Executive Summary

About one out of every three hospitalized adult patients has behavioral health needs that are intertwined with their hospital admission for a medical condition. For instance, a person admitted for a heart condition may also have a mood disorder, the top behavioral disorder for hospitalized patients. Conversely, a patient in the hospital for issues related to a substance abuse disorder, such as a drug overdose, may also have a medical condition, like diabetes, that requires treatment.

Events reported to ECRI Institute PSO and its collaborating patient safety organizations (PSOs) underscore the challenges for healthcare staff in simultaneously managing a patient's medical needs along with the patient's behavioral condition, which, for a variety of reasons, can sometimes become unruly and disruptive, escalating beyond a staff member's ability to control.

This issue of the PSO Navigator reviews some of the patient safety events that can occur and suggests strategies to help staff better address patients' behavioral health needs and medical conditions while maintaining safety for both patients and staff.* These strategies are also summarized in "Patient Safety for Coexisting Medical and Behavioral Conditions."

* In addition to the review provided by ECRI Institute PSO's Advisory Council, ECRI Institute PSO acknowledges the input provided by Andrew Bertagnolli, PhD, senior manager, integrated behavioral health, Care Management Institute, Kaiser Permanente (Oakland, California).

Who Should Read This

Table of Contents


Double Threat to Patient Safety

About one out of every three hospitalized adult patients has behavioral health needs that are intertwined with their hospital admission for a medical condition. For instance, a person admitted for a heart condition may also have a mood disorder, the top behavioral disorder for hospitalized patients. Conversely, a patient in the hospital for issues related to a substance abuse disorder, such as a drug overdose, may also have a medical condition, like diabetes, that requires treatment.

Events reported to ECRI Institute PSO and its collaborating patient safety organizations (PSOs) underscore the challenges for healthcare staff in simultaneously managing a patient's medical needs along with the patient's behavioral condition, which, for a variety of reasons, can sometimes become unruly and disruptive, escalating beyond a staff member's ability to control.

This issue of the PSO Navigator reviews some of the patient safety events that can occur and suggests strategies to help staff better address patients' behavioral health needs and medical conditions while maintaining safety for both patients and staff.* These strategies are also summarized in Patient Safety for Coexisting Medical and Behavioral Conditions.

* In addition to the review provided by ECRI Institute PSO's Advisory Council, ECRI Institute PSO acknowledges the input provided by Andrew Bertagnolli, PhD, senior manager, integrated behavioral health, Care Management Institute, Kaiser Permanente (Oakland, California).

Medical and Behavioral Needs Intertwined

Nearly all hospitals report that they provide care to patients with behavioral health and substance abuse disorders (AHA). In fact, one-third of all adult hospitalizations (excluding maternal stays) involve someone with a behavioral health or substance abuse disorder, which is either the primary reason for the admission or coexists with another medical condition at the time of the admission (Heslin et al.). As depicted in Figure 1. Mental or Substance Abuse Disorders Are Present for One-Third of All Adult Inpatient Stays, 2012, 21.2% of hospitalized patients have a mental disorder, 5.5% have a substance abuse disorder, and 5.6% have a combined diagnosis of a mental and substance abuse disorder.

​Figure 1. Mental or Substance Abuse Disorders Are Present for One-Third of All Adult Inpatient Stays, 2012

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Various studies highlight the fact that behavioral health and medical conditions are often co-occurring and can trigger each other. For example, about one in five patients hospitalized for a heart attack experiences major depression (Bush et al.). Another study found that about four in five patients in the intensive care unit experience delirium during their stays (Girard et al.).

Additionally, the stress of the hospital stay, untreated pain, reactions to medications, and other factors can cause unusual behavior, even in hospitalized patients without behavioral health or substance abuse disorders.

Barriers to Behavioral Health Treatment

Fewer than half of adults and one-third of children with a diagnosable behavioral disorder receive treatment (Russell). The barriers to treatment are well documented and include the following:

  • Declining numbers of psychiatric facilities and beds
  • Shortages of behavioral health professionals
  • Insufficient numbers of staff trained in recognizing behavioral health conditions requiring intervention
  • Patients' lack of health insurance coverage
  • Reluctance to seek care because of the stigma of behavioral health disorders

As a result, the burden of managing behavioral health and substance abuse disorders may fall on the acute care hospital.* Staff, who are expecting to treat medical conditions, must also manage the patient's mental state, yet they may not have the necessary training. Further, staff may sometimes be unaware that a patient with behavioral health issues requires psychiatric medications if the information is not available at admission or not visibly noted in the medical record. The patient may begin to experience symptoms during the hospital stay that staff are either uncomfortable with or unfamiliar with managing. Before long, the patient's behavior becomes increasingly difficult to manage.

The hospital environment may also contribute to the challenges of managing patients with behavioral disorders. Often, patients needing medical treatment arrive at the hospital through the emergency department (ED), where the chaotic environment can trigger unexpected behavior or exacerbate existing behavioral health conditions. Additionally, patients admitted for suicide attempts and treatment of any medical needs associated with an attempt may have access to medications and items that could facilitate another attempt.

These challenges are not limited to adult patients with behavioral disorders. Pediatric patients may suffer from substance abuse problems, suicidal ideation, behavior disorders, and more. Examples of events that can occur as a result are listed in Pediatric Behavioral Events ECRI Institute PSO will cover the unique problems and strategies for managing pediatric behavioral issues separately in an upcoming report.

