ACEP COVID-19 Field Guide

Joint Statement for Care of Patients with Behavioral Health Emergencies and Suspected or Confirmed COVID-19

Joint Statement by the American Association for Emergency Psychiatry, American College of Emergency Physicians, American Psychiatric Association, Coalition on Psychiatric Emergencies, Crisis Residential Association, and Emergency Nurses Association

As with environmental disasters and other crises, pandemics can exceed people’s usual coping skills and capacity, which, in turn, can lead to problems with anxiety, depression, and increased use of substances as well as exacerbation of underlying psychiatric disorders. Factors including, but not limited to, social and physical isolation, uncertainty, fear, evolving facts, changes in how individuals access outpatient care, and public health recommendations can contribute to this stress. People with and without pre-existing psychiatric illnesses can be impacted, which then contributes to a number of challenges for our already taxed emergency and crisis health care systems.

The most severely ill people with psychiatric illnesses have high rates of baseline medical comorbidity, have reduced access to primary care medical resources, and may lack resources to participate in telehealth services. As a result, this group may be more vulnerable to COVID-19 and have limitations in accessing services other than in emergency and crisis settings.¹

For care of behavioral health patients with suspected or confirmed COVID-19: 

1. Encourage preparedness by supporting education and training on the treatment of psychiatric disorders and best practices for the care of behavioral health patients. Consult educational resources, including:
1. ACEP’s resources on “Mental Health and Substance Use Disorders”;
2. Emergency Medicine Foundation’s “CPE Resources”; and
3. Psych Hub’s “COVID-19 Mental Health Resource Hub.”
2. Provide staff with appropriate and adequate PPE. 
3. Encourage the use of existing, available behavioral health crisis services to mitigate unnecessary visits to the emergency department for psychiatric emergencies or for diverting people from psychiatric hospitals whenever possible.
4. Support medical screenings via telehealth or telephone as well as clinical preadmission screenings and assessments by qualified, licensed professionals. In addition, use expanded telehealth, including prescribing controlled substances for opioid use disorder via telemedicine and for patient and provider safety in line with infectious disease recommendations (ie, social distancing). Encourage novel use of telehealth in high-risk environments for diversion and mitigation of unnecessary emergency department visits. For more information, consult resources such as:
1. Substance Abuse and Mental Health Services Administration’s "FAQs: Provision of methadone and buprenorphine for the treatment of opioid use disorder in the COVID-19 emergency”
5. Recognize that patients who present with psychiatric complaints may also have co-occurring medical disorders that warrant a proper medical evaluation. Use pre-existing, evidence-based recommendations and screening algorithms to perform appropriate and directed medical evaluations. Encourage providers to identify alternate methods and modalities to make those assessments in the current COVID environment. 
6. Understand that people will present with an acute psychiatric crisis who are at risk of, have symptoms consistent with, or have tested positive for COVID-19, who will not meet medical admission criteria but will meet criteria for further psychiatric care. Mental health and substance use care, based on the needs of the individual, must remain available. 
7. Discourage the use of restraints while keeping people in the least restrictive setting possible that corresponds to their condition or presenting symptoms. 
8. Ensure that medical personnel are evaluating for signs of domestic violence in children, partners and spouses, the elderly, those with intellectual and developmental disabilities, and other vulnerable populations, as implementation of social distancing and home-based self-quarantine can increase this risk.
9. Encourage staff to formulate aftercare services that are based on existing resources and partnerships in the community.
10. Provide individuals at risk of suicide with local and national resources of people to talk to when they are feeling suicidal, such as the: 
1. Local crisis call center number; 
2. ICAR2E app developed by ACEP; 
3. National Suicide Prevention Lifeline; 
4. Trans LifeLine;
5. Trevor Project; or
6. Crisis Text Line.
11. Encourage the creation and use of psychiatric advance directives by patients, wherever local jurisdictions permit, that will help provide treatment guidance for providers by patients before their symptoms worsens to the point of impairment in psychiatric medical decision making. For more information, see the: 
1. Substance Abuse and Mental Health Services Administration’s resource manual A Practical Guide to Psychiatric Advance Directives.
12. Encourage and promote self-care among those providing care to patients and their families. Acknowledge that health care workers are committed to assisting all shortages and vacancies during this time of crisis and that it is just as important to maintain one’s individual health and wellness for the overall stability of patients and the care delivery system
13. Ensure adequate funding — governmental, nongovernmental, and private funding — to support all activities noted and ensure all insurance agencies, both public and private, provide appropriate and reasonable reimbursement for the care and treatment of patients with behavioral emergencies.
14. Identify patients with behavioral emergencies in your community by working with local agencies (ie, hospitals, outpatient centers, shelters, and public agencies).
15. As much as possible, try to ensure all behavioral health patients have phone access and that their numbers are recorded, but be cognizant of CFR-42 regulations if this information is shared across organizations.
16. Create a process to contact all identified patients on a regular basis for “check-ins” during the pandemic, ideally at least weekly and, if resources allow, several times per week. Consider using “furloughed” staff to help with this task. Consider a process to identify at-risk behaviors and concerns during these check-ins, and establish standard processes to address concerns once identified.
17. Create a standard approach to the organizational and community messaging that occurs during these check-ins, which can be particularly helpful in mitigating anxiety associated with the pandemic.
18. Make a list of community online resources, particularly any local online Alcoholics Anonymous and Narcotics Anonymous meetings, even if some patients will not have access to these electronic tools, because these programs can make a significant difference when they are accessible.

Reference

Osborn DP. The poor physical health of people with mental illness. West J Med. 2001;175(5):329-332. doi:10.1136/ewjm.175.5.329