Quality of care for behavioral health patients in the ED has been dramatically improved at Rideout Regional Medical Center in Marysville, CA, with a program that aims to get professional help to people in need as soon as possible. In addition, the ED dramatically reduced its length of stay for these patients.
By serving mentally ill patients better, the hospital also benefits with less overcrowding in the ED, decreased violence from frustrated patients, and less need to warehouse patients until a doctor can see them.
Prior to implementing a program that involves telepsychiatry services, the Rideout ED struggled with the same issue seen in most hospitals across the country: Patients needing behavioral healthcare appeared in the ED often and would be cleared medically, but they then had to wait until a psychiatrist could see them, and that meant keeping them in the ED and dealing with disruptions or even violence from some patients, says Theresa Hyer, RN, director of emergency services at Rideout. Simply finding space for them to wait also was an issue and some would stay for days until they could be admitted to a mental health facility.
“Patients sat and waited and didn’t get a true mental health assessment from a psychiatrist until they were admitted to a facility,” Hyer says. “We did our best, but it wasn’t good for the patient and it was a functional problem for the ED.”
That was the situation in most EDs, says Scott Zeller, MD, vice president of psychiatry with CEP America, a company based in Emeryville, CA, that provides staffing and other services to EDs across the country. Zeller is the former chief of psychiatric emergency services of the Alameda Health System in California, where he led one of the busiest psychiatric EDs in the country, and he is past president of the American Association for Emergency Psychiatry.
“I find this strange and frustrating because this is the only illness where the default treatment plan is admission,” Zeller says. “But if you go to the ED with an asthma attack, they’re going to give you the treatment you need and send you home. We should be treating people in the ED and resolving their problems in the emergency setting, just like any other emergency.”
Most psychiatric emergencies can be resolved within 24 hours, Zeller says. The lack of beds, leading to backup and long waits, is because of the automatic decision to admit the patient, he says.
“If you admitted everybody who came to the hospital with chest pain, you’d run out of beds very quickly. But only 10-15% are admitted,” Zeller says. “There are similar numbers with psychiatry indicating that if you get these patients the help they need in the emergency setting, you’ll end up admitting only 20-30%.”
Rideout addressed the problem by making it possible for patients to be evaluated without delay by county mental health workers in the ED, and when necessary the patient can receive a full mental health assessment in the ED through telemedicine. The hospital contracted with a company that provides access to psychiatrists at all hours through telemedicine.
“The ED had become just a holding ground for psychiatric patients. Instead of waiting for that elusive mental health bed, we now use our county health workers to start the behavioral screening, and then if they need to, the patient can talk to a psychiatrist within minutes rather than waiting for a bed they might not even need,” Hyer says. “They might be able to get the patients on medications that will clear them and they don’t even need to be admitted.”
The county mental health workers and the telepsychiatry provider also work to develop a plan for a safe discharge back home, another process that previously would not have begun until the patient reached a mental health facility.
Hyer says the effects have been significant.
“It has taken between three and five hours off the length of stay for every single mental health patient, but on top of that is has improved the quality of care big time for those patients,” she says. “The mother of a long-time psychiatric patient came up to me and told me that she had never seen treatment like and just raved about the care he received in our emergency room. She said it was unlike anything she had ever seen before, and he had been to quite a few really well-known healthcare organizations.”
The improvement in turnaround time to discharge is a major benefit for the ED, Hyer says. The effect is felt throughout the ED because fewer mental health patients waiting in the ED means more staff, space, and other resources are available.
“Each one of those people require a sitter to stay with them to make sure they’re safe and the staff are safe, so all the resources are affected when you decrease length of stay,” Hyer says. “But the best part about this is that it’s really treating the human needs of the psychiatric patient. A lot times an emergency room will come up with ways to push people through quicker, but it’s not always getting them what they need. This gets you both benefits.”
The program relies on building a good relationship with county mental health workers, Hyer says. She encouraged and empowered them to assess and treat mental health patients with the same approach that the ED provides for physical illness or injury — timely assessment, treatment, and discharge or on to the appropriate place. Urgency is warranted sometimes because a person on the edge of a psychotic episode may actually need care just as quickly as someone having a heart attack.
“They see the patients the second they come through the door and get telepsychiatry involved right off the bat,” Hyer says. “These are master’s-level mental health professionals and they focus on spotting the patient with a mental health issue and providing care as quickly as possible, which is a big turnaround from when we had to just hold on to them a while, sometimes a long while.”
The county workers created a three-way pathway they use to make decisions from the beginning about how they will try to help the patient. They place each patient on a clinical pathway intended to result in the patient being discharged home, sent to a psychiatric bed, or given a medical bed because there are physical conditions also needing care.
Zeller says providing mental health access as quickly as possible changes everything.
“If you can get a psychiatrist to a patient with a psychiatric emergency quickly, you’re going to change the course of what’s happening and their chance of being able to go home goes through the roof,” Zeller says. “You’re giving them better care and taking a strain off the system.”
Getting the patient out of the ED as soon as possible can be the best quality care, even though the hospital benefits as well, Zeller says. A typical ED setting can be a bad place for a person with psychiatric issues to stay a while, he says.
“If you’re having paranoid hallucinations or are despondent and suicidal, two very common diagnoses, being in a noisy, confining ED is not going to be helpful for you and might make your situation much worse,” Zeller says. “The noises, sounds of people in pain, people rushing by, police present, lots of blinking lights and strange buzzers. In many cases, getting them out of that environment as soon as possible is in their best interest.”
The program has improved quality of care without the hospital investing much money, Hyer notes. The telepsychiatry service’s monthly fee is the biggest expense, with a fee for each encounter with a psychiatrist. The county pays their mental health workers and for some psychiatric care. The program has been in place for less than a year, so the financial benefit hasn’t been formally calculated yet.
“The win for the hospital is that even though there are some expenses, beds are opened up,” Hyer says. “Our normal turnaround time for a medical patient is only 140 to 150 minutes, so you can imagine how many times we could have moved a patient through a bed that a single mental health patient is occupying for four or five days.”
Quality of care for behavioral health patients in the ED has been dramatically improved at Rideout Regional Medical Center in Marysville, CA, with a program that aims to get professional help to people in need as soon as possible.
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