Finding Solutions for Better Patient Management

The Patient Protection and Affordable Care Act (PPACA) creates an impetus to better manage individuals with behavioral health conditions by facilitating expanded health insurance coverage and better coordination of care in the primary care setting through accountable care organizations (ACOs) and medical homes (AHA). But healthcare facilities cannot wait until these initiatives are in place. As healthcare leaders know, failure to manage patient violence and other disruptive patient behaviors can jeopardize patient and staff safety, contribute to low staff morale, and even lead to federal and state citations and fines for safe-workplace violations. The strategies listed in this report provide some solutions for healthcare organizations while the healthcare sector strives to identify better systems for managing behavioral health issues in the primary care setting.

What We Are Seeing

Examples from the Database 

In the two years that ECRI Institute has compiled its list of the top 10 patient safety concerns for healthcare organizations, managing the needs of behavioral health patients in acute care settings has been among the top concerns. In their review of events submitted to the event report database, ECRI Institute analysts have identified numerous reports of patients who exhibit psychiatric illness or emotional agitation in addition to their medical conditions. Many of the reports describe incidents of patient violence, some of which cause harm to the patient, staff, or others. Refer to ECRI Institute Guidance; to access the 2015 report of the top 10 patient safety concerns for healthcare organizations.

ECRI Institute PSO analyzed the types of events associated with hospitalized patients who also have a behavioral health condition among events reported to us and our partner PSOs. Events are reported to ECRI Institute PSO's reporting system using the Agency for Healthcare Research and Quality's Common Formats. The Common Formats do not have a specific event report format for behavioral events; instead, behavioral events may be addressed in any of the structured event report formats. Therefore, we limited our search to the six event report formats (i.e., emergency services, falls, medications, perinatal, security, and other) most likely to include behavioral issues.

We further refined the query to identify terms in the event narratives suggestive of behavioral and substance abuse issues (e.g., "suicide," "self harm," "hallucination," "withdrawal"). Although it is possible that the terms used for the query did not identify all behavioral events, the search results provide a snapshot of events that can occur in healthcare organizations.

​Figure 2. ECRI Institute PSO Data Snapshot: Self- Inflicted Injuries, Physical Assaults Are Top Security Events Involving Violence

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The database query was applied to events submitted over the one-year period June 1, 2014, through May 31, 2015. With the nearly 3,500 events identified, we focused our review on the 232 events identified with harm scores of E through I. Harm scores are based on the National Coordinating Council for Medication Error Reporting and Prevention's Index for Categorizing Medication Errors to indicate harm levels (Hartwig et al.). Although originally designed for medication errors, the index—with its nine categories for harm labeled A (least harmful) through I (death)— is often used for non-medication-related events to indicate the event's effect on the patient (e.g., an error reaches the patient but does not cause harm, an error contributes to permanent harm, an error contributes to patient harm). Events with a harm score of E through I are associated with patient harm.

While many of the events describe incidents of patient violence (see Figure 2. ECRI Institute PSO Data Snapshot: Self- Inflicted Injuries, Physical Assaults Are Top Security Events Involving Violence for a summary of the type of violence described in these particular events), the search also uncovered other situations that have the potential to interfere with the care of patients with behavioral health needs.

Medical Condition Overlooked or Dismissed

Some of the event reports suggest that caregivers may overlook or dismiss the medical symptoms of patients whose admission is primarily related to a behavioral or substance abuse disorder. In one event,* concerns are raised that a caregiver dismissed a patient's abdominal pain and vomiting by attributing the symptoms to alcohol withdrawal, although the symptoms could have been caused by an additional undiagnosed medical condition.

The patient reported abdominal pain, a bloody stool, and vomiting. The nursing supervisor was notified and stated, "She's probably withdrawing; call the attending physician and let him know the patient has a history of alcoholism." The supervisor was argumentative about the potential seriousness of the patient's condition when I stated that I found them concerning.

* The details have been deidentified in this and all other events summarized in this report.

In another report, a patient with a history of diabetes was hospitalized for suicidal ideation. During the stay, the patient became hyperglycemic and had to be transferred to a critical care unit (CCU). The report suggests that the patient's diabetes was inadequately managed while the behavioral concerns were being addressed.

The patient was here for suicidal ideation and was in restraints for safety concerns. He has a medical history of diabetes. The sitter called me to the bedside. The patient had signs of diabetic ketoacidosis. The patient was admitted to the CCU for treatment of diabetic ketoacidosis and a possible pulmonary embolism.

Substance Abuse Withdrawal

Just as there is a risk of mistakenly attributing a patient's changing medical condition to their mental state, some events describe the failure to detect a patient's substance abuse disorder until the patient develops withdrawal symptoms. For example, in one event, staff noted significant changes in a patient's mental status during the night and realized the changes may be due to alcohol withdrawal after the family told staff that the patient was a heavy drinker. The patient was then transferred to an intensive care unit.

In another case, an order for an alcohol withdrawal assessment was overlooked for a trauma patient until the patient had symptoms of confusion and profuse sweating.

An alcohol withdrawal assessment was ordered for a trauma patient on admission, but it was not done until five days into the patient's stay. The patient was found to be confused and diaphoretic. The patient received medication for withdrawal.

Staff must also be alert for drug-seeking behavior by hospitalized patients with substance abuse disorders. Patients seeking narcotics may complain of untreated pain or, as in the following event, self-administer drugs obtained surreptitiously at the hospital or brought to the patient by visitors.

The patient was found by the mother in the bathroom and was unresponsive and diaphoretic. A rapid response team was called. A flush was found connected to the patient's PICC [peripherally inserted central catheter] line. Security searched the patient’s belongings and sent suspicious items to the toxicology lab. The patient became agitated, refused a psychiatric consult, and threatened to leave AMA [against medical advice]. The patient was placed on 1:1 monitoring.  

