Adam J. Fulginiti

As mental and behavioral health care grows more universal, and the delivery of healthcare services becomes more diverse, providers must be prepared to account for shifting landscapes regarding the standard of care. Given new trends emerging within this field, there are best practices providers can utilize to manage and mitigate risk in the emergency room setting.

Vetting and Training Personnel
Within the context of behavioral health emergency room treatment, vetting and training of personnel constitutes a key factor in litigation which often manifests in corporate negligence claims. Institutional providers may face exposure not only for the actions of their staff related to the patient, but also the operation of the facility itself. This includes factors such as the hiring and retaining of personnel, the adequacy of policies and procedures, adequacy of facilities and equipment, and notably, training and oversight of staff.

While all licensed providers in the ER should ideally be proficient in handling behavioral health patients, treatment of these patients should be assigned to providers with relevant experience, given the unique challenges these patients present. Providers should be proficient in modalities germane to behavioral health, which include screening tools regarding depression, violent ideations, trauma, and substance abuse. They should also be competent in the performance of safety checks regarding risks for ligature, suffocation, and/or items that can be thrown, broken, or otherwise used to harm the patient or others. Proficiency should be demonstrated by physicians, nurses and other mid-level providers, as well as other “ancillary staff.” Behavioral health settings often include a safety observer and security personnel who can also be utilized in crisis cases involving agitation or risk/history of violence/self harm. Social workers and other crisis specialists may also be employed. Regardless of the role of the personnel involved, providers interacting with behavioral health patients in the ER should be proficient in observation, communication, and engagement.

In addition to ensuring proper vetting and training of ER staff, documentation of these processes should be created and maintained in credentialing and/or personnel files. Examples of relevant materials include initial training/orientation, acknowledgment of receipt related to policies and procedures, and ongoing education and training. 

Telemedicine in the Behavioral Health ER
Logistically, telemedicine can and often is utilized to supplement staffing and maintain continuity of services. For larger institutions, daytime and evening shifts may employ in-person coverage but for overnight hours, psychiatric telemedicine services may be utilized. Smaller institutions, which typically have less access to in-person staff, may utilize psychiatric telemedicine with greater frequency. In either scenario, psychiatric telemedicine enhances the ability of healthcare institutions to service and treat a broader array of patients, irrespective of the staff physically present.

While the benefits of psychiatric telemedicine may be obvious, they come at a cost, as the risks and exposure common to all telemedicine practice exist and, in fact, may be enhanced, within the setting of ER behavioral health treatment. This primarily derives from the lack of in-person contact, the quintessential element of telemedicine. Generally speaking, the inability of a provider to be physically present with a patient can impact the therapeutic dynamic. This “disconnect” between in-person care and telemedicine can be pronounced in the context of behavioral health treatment, where factors such as body language, eye contact, and other manifestations may be more difficult to appreciate. Lack of in-person contact may also impact the provider’s rapport with the patient, potentially limiting the patient’s trust. This may affect the patient’s candor with the provider, which may in turn diminish the provider’s ability to generate a properly-informed diagnosis and treatment plan.

In light of these challenges, institutions should ensure telemedicine providers involved with behavioral health patients are proficient with this type of practice. Tactics such as maintaining patient engagement, conducting objective screening, and obtaining as detailed a history as possible are key to mitigating potential adverse outcomes. The institution should also maintain up-to-date telemedicine-related technology to minimize challenges associated with behavioral health telemedicine in the ER. In the event the telemedicine provider determines in-person care or admission is necessary, institutions must be prepared to handle such a recommendation, be it through on-site treatment or the facilitation of transfer to another facility.

Subcontracted Services
Larger healthcare institutions, especially those in an academic setting, maintain their own psychiatric medicine service, which is flush with attending physicians, fellows, residents, and other mid-level providers. Consequently, the need to subcontract outside providers to assist with behavioral health treatment in the ER is typically unnecessary. However, smaller healthcare institutions may not have access to in-house psychiatric services, or, may have limited access throughout a 24-hour time period. Smaller institutions may therefore need to subcontract with an outside psychiatric provider in order to furnish or supplement in-house psychiatric services.

