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Waiting room crowding and agitation in a dedicated psychiatric emergency service

Rif S. El-Mallakh, MD

Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, USA

Amanda Whiteley, MD

Seven Counties Services, Inc. Louisville, KY, USA

Tanya Wozniak, MD

River City Psychiatry, Louisville, KY, USA

McCray Ashby, MD

River City Psychiatry, Louisville, KY, USA

Shawn Brown, MD

Louisville Behavioral Health System, Louisville, KY, USA

Danya Colbert-Trowel, MD

Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, USA

Tammy Pennington, MD

River City Psychiatry, Louisville, KY, USA

Michael Thompson, MD

River City Psychiatry, Louisville, KY, USA

Rokeya Tasnin, MD

Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, USA

Christina L. Terrell, MD

Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, USA

BACKGROUND: Emergency department crowding is a growing problem that impacts patient care and safety. The effect of crowding has not been examined in emergency psychiatric services.

METHODS: The association between patient census and use of restraints, seclusion, and anti-agitation medications as needed was examined for 1 month.

RESULTS: A total of 689 patients were seen in 31 days. The average hourly census was 6.8±2.8 (range 0 to 18). There were 33 incidences of seclusion or restraint and an additional 15 instances of medications administered for agitation. The use of seclusion, restraint, or medication for agitation was significantly associated with census (r2=0.3, F=5.47, P=.036).

CONCLUSION: Crowding in emergency psychiatric waiting rooms may increase the need for seclusion, restraint, or medications for agitation.



Emergency services utilization appears to be increasing with consequent crowding.1 Crowding in emergency departments causes delay in patient care and can adversely affect patient outcome2 with delays in addressing patients’ needs.3 Crowding had multiple etiologies1,2 and does not resolve with single act solutions such as physical space expansion.4

Crowding in emergency psychiatric services (EPS) also is a growing problem. Within a decade, EPS visits nearly have doubled from 12% in 1990 to 1992 to 20% in 2000 to 2002,5 while psychiatric services have become less available.6 At the University of Louisville Hospital’s EPS, the city’s only 24-hour psychiatric emergency room, the number of patients evaluated has risen from 5,600 in 2003 to 6,350 in 2007, a 13.4% increase. Because of the potential for agitation and violence and the need to maintain safety are among the most important issues in psychiatric units, we examined the use of seclusion/restraint and anti-agitation medication as a function of crowding.


Study design

We conducted a retrospective review of data collected for quality assurance. One month was examined. Because the data were collected for quality assurance purposes, a human studies committee review is not required.

Study setting and population

The study was performed in the EPS of a university hospital of a medium-sized US city (approximately 1,000,000 people). This EPS is the only 24-hour psychiatric emergency room in the city and receives most of the emergent psychiatric patients. Of the approximately 600 patients seen each month, approximately 14% are brought in by a legal involuntary commitment (known as Mental Inquest Warrant in Kentucky).7 The city also has a police-based crisis intervention team, which accounts for approximately 16% of all EPS patients.7 The waiting room measures 257 ft2 and contains 11 chairs. Additionally, there is a small nursing unit with 5 beds and 1 seclusion room. Patients occupy these spaces until they are discharged.

Study protocol

Data regarding census, use of restraints or seclusion, and use of as needed anti-agitation medication were prospectively collected for 1 month.

Data analysis

Data were analyzed with descriptive statistics and regression analysis utilizing StatView software (SAS Institute Inc., Cary, NC, USA, copyright 1992).


A total of 689 patients were seen in the EPS over 31 days. The average hourly census was 6.8±2.8 (range 0 to 18). There were 33 incidences of seclusion or restraint, during which anti-agitation medication may or may not have been administered, and medications for agitation were administered an additional 15 times for a total of 48. The combined use of seclusion, restrain, or medication for agitation was significantly associated with census (FIGURE 1) (r2=.3, F=5.47, P=.036), although seclusion/restraint alone was not related to census (r2 =.0003, F= .003, P=.95), nor was anti-agitation medication alone related to census (r2=.0002, F=.02, P=.97).


The relationship between the use of seclusion/restraint or anti-agitation medication and total census (best fit graph)


The current data suggest that in the studied EPS facility, at a threshold of approximately 13 patients, aggression and agitation increase when measured by the need to use restraint, seclusion, or pharmacologic agents (FIGURE 1). Upon reaching that threshold, the rate of use of nursing safety interventions increases markedly. This threshold probably is unique to the environment in which the study was done.

Crowding is known to increase aggression in other mammals. For example, rhesus monkeys will display aggression with increased subject density, and the animals who are the target of this aggression are the more behaviorally inhibited individuals.8 Crowding in inpatient psychiatric units is associated with aggression.9 In 1 study, most incidents were of verbal aggression and were directed at other patients or at staff when they set limits. Violent incidents were more likely to be perpetuated by more severely ill individuals.9 This variable may explain why crowding was not associated with aggression or violence in a medium security jail.10 Alternatively, if the observation of a threshold noted in the current study is a general phenomenon, it may be that the negative study by Hardie10 simply had not achieved that crowding threshold.

As funding for psychiatric services becomes more scarce and services more limited,6 crowding in emergency psychiatric units will continue to increase.5 This will bring additional stressors that are likely to adversely affect the quality of care for all patients. The current study only focused on safety and nursing interventions to maintain safety, but other aspects of patient care are likely to be affected, as they are in medical emergencies.3

The current study has limitations. The retrospective design prevented us from examining the incidences in more detail. Additionally, we describe an association between crowding and the need of nursing safety intervention, but cannot document a cause-effect relationship. Finally, we could not determine the severity of illness of individuals requiring nursing intervention for safety.


Despite these limitations, our data document a relationship between crowding and the need to maintain safety through use of seclusion, restraint, or calmative medication. The relationship appears to display a threshold phenomenon, whereupon once the threshold is reached, the use of interventions increases markedly. Attention to crowding and attempts to reduce crowding may be associated with better patient outcomes.

DISCLOSURES: Dr. El-Mallakh is a speaker for AstraZeneca, Bristol-Myers Squibb, Merck, Novartis, and Pfizer, Inc. Drs. Whiteley, Wozniak, Ashby, Brown, Colbert-Trowel, Pennington, Thompson, Tasnin, and Terrell report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

ACKNOWLEDGEMENTS: No financial support was provided for this study.


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CORRESPONDENCE Rif S. El-Mallakh, MD Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, MedCenter One, 501 East Broadway, Suite 340, Louisville, KY 40202 USA E-MAIL