Suicidal Patients

Patients admitted for suicide attempts may have other medical conditions that require monitoring in addition to physical injuries from the suicide attempt, as in the case of the suicidal patient described above who needed monitoring for his diabetes. Most suicidal patients will arrive through the ED and, while their injuries are being treated, must be kept in a safe environment where they can be closely monitored by staff and where they do not have access to items that can be used for another attempt. As the following event describes, suicidal patients may seize any opportunity to escape or inflict more harm on themselves.

The patient had intentionally overdosed. She was combative and verbally abusive. She was put in restraints and manually restrained while being given activated charcoal. After the restraints were removed, the patient broke into the sharps container and lacerated her wrists with the needles.

Even with close monitoring, events can still occur if unsafe items have not been removed from the patient’s room and belongings, as described in the following event.

The sitter was right at the patient’s bedside. The sitter heard a clicking sound under the bedsheet and asked the patient what it was. The patient showed the sitter a corkscrew and admitted that he was cutting himself.

Disruptive Patient Transfers

ECRI Institute PSO analysts reviewed several events of patient agitation that were triggered when the patient was transferred to another level of care. In the following event, a patient’s withdrawal symptoms escalated out of control when the patient was transferred from the CCU to another unit. Staff had not been informed that the patient’s alcohol withdrawal symptoms had become more severe just before the patient’s transfer.

The patient was in the CCU and being treated for alcohol withdrawal. The floor nurse received a report that the patient was stable for transfer from the unit. Upon transfer, the patient was very agitated and threatened to leave AMA. The doctor gave the patient multiple doses of an antianxiety medication. Security and the nursing coordinator were also called to the bedside. Documentation indicated that two hours before the transfer, the patient’s CIWA [Clinical Institute Withdrawal Assessment of Alcohol Scale] score had increased. This was not stated in the report to the floor nurse. The patient was transferred to the medical intensive care unit.

Psychiatric Services Unavailable, Staff Untrained

According to the American Hospital Association, only 27% of community hospitals have an organized inpatient psychiatric unit (AHA). As a result, acute care staff may not have immediate access to behavioral health professionals able to assist them in managing a patient’s behavioral condition, as in the following event.

A psychiatric consult was ordered five days ago, and the patient has still not been seen by a psychiatrist. The patient has symptoms associated with altered mental status. The admitting provider is waiting for a psychiatrist’s recommendations. We will reorder the consult.

Hand in hand with a shortage of behavioral health professionals available to staff is the issue of staff training. Event reports suggest that some staff lack the skills to manage patients’ behavioral health needs or are insensitive to patients’ conditions, as in the following two reports.

The patient said that the doctor told her that her depression and cutting were "funny" and laughed.

The parents are concerned that their child needs treatment for anxiety and depression and that the doctor’s approach only seems to make things worse.

Staffing Concerns

The demands of managing patients’ coexisting physical and behavioral needs may leave staff pressed for time to manage example, raises concerns about the "safety hazards for patient care" when staff have insufficient time to address patients’ medical and behavioral needs.

Some events also describe staff members’ reluctance to help manage a combative patient. In the following event, a patient started acting out, but the patient’s nurse, who was nearby, did not intervene.

I entered the nursing unit to find the patient trying to hit the CNA [certified nurse’s aide]. I and the other nurses came to the CNA’s aid and tried to redirect the patient back into the room and calm her down. I saw the patient’s nurse at the desk and asked if the patient is hers. She replied that she has other patients to care for, too

Events can deteriorate if staff do not enlist help or follow the organization’s procedures for managing a combative patient, as in the following event.

The patient eloped from the room. Security wasn’t called. Two staff members attempted to stop the patient. The patient and the two individuals wrestled to the ground. Security heard the commotion and got involved. The staff members have scratches and bite marks.

Psychiatric Medication Errors

Events submitted to ECRI Institute PSO and its collaborating PSOs suggest that patients’ behavior can escalate if psychiatric medications are unavailable to staff on the unit or if there are errors in giving the medications. In the following event, the care unit’s depleted supply of an antianxiety medication had not been replenished. Staff on the unit needed the medication for a patient going through withdrawal and experiencing escalating anxiety.

The patient was escalating in anger and physical harm to self. Valium was not available on the unit because the stock supply was depleted. Another nurse had to go to other units to get Valium for withdrawal symptoms for this patient as well as five others needing it. Depleted stock medications is an ongoing problem on our unit on weekend day shifts.

In other events, omissions of prescribed psychiatric medications put patients at risk. Not only are patients affected, but staff may be confronted with increasingly difficult-to-manage behavior, as in the following event.

The order for the patient’s antipsychotic medication had expired, although the doctor’s progress note said to continue with it. The patient had not received the medication for two days and was sleeping less, more irritable, and threatening to hit staff. This was not the patient’s normal disposition. On the third day, the nurse realized the medication order had not been renewed. The patient is at risk for decompensation; we will continue to monitor the benefits of the medication.

Several events describe omissions of medications for alcohol or drug withdrawal and the effect on patients when their withdrawal symptoms are unmanaged.

The patient was on methadone maintenance before his admission over the weekend. The physician assistant ordered methadone with a note for the unit physician to follow up with the order on Monday. No methadone was ordered on Monday, and the patient started exhibiting withdrawal symptoms. When the order was finally placed, pharmacy would not fill it because the order was placed incorrectly, further delaying this stat order of methadone.

Even an omission of one medication dose to prevent withdrawal symptoms has the potential to harm a patient, as in the following event. The patient’s midnight Librium for prevention of alcohol withdrawal [symptoms] was not administered by the nurse because the patient was asleep. The dose omission is dangerous on account of the patient being in severe alcohol withdrawal. The patient subsequently displayed vital sign instability and required an additional antianxiety medication.

