ECRI Institute Issues New Recommendations for Managing Acute Care Patients with Behavioral Health Needs

New analysis, tools, and strategies from ECRI Institute Patient Safety Organization (PSO)

November 14, 2018

PLYMOUTH MEETING, PA—ECRI Institute Patient Safety Organization (PSO), the nation's leading federally designated Patient Safety Organization, identifies gaps in care and issues new recommendations to help hospitals manage acute care patients with behavioral health needs.

According to the National Institute of Mental Health, eighteen percent of adults have had a diagnosable mental illness in the past year. Forty two percent of inpatient stays, primarily for a physical health condition, involve a co-occurring mental or substance abuse disorder (Owens et al).

ECRI Institute PSO conducted a deep dive analysis of nearly 2,400 event reports involving patients with behavioral health needs in nonpsychiatric acute care settings. More than half of the events involved patient violence against others; less than half were categorized as emotional or mental health manifestations. Patients suffered temporary or minor harm in 81 incidents and major or permanent harm in three incidents. In one event, the patient died.

"Behavioral health issues have been one of our top 10 patient safety concerns for the past three years," says William Marella, ECRI Institute executive director of PSO Operations and Analytics. "Our close work with healthcare providers identifies flashpoints in care delivery and highlights patient needs that often aren't met."

ECRI researchers observed that many general acute care units are ill equipped to meet these patients' needs and sometimes, staff are not aware of the patient's behavioral health needs until a crisis occurs.

Failing to meet patients' behavioral health needs negatively affects patient safety, quality of care, occupational health, patient and staff satisfaction, security and risk management, legal and regulatory compliance, public relations, and the organization's operations and finances.

ECRI's sentinel report, Deep Dive™: Meeting Patients' Behavioral Health Needs in Acute Care, provides a framework for identifying behavioral health care gaps and choosing strategies that work for acute care organizations and their patients. It includes in-depth findings, results, tools, case studies, and recommendations for organizations to adopt and implement. Improvement strategies include changes in clinician training, the physical environment, and coordination with the community. The report highlights strategies that have been used successfully by PSO members and other providers across the US.

The full report is available to PSO members, and an executive brief is publicly available at For more information, contact ECRI Institute at (610) 825-6000 or

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About ECRI Institute
ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research to healthcare to discover which medical procedures, devices, drugs, and processes enable improved patient care. As pioneers in this science for 50 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. Strict conflict-of-interest guidelines ensure objectivity. ECRI Institute is designated an Evidence-based Practice Center by the U.S. Agency for Healthcare Research and Quality. ECRI Institute PSO is listed as a federally certified Patient Safety Organization by the U.S. Department of Health and Human Services.

For more information, contact:
Laurie Menyo, Director of Public Relations and Marketing Communications
(610) 825-6000, ext. 5310