In the Know

Emergency Rooms Adapt for Patients with Mental Health Needs

08.13.2018 PSJH Network

There’s a new model for hospital emergency rooms and given the pressures on the health care system it appears to have arrived just in time.

Most hospital emergency care centers are ordered chaos — a kid with a broken leg and a worried parent in one room, a mountain biker with a concussion in another, a muttering and bleeding homeless man in a third.

But at St. Joseph Hospital in Orange — one of the busiest ERs in Orange County — there now are two separate emergency areas that administrators say allows all patients to receive faster triage while providing mentally ill patients with tailored, comprehensive treatment.

When a patient is admitted, a mental health assessment is made. Those with mental illness are treated for their physical condition, but also are seen by a special team that includes a social worker, nurse practitioner, a psychologist and a psychiatrist.

Emergency and behavioral health treatment at St. Joseph is expected to improve even more with a combined $13 million-plus fundraising effort to expand facilities for mentally ill ER patients.

The needs of the mentally ill are different, explains Glenn Raup, executive director of emergency nursing and behavioral health services at St. Joseph. Yet few if any other hospitals in California, he reports, offer a separate ER for mentally ill people.

In regular emergency care centers, bright lights help doctors and nurses make fast diagnoses, orderlies move swiftly, people confer in hallways, machines beep and blink.

But for many mentally ill patients, noise, lighting and movement can be frightening.

St. Joseph’s new ER facility for mentally ill patients is like no other. Lighting is low, machines work in a whisper, caregivers speak in hushed tones, visitors are limited.

There’s also a very sturdy guard.

But transforming hospital care doesn’t come easy or cheap. If St. Joe was a retail store, creating an ER for the mentally ill would be called a loss leader.

Instead of being a money maker, the move took morality and moxie. It also took vision.


Raup is either obsessed with degrees or he loves learning. Spend some time with this man who recently rappelled off a 16-story building to raise funds to fight addiction and it’s clear it’s the latter.

The director also loves serving and, yes, challenges.

He’s been on the front lines as well as behind a desk. He’s performed an emergency tracheotomy with a pen. The patient lived. And he’s massaged a heart that stopped beating during surgery. The patient died.

Still, the experiences, however painful, informed both his thinking and his confidence. The registered nurse realized, “I can do this.”

He admits to two master’s degrees and a Ph.D. Before becoming an administrator at St. Joe, he was a police officer in Kansas, a registered nurse, a SWAT paramedic in Houston and a college dean in Colorado.

Raup and his wife announced their move to Denver with relatives by Skyping — from the front porch of the house where his relatives lived.

But the reason for the move was serious. Raup’s brother, Greg, was diagnosed with severe multiple sclerosis. He died two years later at age 40.

Now 50, Raup spends much of his time thinking about the larger issues of treating people. “We take people from a death situation, to a life situation,” he says. “But the bigger question is why are these people coming into my ER?

“ER is an example of the total failure of the whole system. All social ills end in ER.”

Pause for a moment and ponder his points.

Raup isn’t saying ERs are a failure. Rather, he is saying that if things were designed better — perfectly, really — health care wouldn’t be handling so many emergencies.

Consider cellphones. Yes, cellphones.

The inventors and designers of cellphones don’t consider the spiritual and mental health impacts of people texting rather than talking, Raup says. They don’t take into account the physical hazards of texting while driving.

If cellphones were designed differently, there could be fewer patients in emergency rooms.

“We need to look upstream,” Raup explains, “to where all these failures occur.”

Stay with me here because it is this kind of thinking that led to St. Joseph Hospital agreeing to revamp triage.


When a typical patient arrives in the ER with chest pains, the job is to treat the problem. Raup says, “He’s one and done.”

But diagnosis and treatment for a mentally ill patient often is more complicated. “There’s a psychiatric component,” he says. “Some have anger, others are bipolar, others have eating disorders.”

Before the new ER facility was built, regular physicians treated all patients. Now, mentally ill people — homeless as well as people with homes — are treated by a special team.

Administrators say this allows physicians in the main ER to focus on the stream of strokes, heart attacks and trauma.

Raup walks through the area for mentally ill patients. There are eight beds with another three-dozen beds elsewhere in the hospital for longer-term mentally ill.

Four beds are empty on this day — an example of swift, efficient care, Raup offers. “Staff,” he says, “are rocking it.”

Raup also points out it is mid-morning, a typically quiet time of day. ERs heat up in the afternoon and peak hours usually run from about 8 at night to early morning.

About 5 percent of ER admissions involve mentally ill patients, and an estimated 80 percent to 90 percent are treated and released. Yet the numbers are staggering.

Raup reports that St. Joe averaged 330 mentally ill patients a month before the new facility was built. Since it opened, that number has jumped to 420 patients a month because of the shift in function.

“I’m still band-aiding,” the director admits.

Getting the facility up and running hasn’t been easy. Along with grants and the fundraising campaign, there also had to be a cultural change for separating out mentally ill patients.

“In some places there’s a philosophy of, ‘Build it and they will come,’” Raup allows. “I say, ‘Build it because they are already here.”

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Article originally appeared in the Orange County Register by David Whiting. Photo by Mindy Schauer, Orange County Register/SCNG.

Categories: Mental Health, Innovation