Lessons Learned

Opportunities for Improvement

Multidisciplinary Approach 

Caring for individuals with coexisting behavioral and medical conditions requires a multidisciplinary approach, involving clinicians, caregivers, pharmacy, behavioral health professionals, social services, and others. Caregivers should consider all possible medical and behavioral causes for a patient’s agitation and consult behavioral health and medical experts for input. While agitation can be caused by alcohol or drug withdrawal, delirium, dementia, or an existing psychiatric condition, it can also have a physical cause. Patients may express the physical discomfort of an overlooked urinary tract infection, pulmonary infection, or impacted bowel with mental status changes, delirium, or aggression. 

Some hospitals with behavioral health units provide staff on the medical units with access to their behavioral health teams when staff need help managing medical patients on other units with coexisting behavioral complexities (refer to Behavioral Health Resource Teams for an example of one hospital’s approach). Other multidisciplinary approaches have been developed to focus on a particular patient population. For example, in recognition of the special needs of hospitalized elderly patients who may have a combination of cognitive impairment and medical needs, some hospitals have established geriatric units where medical and behavioral health specialists work together in caring for the patients (Dimattia).

Pharmacy Department Support

Given the possibility that some medications or a combination of medications may affect patient behavior in undesired ways, caregivers should enlist their pharmacy departments to provide guidance on medications’ effects on behavior, as well as possible drug interactions and contraindications. Pharmacists should work closely with nursing staff to ensure that patients’ medication schedules are closely monitored to prevent any interruptions in administering the patients’ psychiatric medications.

The pharmacy departments should also regularly check the medication inventory on the unit to confirm that there is an available supply of necessary medications to manage emergency psychiatric conditions. To ensure that the medication inventory is adequately maintained, the pharmacy department should monitor units’ medication usage reports to check that the medication inventory does not dip below a predetermined level based on the unit’s typical usage rate.

Additionally, if a particular medication is in short supply or unavailable due to a national drug shortage, the pharmacy department should identify a suitable alternative and inform staff about the substituted medication and dosing instructions (for more information about managing drug shortages, refer to ECRI Institute Guidance).

Medication Reconciliation

Several of the events for this analysis indicated that inadequate medication reconciliation can be harmful for patients who require ongoing medication for a behavioral condition. Failure to correctly identify patients’ medical or behavioral health medications, continue medications, or provide medications in the correct doses on admission or discharge can lead to a serious harmful event requiring unexpected and additional care, transfer to a higher level of care, or readmission.

For example, patients with substance abuse disorders can experience withdrawal symptoms when medications to manage their withdrawal are omitted from their medication orders. There is also the risk that medications for medical conditions are overlooked for patients being monitored for behavioral conditions, as was the case with the suicidal patient who experienced diabetic ketoacidosis.

The process of medication reconciliation is intended to prevent medication errors by systematically evaluating the medications a patient is taking for medical and behavioral conditions to ensure that any medications that are added, changed, or discontinued are carefully reviewed, with the goal of maintaining an accurate list of the patient’s medications. The process should be undertaken with every change in a patient’s level of care along the continuum of care, such as at hospital admission and discharge, during level-of-care transitions within a healthcare facility (e.g., from an intensive care to a medical-surgical unit), and before and after transfers to another facility. Failure to correctly reconcile patients’ medications can lead to harmful events requiring unexpected and additional care, transfer to a higher level or care, or hospital readmissions. Refer to ECRI Institute Guidance for additional resources on the topic.


Not all healthcare facilities have access to behavioral health professionals on the facility premises. Some hospitals have identified a role for telemedicine to facilitate electronic behavioral health consults between patients and behavioral health specialists able to "visit" with the patient from a remote location. While the patient and behavioral health professional may not be in the same room, the visit can still be one-on-one with videoconferencing technology. The South Carolina Department of Mental Health and the South Carolina Hospital Association received funding to establish a statewide telepsychiatry network serving all hospitals with EDs in the state. ED clinicians have 24-hour access to the network’s psychiatrists and psychiatric residents who can provide psychiatric assessments, prescribe medications, and initiate treatment as needed. About 15 telepsychiatry consultations are provided every day. (SC DMH "The DMH Telepsychiatry")

Previously, patients could wait two to three days before being assessed by a behavioral health professional. As of May 2015, the average wait time for an assessment had decreased to 8.5 hours, and about 42% of individuals receiving telepsychiatry consultations were discharged that same day (SC DMH "The DMH Telepsychiatry"). The state reports that patients who participate in a telepsychiatry consultation are two times as likely to use the community resources after discharge as patients with similar needs who do not receive a telepsychiatry consult (SC DMH "Program Summary").

Nevertheless, telepsychiatry has significant barriers that can affect its implementation and use. Obstacles include costs, licensing, credentialing, privileging, privacy and security protections, and the liability aspects of providing medical opinions and care to patients that a practitioner does not see face-to-face. Facilities considering a telepsychiatry service may be interested in practice standards and guidelines for telepsychiatry available from the American Telemedicine Association (ATA) (see Online Resources for information on accessing the guidelines). ECRI Institute also provides guidance on telemedicine (refer to ECRI Institute Guidance for more information).

Staff Training

Staff members who are not trained as behavioral health professionals must be prepared to manage combative patients and, in particular, to recognize verbal and behavioral cues that suggest a patient could become aggressive. Most violent behavior is preceded by warning signs. When a patient first shows signs of agitation, staff members may find that they can use de-escalation techniques, such as nonchallenging verbal exchanges, to defuse the tension. They must be attuned to their own words and actions, such as body language and tone of voice, which can further provoke the patient.

