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“The issue is not being able to provide the attention. I’ve left at night and come back the next day and they’ll still be here. We give emergency medicines to keep them sedated, but there’s no social intervention, no conversation. It’s just like we can’t keep an ICU patient down here. We can get them stable, and we keep them as safe as we can, but we’re not skilled in managing these patients for more than a few hours. And we’re expected to take care of new patients coming through the door.”

Keeping mental health patients in the ED also creates a potentially dangerous work environment, Cota says.

“A man came in and we tried to restrain him, but no one could get near him,” Cota says, describing an incident last year at her former job in an emergency department in Northern California. “Then he got combative and tore the room apart. He jumped up on the gurney, tore the ceiling tile and rebar from the ceiling, and started hitting at people.”

Before anyone was hurt, one of the staff nurses managed to get the patient’s attention and “talk him down,” Cota says, adding that similar incidents happen several times a month. “Patients who have behavioral issues are difficult to read. It’s the unpredictability of it that most nurses say gives them the most anxiety.”

JoAnn Lujan, LCSW, director of the WestCare Community Triage Center in Las Vegas, agrees — and adds that it’s also a safety issue for other patients in the emergency department.

“Not only are you dealing with an individual with severe mental illness that’s going untreated, but they’re angry that they are sitting in the emergency room without treatment,” Lujan says.

Wrong place at the wrong time

“Picture yourself as a person waiting to be treated for a fracture, listening to somebody screaming and yelling, paranoid, not using the best language about what’s happening to them as they are handcuffed to a gurney. You hear this person yelling, ‘I’m going to get you!’ Think about how that affects their care. Our emergency rooms were not meant to be psychiatric wards.

“These nurses didn’t choose to go into psychiatric nursing, yet that’s exactly what we’re expecting them to be,” Lujan says. “They’ve been bit, hit. How do you provide mental health treatment in an emergency room, where you don’t have walls but curtains?”

Recently, Brackenridge Hospital in Austin, Texas, instituted an innovative program to cope with the increase in the number of psychiatric patients coming into the ED: hiring psychiatric patient “sitters.” These nonprofessionals simply keep watch and alert nurses, security, techs, the police department, or social workers if patients need help or look like they might flee the emergency room, says Laurie Toth, RN, BSN, director of the Brackenridge children’s emergency department.

“We don’t want to restrain people chemically or physically,” says Toth, who was director of both children’s and adult emergency services for five years. “We’d like the least restrictive method of dealing with them, and also keep them from eloping from the ER. It’s really hard to keep an eye on everyone.

The 28-bed ED also has social workers available 24/7. “ERs that don’t have social work support, it can be difficult for the nurses. The social workers make a big difference. They are knowledgeable,” Toth says.

In addition to doing evaluations and facilitating transfers for patients who have been medically cleared, social workers offer advice, helping nurses work with unpredictable and potentially violent patients.

“It’s basic kinds of tips, like don’t turn your back on [psychiatric patients], make sure your back is to the door, don’t touch a psychotic patient,” Toth says.

Separate spheres of care

Hospitals that are fortunate enough — and well-funded enough — to have a separate psychiatric emergency department or an inpatient psychiatric unit have an advantage over those that must treat mental health patients in a sole emergency room.