With Emergency Department (ED) visits related to mental health and substance abuse on the rise in recent years, and the likelihood of these patients boarding in the ED remaining steady, the need for dedicated protocols to ensure the safety of behavioral health patients and their caregivers remains paramount.

A recent blog post looked at an analysis of medical malpractice cases in the Comparative Benchmarking Report (Candello) that closed 2015–2019, where Emergency Medicine is the fifth most frequently named responsible service (9%) and comprises 12% of gross indemnity paid. In the analysis, 5% of the ED-related cases had an allegation that involved safety and security.

Our recent CBS Educational Webinar presented a case study of how one community hospital improved care management of behavioral health patients in the ED.


AshleyYeats-sqAshley Yeats, MD, an emergency medicine provider by training and former hospital CMO, shared a case study of his experience at Beth Israel Deaconess Hospital – Milton, in supporting staff and providers in the ED. Dr. Yeats was also a contributor to CRICO’s AMC PSO white paper on safety strategies for Behavioral Health patients in the ED.

The closure of a neighboring facility caused a sharp increase of behavioral health patients in the ED at BID-Milton. This impact prompted a review of safety protocols in protecting at-risk patients in the ED. The increase of ED behavioral health visit volume, along with a lack of psychiatric beds in the state, led to prolonged ‘boarding’ of ED behavioral health patients. The ED lacked onsite psychiatric services and identified there was no clear physician ownership nor nurse assignment of behavioral health patients.

The hospital received a grant to support its efforts to improve care delivery of behavioral health patients. The program outlined the following goals:

  • Elevate staff knowledge competency & confidence
  • Reduce ED boarding hours
  • Acknowledge & address changing demographics
  • Transitions of care
  • Coeducate hospital and community BH systems on scope and function
  • Help patients identify and access key agencies to leverage resources
  • Develop individualized ED care plans for high utilizers

To achieve these goals, Dr. Yeats and his team set out to address triage, boarding, and care integration.

Before Program Implementation

After Program Implementation

Patient arrival to ED:

  • Patient triaged by RN
  • Medical clearance by ED MD
  • Emergency Services Provider (ESP) mobiles to ED for evaluation – inconsistent information sharing across agencies
  • Patient enters the “black hole” of ED boarding
  • ESP visits ED daily for mental status update

Patient boarding status & discharge:

  • No case management by hospital/aggressive insurance screen
  • No proactive evaluation of ED care or ED usage patterns
  • No dedicated resources targeted at the progression and assessment of patients through system
  • No formal patient or family education
  • No medication reconciliation or coordination with outpatient psychiatric providers
  • No hospital warm handoff to receiving provider and no community follow up

Patient arrival to ED:

  • Patient arrives
  • Care Integration notified
  • Record reviewed/utilization pattern assessed
  • ED care plan initiated
  • Insurance confirmed, collection of collateral initiated
  • Outpatient team, PCP contacted
  • Group home plans sought; family meetings held
  • Patient education & CBT, medication reconciliation, music therapy, chaplaincy engaged

Patient boarding status & discharge:

  • Assess for ED return care plan – developed, if appropriate
  • Assess need for shared ESP care plan (Care Alert)
  • Warm handoff to discharge facility
  • Follow up with patient, family and provider for up to 7 days (and longer if appropriate)



Dr. Yeats made clear that this is a challenge and can be difficult to address. While he was able to secure grant funding, there are steps an organization can take, though it will require planning, management and resources. Success factors included:

  • Successful integration of community-based practice of mental health providers into the ED
  • Hardwired care processes in the ED
  • “Humanized” behavioral health population in the ED
  • Extensive collection of collateral patient information
  • Initiate medications and support in the ED
  • Longitudinal management of care transitions

During the presentation, Dr. Yeats said it was important to celebrate the early wins and to look for nurse and physician champions. A key part of the program was to embrace security as a member of the team. This took the shape of including security in huddles. One security staff said, “Now I’m a valued part of the team and can make a difference keeping patients and staff safe. I spend eight-hours with the patient…there’s so much I have to contribute at the huddles.”

One of the things that had a big impact was the music therapy that was brought in. It had a calming effect on the patients, but also for the staff. It also prompted non-behavioral health patients to comment on the care and compassion they saw being delivered across the ED. (For those interested in implementing music therapy, Dr. Yeats suggested reaching out to your hospice care services.)


Dr. Yeats closed with a call to action for hospitals and providers:

  • As ED providers we need to do more than “board” BH patients. This is humane, important, and feasible.
  • Accept the fact that BH patients are accessing the ED in growing numbers – there is no evidence to suggest that will change. Yesterday’s approach no longer works.
  • Acknowledge that the solution is not 100% external – EDs are part of the answer – patients deserve our skill, our care, and our compassion.
  • Build a PROGRAM that impacts patient care, the safety of staff and patients, ED throughput, and staff engagement.

A recording of the complete webinar is available: View the recording

Written By
Katy Schuler, MSc
Katy Schuler was the Marketing Manager for CRICO Strategies.
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