Educating staff about these warning signs and about appropriate approaches for managing the patient, as well as when and how to summon additional assistance, can prevent the situation from escalating into a crisis, requiring activation of the organization’s violent incident response team or the use of more forceful measures, such as restraints. Refer to ECRI Institute Guidance for more resources on prevention of patient violence.

Staff training should also cover many of the medicolegal issues that can arise in managing patients with behavioral health disorders, including the appropriate use of restraints, refusal of treatment, forced medication, special issues involving minors, patient confidentiality, involuntary commitment, and privacy rights (refer to HIPAA Privacy Rule Considerations for more information). Staff should be familiar with applicable state and federal laws and the organization’s procedures for addressing these issues, as well as whom to contact within the organization for help.

Competency Assessment

In addition to providing staff training, healthcare organizations should ensure that staff demonstrate competency in caring for individuals with behavioral health conditions. Staff competency assessment should include staff understanding of the warning signs of potentially disruptive patient behavior and the protocols for managing troublesome patient behavior on non–behavioral health units to prevent urgent situations from arising.

Competency assessment is an ongoing process that includes training, demonstration of skills, maintenance and improvement of skills, and methods to track and monitor skills (Whelan). Hospitals are required by accrediting organizations, such as the Joint Commission, to perform competency assessment upon hire and regularly thereafter to ensure that skills are maintained and improved.

Alert System

While training can provide staff more confidence in managing difficult patients, staff also benefit from knowing in advance whether a patient has a history of aggressive behavior. Healthcare organizations should develop a process to identify on admission patients who have the potential to become violent based on a history of violence, suspected substance abuse, and cognitive impairment.

Information about the patient’s risk for difficult behavior must be communicated to staff who need to know such information, such as staff receiving the patient during a handoff. Transporters and ancillary staff, including security, who have only intermittent contact with the patient and may be unaware of information about the patient in the medical record, must be informed of the patient’s risk of becoming aggressive. Communication about a patient’s risk for violence must be approached with the same level of seriousness as communication about other patient risks, such as the need for fall precautions for patients at risk of falling or contact precautions for an infection.

Protocols to Minimize Likelihood of Events

Several protocols may help to reduce the likelihood of patient outbursts and minimize any harm to the patient and staff if a patient's agitation escalates. Examples of such protocols are as follows:

  • Place the patient in a room that can be seen from the nurse's station for close monitoring of the patient and the patient's interactions with staff and visitors.
  • Adopt measures to minimize anxiety-producing stimuli, such as unnecessary noise, or interactions that can increase the patient's stress level.
  • Closely monitor the patient during meal times and shift changes, when disruptive behavior can increase.
  • Affix furniture to floors, if possible, and remove or secure decorative items, such as pictures and vases, from the room so that the items cannot be used as weapons or projectiles.
  • Arrange furniture in the room to prevent staff entrapment if staff must leave the room quickly.
  • Discourage employees from wearing necklaces or chains that could be used for strangulation during a patient confrontation and from carrying items that could be used as weapons, such as keys and pens.  

ED Environment

Even though it is the hospital entry point for most patients, the ED is often poorly suited for patients with behavioral health disorders. ED crowding, insufficient space, long waits for assessment, and the presence of security staff monitoring the patient are all factors that can cause the patient to become agitated and anxious. What might have been a successful encounter can quickly turn into a confrontation between the patient and caregivers, with the patient refusing to cooperate due to the influence of environmental stimuli. Some measures that may increase the likelihood of a successful outcome in the ED include the following:

  • Ensure that the initial evaluation of a patient with an apparent behavioral health issue involves an investigation into possible medical causes contributing to the patient's behavior.
  • Conduct an initial suicide risk assessment at triage to ensure interventions are in place for high-risk patients; the assessment should be updated as more information is obtained and as the patient's condition changes.
  • Foster staff sensitivity to the needs of patients with behavioral health issues (e.g., psychiatric, medical) despite, for example, staff's possible frustration with a substance abuser who may be a "frequent flyer" (frequently returning patient) in the organization's ED.
  • Minimize the duration of the patient's wait to be assessed and evaluated by a behavioral health clinician.
  • Create a waiting area that is comfortable and safe for everyone and designed to minimize stress (e.g., sufficient seating and space, adequate room temperature, no unnecessary noise).
  • Move the patient to a quiet area, away from the bustle of the ED patients.
  • Ensure the patient is supervised, while balancing the patient's need for privacy. Some facilities have set up dedicated space for patients with psychiatric emergencies where staff can observe the entire area from a central location.
  • Educate all ED staff, including security personnel, on interacting with people with behavioral health disorders.  

Rapid Response Teams

If a patient starts to show signs of loss of control, staff must be prepared to remove themselves and others in the area from the situation and to activate the organization's procedure for immediate response to potentially violent behavior. The notification system should use redundant processes, such as a combination of activating panic buttons and overhead code alerts, in case one of the measures fails.

At one hospital, for example, an interdisciplinary team of responders specially trained to interact with combative patients is activated when there is an overhead "code gray" alert. Team members consist of inpatient nursing staff, clinical administrators, inpatient therapists, psychiatrists, and security staff. (Ferguson and Leno-Gordon)

The team debriefs after each event and meets monthly to discuss difficult cases and review performance data. The team also conducts drills to practice their response to mock events and to identify any areas for improvement in their response. (Ferguson and Leno-Gordon)

Most facilities deploy their security staff to provide assistance with difficult-to-manage patients, they should ensure that security staff, including personnel provided by outside agencies, receive the necessary training to manage patients with behavioral health needs and understand the organization's procedures for intervening with these patients.

Patient Suicide: Assessment and Prevention

The suicide rate among hospital inpatients is three times as high as the rate in the general population, underscoring healthcare facilities' important role in addressing suicide prevention (Dhossche et al.). In addition to suicide deaths and attempts that occur in the inpatient setting, thousands of patients are seen in EDs every year after attempting suicide.

