach

Introduction: Clinicians in overburdened emergency departments (EDs) and other acute care environments provide a broad array of services. In addition to handling emergent medical or surgical conditions such as trauma, heart attack, or stroke, ED providers are often the front line of care for patients with psychiatric disorders. Demand for a full spectrum of care provided in EDs continues to grow. The Institute of Medicine report Hospital-Based Emergency Care: At the Breaking Point describes the ways in which demand for care in EDs far outpaces supply in the United States. The volume of patients with psychiatric complaints in EDs has continued to grow as part of this trend. Increasingly, ED providers are called on to assess and manage patients in psychiatric crisis, often for days at a time. A number of factors have contributed to this greater use of EDs by patients who are in need of psychiatric assessment and care. These factors include shortages of psychiatrists and other mental health professionals, limited and often fragmented systems of outpatient psychiatric care options, lack of other sources of support for persons with chronic mental illness, and steadily diminishing inpatient psychiatric beds, both acute and long-term. Not surprisingly, patients and families seeking help for psychiatric conditions for which the community provides no other services look to the ED as the provider of last resort. With fewer inpatient and outpatient resources available, patients wait longer in the emergency setting, contributing to crowding, and in some situations adversely affecting staff and patient safety.