Additionally, the need for security services in the ER has been on the rise. In a 2022 American College of Emergency Physicians survey, 85% of those surveyed expressed that the rate of violence experienced in emergency departments has increased over the past five years. In this regard, 55% said they had been physically assaulted, almost all by patients, with a third of those resulting in injuries. Notwithstanding the societal stigma imposed upon psychiatric patients and those struggling with addiction, these same physicians reported that psychiatric patients, along with those seeking drugs or under the influence of drugs or alcohol, comprised over 80% of the assaults experienced. Given the increasing risk that ER providers face, institutions may opt to retain and/ or increase their security staff and technology, often through subcontracting with a third party.

The importance of delineating parameters of the subcontractor relationship, particularly responsibility for certain tasks, is key. To the extent such companies are enlisted to provide services, institutions should understand what services these entities are obliged to perform and what they are not. This typically can be addressed through service agreements or similar contracts, which provide guidance regarding the apportionment of responsibilities. Within these contracts, indemnity provisions are critical to identifying exposure in the event of an adverse outcome and potential litigation.

For example, when contracting with an outside provider to provide in-house psychiatry services, the parties must have a clear understanding of their respective roles in the hiring, orientation and training, credentialing, supervision, and control over the provider. The contract should clearly layout each party’s responsibilities. Such contracts typically require outside vendors to hire the provider and to ensure they are qualified for the proposed role in the ER. At the same time, the contract may significantly limit the vendor’s role regarding supervision/control over the care furnished by the provider. The hospital typically has responsibility for the orientation and credentialing of the provider, as well as supervision of their work pursuant to hospital/ER policies and procedures. The contract should address other issues such as scheduling, disciplinary action, removal or termination of the provider, and, of course, indemnity and contribution.

For security staff, many of the same issues exist. There must be a clear delineation of responsibility for vetting and hiring the security staff, and responsibility for ensuring they are qualified and receive the proper and necessary training. The ability to discipline and/or terminate security staff should also be clearly stated. As for behavioral health, depending on the ratio of behavioral health patients in the ER, a healthcare provider should consider providing security staff with advanced training on how to manage patients with behavioral health issues, including those actively in crisis. Either way, the ER should have a sufficient number of properly trained security staff present at all hours to effectively manage a typical shift’s behavioral health caseload.

Crisis Management and Facilities
Behavioral health patients come with their own unique challenges, especially those who present to the ER in active crisis. Proper screening and assessment of patients in crisis is necessary to not only protect the patient and provide them with the proper treatment, but also to protect others. In addition to vetting and training personnel, the use of telemedicine, and the decision to subcontract certain functions, the ER must have comprehensive policies and procedures regarding provision of care to behavioral health patients. For patients in crisis, policies and procedures should include where the crisis patient should be located in the ER, the protocol for monitoring/surveillance, and the protocol for security (often dependent on the presence, or lack thereof, of a history of violence or indication of potential violence).

If possible, a specific number of treatment rooms should be set up for patients in crisis, with all potentially harmful objects removed from the room. These rooms should be located in an area of the ER where security can be effectively provided and which do not allow easy access to exit points. Consideration should be given to security cameras to assist with monitoring, as surveillance footage may be pertinent in the event of an incident and potential, future litigation. If there are crisis intervention specialists in the ER, these specialists must be able to appropriately monitor and access patients in order to facilitate safety and treatment needs. If specific rooms cannot be designated for crisis patients, then the ER should have a plan for what to do when a crisis patient arrives in the building. This includes accounting for where patients are screened and assessed, where they are located, how they are monitored, how to make their environment safe and keep them safe, and how to protect the safety of others. 

Reprinted with permission from the April 23, 2024, issue of the The Legal Intelligencer © 2024 ALM Media Properties, LLC. Further duplication without permission is prohibited. All rights reserved. 

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