While clinicians cannot always predict which patients will attempt suicide, they should assess patients for suicide risk and adopt measures to reduce the likelihood that a patient will attempt suicide while in the hospital. Prevention measures include close patient monitoring, removal of structures and materials from the patient's room that the patient could use to attempt suicide, staff awareness of suicide prevention strategies, and effective communication among caregivers about a patient's risk.

Monitoring intervals longer than every 15 minutes to check on a patient at suicide risk are considered inadequate (Lieberman et al.). One hospital, concerned that death by asphyxiation may occur in as little as five minutes, requires that staff be in visual contact with the patient at all times, and some patients may even require one-to-one observation (Sullivan et al.).

Patient and Family Engagement

With most patients, family members know the patient best. If the patient has a behavioral disorder, family members can provide input about their loved one's behavioral needs (including information about any psychiatric medications taken by the patient) and explain what can trigger a change in the patient's behavior. Family members may also know the best approaches to help calm that patient. Indeed, Joint Commission hospital accrediting standards specify that facilities should engage the patient and family members in identifying behavior management interventions if they are needed (Joint Commission).

Patients should be encouraged to identify as support persons the individuals whose opinions about their healthcare is valued and whose involvement they believe would be helpful. For example, by engaging the patient and a designated support person in bedside change-of-shift reports whenever possible, the patient or support person may become aware of psychiatric medications that were omitted from the patient's usual drug regimen. In listening to staff members discuss the patient's care, the patient or support person may be able to identify situations that could increase the patient's anxiety. Or by providing patients and an authorized support person with open access to their medical records, they may identify errors in their medication orders, such as psychiatric drug omissions.

Resources to promote patient and family engagement are available from the Agency for Healthcare Research and Quality (AHRQ) and the Institute for Healthcare Improvement (IHI) and are listed in Online Resources.

Community and Primary Care Resources

The needs of a patient with a behavioral health disorder do not vanish at discharge. The organization should refer patients to community support groups, treatment centers, and other resources to obtain help after discharge. Staff should emphasize with the patient the importance of using these services to prevent psychiatric emergencies from arising and the patient's possible return to the hospital. A case manager or social worker from the hospital should follow up with the patient after discharge to ensure that the patient is adhering with the discharge plan and, if not, to explore and address the reasons for noncompliance.

In addition, caregivers should be aware of medical conditions that may trigger behavioral health issues and should ensure that patients' mental health needs are assessed during their stay and that these patients also have access to appropriate resources at discharge.

Ultimately, patients with behavioral health disorders may be best served in the primary care setting where their physical and behavioral health needs can be managed holistically. Patients with behavioral health disorders may be prone to concurrent medical problems. In a study of more than 400 patients with either schizophrenia or bipolar disorder, half of the patients needed one or more referrals for a nonpsychiatric problem, such as obesity, high blood pressure, or diabetes, possibly resulting from the use of antipsychotic medications. Earlier resolution of any medical problems may positively influence the patient's psychiatric outcome. (Douzenis et al.)

PPACA created incentives for the development of patient-centered medical homes where healthcare is delivered by a team of individuals, including behavioral health professionals able to address the patient's needs in the primary care setting. Other payment models, such as ACOs, provide incentives to integrate behavioral healthcare and primary care by allowing providers to share savings from effectively managing patients' care. (Crowley and Kirschner)


Co-occurring medical and behavioral conditions among hospitalized patients create unique and challenging risks for both patients and staff. Events reported to ECRI Institute PSO and its collaborating organizations underscore that these concerns are pervasive and demand that healthcare organizations find solutions. The strategies listed in this report provide a foundation; organizations may identify additional approaches to suit their special needs.

Although health reform initiatives may help in better managing patients with behavioral disorders in the primary care setting, the task of comanaging patients' behavioral and medical needs will continue to confront hospitals and their staffs. ECRI Institute PSO will continue to address this issue in its reports, webinars, and other activities. If your organization has identified an approach that is working, consider sharing your story. Working together, healthcare organizations can devise strategies to improve the care of patients whose medical and behavioral needs are intertwined.




American Hospital Association (AHA). Bringing behavioral health into the care continuum: opportunities to improve quality, costs and outcomes [online]. 2012 Jan [cited 2015 Aug 10]. http://www.aha.org/research/reports/tw/12jan-tw-behavhealth.pdf

Bush DE, Ziegelstein RC, Patel UV, et al. Post-myocardial infarction depression [online]. Evidence Report/Technology Assessment no. 123. 2005 May [cited 2015 Aug 10]. http://archive.ahrq.gov/clinic/epcsums/midepsum.htm

Crowley RA, Kirschner N; Health and Public Policy Committee of the American College of Physicians. The integration of care for mental health, substance abuse, and other behavioral health conditions into primary care: executive summary of an American College of physicians position paper. Ann Intern Med 2015 Aug 18;163(4):298-9. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/26121401

Dhossche DM, Ulusarac A, Syed W. A retrospective study of general hospital patients who commit suicide shortly after being discharged from the hospital. Arch Intern Med 2001 Apr 9;161(7):991- 4. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/11295962

Dimattia A. Lower Bucks Hospital opens senior behavioral health unit [online]. Intelligencer 2015 Aug 6 [cited 2015 Aug 10]. http://www.theintell.com/news/communities/bristol/lower-bucks-hospital-opens-new-senior-behavioral-health-wing/article_918671d4-06c8-5deb-be6e-1582c87f565f.html

Douzenis A, Seretis D, Nika S, et al. Factors affecting hospital stay in psychiatric patients: the role of active comorbidity. BMC Health Serv Res 2012 Jun 19;12:166. Also available at http://www.biomedcentral.com/1472-6963/12/166 PubMed: http://www.ncbi.nlm.nih.gov/pubmed/22713232

Ferguson J, Leno-Gordon D. Dial 7788 "code grey—PIP3—male side" "this is the head nurse" [online]. J Safe Manag Disrupt Assaultive Behav 2010 [cited 2015 Aug 17]. http://www.crisisprevention.com/CPI/media/Media/Resources/research/Coney-Island-Hospital.pdf

Girard TD, Pandharipande PP, Ely EW. Delirium in the intensive care unit. Crit Care 2008;12 Suppl 3:S3. Also available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2391269 PubMed: http://www.ncbi.nlm.nih.gov/pubmed/18495054

Hartwig SC, Denger SD, Schneider PJ. Severity-indexed, incident report-based medication error-reporting program. Am J Hosp Pharm 1991 Dec;48(12):2611-6. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/1814201

Heslin KC, Elixhauser A, Steiner CA. Hospitalizations involving mental and substance use disorders among adults, 2012 [online]. HCUP statistical brief no. 191. 2015 Jun [cited 2015 Aug 17]. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb191-Hospitalization-Mental-Substance-Use-Disorders-2012.jsp

Joint Commission. Comprehensive accreditation manual for hospitals. Oakbrook Terrace (IL): Joint Commission Resources; 2015.

Lieberman DZ, Resnik HL, Holder-Perkins V. Environmental risk factors in hospital suicide. Suicide Life Threat Behav 2004 Winter;34(4):448-53. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/15585466

Russell L. Mental health care services in primary care: tackling the issues in the context of health care reform [online]. 2010 Oct 4 [cited 2015 Aug 10]. https://www.americanprogress.org/issues/healthcare/report/2010/10/04/8466/mental-health-care-services-in-primary-care

South Carolina Department of Mental Health (SC DMH):

The DMH telepsychiatry program [online]. 2015 Jun 9 [cited 2015 Aug 18]. http://www.state.sc.us/dmh/telepsychiatry

Program summary [online]. 2014 Oct 24 [cited 2015 Aug 18]. http://www.state.sc.us/dmh/telepsychiatry/2014_prog_summary.pdf

Sullivan AM, Barron CT, Bezmen J, et al. The safe treatment of the suicidal patient in an adult inpatient setting: a proactive preventive approach. Psychiatr Q 2005 Spring;76(1):67-83. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/15757237

Whelan L. Competency assessment of nursing staff. Orthop Nurs 2006 May-Jun;25(3):198-202. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/16735851

Resource List

ECRI Institute Guidance*

  1. Duty to warn or protect [guidance article]: https://www.ecri.org/components/HRC/Pages/MenH4.aspx
  2. Emergency department monitoring of suicidal patients [custom research response]: https://www.ecri.org/components/PSOCore/Pages/Research-Response-Dec-2013-Monitor-Suicidal-Patients.aspx
  3. Health information privacy standards [guidance article]: https://www.ecri.org/components/HRC/Pages/LawReg19.aspx
  4. Medication reconciliation [guidance article]: https://www.ecri.org/components/HRC/Pages/pharm8.aspx
  5. Patient violence [guidance article]: https://www.ecri.org/components/HRC/Pages/MenH2.aspx
  6. Planning, communication key in coping with shortages: https://www.ecri.org/components/HRC/Pages/RMRep0811_Focus.aspx
  7. Refusal of emergency psychiatric treatment [guidance article]: https://www.ecri.org/components/HRC/Pages/MenH3.aspx
  8. Strategies for responding to patient violence [custom research response]: https://www.ecri.org/components/PSOCore/Pages/Research-Response-May-2013-Patient-Violence. aspx
  9. Substance abuse screening tools [custom research response]: https://www.ecri.org/components/PSOCore/Pages/Research-Response-Jan-2014-Substance-Abuse-Screen-Tools.aspx
  10. Suicide risk assessment and prevention in the acute care general hospital setting [guidance article]: https://www.ecri.org/components/HRC/Pages/MenH1.aspx
  11. Telemedicine [guidance article]: https://www.ecri.org/components/HRC/Pages/MedTech17.aspx
  12. Top 10 patient safety concerns for healthcare organizations 2015: https://www.ecri. org/components/PSOCore/Pages/PatientSafetyTools.aspx

* For information on obtaining ECRI Institute resources, contact ECRI Institute PSO at psohelpdesk@ecri.org.

Online Resources

  1. AHRQ's Guide to Patient and Family Engagement in Hospital Quality and Safety: http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/index.html
  2. ATA's Practice Guidelines for Videoconferencing-Based Telemental Health: http:// www.americantelemed.org/docs/default-source/standards/practice-guidelines-for-videoconferencing-based-telemental-health.pdf
  3. ATA's Practice Guidelines for Video-Based Online Mental Health Services: http://www.americantelemed.org/docs/default-source/standards/practice-guidelines-for-video-based-online-mental-health-services.pdf?sfvrsn=6
  4. IHI's Delivering Great Care: Engaging Patients and Families as Partners: http://www.ihi.org/resources/Pages/ImprovementStories/DeliveringGreatCareEngagingPatientsandFamiliesasPartners.aspx
  5. U.S. Department of Health and Human Services' guidance on HIPAA privacy rule and sharing information related to mental health: http://www.hhs.gov/ocr/privacy/hipaa/understanding/special/mhguidance.html


Patient Safety for Coexisting Medical and Behavioral Conditions

  1. Adopt a multidisciplinary team approach for patients with coexisting conditions.
  2. Provide staff with access to behavioral health professionals.
  3. Enlist pharmacy department support to ensure an adequate inventory of psychiatric medications on units.
  4. Conduct medication reconciliation to ensure review of patients' psychiatric medications.
  5. Consider telepsychiatry to facilitate behavioral health consults for patients.
  6. Provide staff training and assess staff competency in managing combative patients.
  7. Minimize anxiety-producing stimuli in the patient's room and in ED waiting areas.
  8. Activate a rapid response interdisciplinary team when combative situations escalate.
  9. Assess patients for suicide risk, and adopt measures to prevent suicide attempts.
  10. Identify community resources available to patients at discharge.

Pediatric Behavioral Events

Some of the events involving patients with co-occurring behavioral and medical conditions illustrate the unique challenges related to the pediatric population. The following examples describe some of the scenarios reported to ECRI Institute PSO and its collaborating organizations:

  1. Abusive behavior (e.g., biting, kicking, spitting, pulling hair) causing injuries to staff and requiring assistance from security
  2. Agitation from substance abuse withdrawal
  3. Aggressive parental behavior that impacts the child's care
  4. Domestic conflicts (e.g., between parents, between child and parent) erupting in the patient's room
  5. Elopement from the unit and the ED
  6. Events involving the use of restraints
  7. Refusal to comply with treatment (e.g., take medications, prepare for testing, cooperate with staff)
  8. Threats of self-harm
  9. Suicide attempts

ECRI Institute PSO will address strategies for managing behavioral conflicts with pediatric patients in an upcoming report. If your organization has implemented successful strategies to help in managing behavioral issues that arise with pediatric patients, please share them with us so that we can also share the lessons you have learned with other PSO members and collaborating organizations.

Behavioral Health Resource Teams

At Indiana University Health Bloomington Hospital, staff on the medical units can call its behavioral health resource team for assistance in assessing and handling patients who are displaying difficult behaviors, such as pulling at their intravenous lines, trying to get up without assistance, or acting aggressively. There is always at least one member from the team available at any time.

When a team member is called to assist with a patient, they will also meet with the patient's nurse and offer suggestions to help manage the particular patient. Rather than taking over the patient's behavioral care needs, team members empower and educate staff in dealing with challenging patients. Team members can also be called to the ED to help evaluate a patient and determine whether that patient requires hospitalization for behavioral issues or can be treated in the outpatient setting with available community resources.

Since implementing the team in 2005, the hospital has been able to decrease the number of escalating events requiring the involvement of security and increase nursing staff's comfort level in managing the patients.

Sources: American Hospital Association. Hospital behavioral health plan [online]. 2009 [cited 2015 Jul 29]. http://www.aha.org/hospital-members/advocacy-issues/mentalhealth/caseex/09caseex-bloomington.shtml; Branam, Scott (Program Director, Behavioral Science, IU Health Bloomington Hospital). Conversation with: ECRI Institute. 2015 Aug 11

HIPAA Privacy Rule Considerations

In addition to managing some patients' co-occurring medical and behavioral needs, questions can also arise about the patients' privacy protections under the Health Insurance Portability and Accountability Act (HIPAA) privacy rule. In recent guidance, the U.S. Department of Health and Human Services addresses some of the more frequently asked questions about when it is appropriate under the privacy rule for a healthcare provider to share the protected mental health information of a patient. The guidance clarifies when HIPAA permits healthcare providers to communicate with a patient's family members, friends, or others involved in the patient's care; consider the patient's capacity to agree or object to the sharing of their information; involve a patient's family members, friends, or others in dealing with patient failures to adhere to medication or other therapy; communicate with family members, law enforcement, or others when the patient presents a serious and imminent threat of harm to self or others; and communicate to law enforcement about the release of a patient brought in for an emergency psychiatric hold.

The guidance often reminds caregivers to consider "the best interests of the patient" while considering any more stringent privacy standards, such as state confidentiality laws. For example, if the patient is unable to agree or object to a disclosure due to emergency circumstances (e.g., temporary psychosis, being under the influence of drugs or alcohol), the provider must determine if sharing the information is in the patient's best interests. Once the patient gains capacity, the provider should offer the patient the opportunity to agree or object to any future sharing of the information, the guidance says. Refer to "Online Resources" for information on obtaining the U.S. Department of Health and Human Services guidance.

Source: U.S. Department of Health and Human Services. HIPAA privacy rule and sharing information related to mental health [online]. 2014 Feb 20 [cited 2015 Jul 29]. http://www.hhs.gov/ocr/privacy/hipaa/understanding/special/mhguidance.html

Education Teaser

Which of the following hospital settings or scenarios is not a high risk for drug diversion?

    a. Operating room

    b. During the delivery of drugs to patient care areas

    c. During transfer of patients from one unit to another

    d. Pharmacy

    e. When retrieving drugs from automated dispensing units

Examples of ways employees may divert drugs include all of the following except:

    a. Removing leftover substances from a sharps container.

    b. Disposing medication waste improperly.

    c. Inaccurately documenting medication administration at points of care.

    d. Substituting the diverted medication for another medication.

    e. None of the above. They are all ways to divert drugs.

Earn AMA PRA Category 1 credits! Access online courses on this topic through ECRI Institute's e-Learn at https://www.ecri.org/components/Pages/e-Learn.aspx.

Related Resources

Topics and Metadata


Behavioral Health


Hospital Inpatient

Clinical Specialty



Pharmacist; Nurse; Risk Manager; Quality Assurance Manager; Behavioral Health Personnel; Clinical Laboratory Personnel; Clinical Practitioner; Patient Safety Officer; Healthcare Executive

Information Type


Phase of Diffusion


Technology Class


Clinical Category



SourceBase Supplier

Product Catalog








Publication History