By Dorothy Brooks
Boarding has become a major problem for EDs because of the surge of patients presenting with psychiatric emergencies. Unfortunately, the number of psychiatric beds available has not changed much, according to Scott Zeller, MD, an assistant clinical professor of psychiatry at the University of California, Riverside.
“The estimate now is that about one in every seven patients presenting to the ED is there for a behavioral health emergency,” says Zeller, vice president of acute psychiatry at Vituity, a large, multispecialty, physician-led partnership headquartered in Emeryville, CA. “However, most EDs are still kind of following the plan for when the numbers were more like one in 20.”
Emergency clinicians might perform a medical screening exam and then try to refer the patient to somewhere else, most likely an inpatient psychiatric hospital. However, while the plan worked fine when there was an ample supply of psychiatric beds, the math does not add up today. “If we are all referring these patients for inpatient psychiatric care, and the inpatient beds are all full, it ends up with people staying for hours, and sometimes days, boarding in EDs,” Zeller says. “The ED is not an ideal location to be in if you are having a psychiatric crisis.”
How do EDs solve this problem? Zeller thinks part of the answer involves treating psychiatric emergencies on par with other medical emergencies, such as chest pain or an acute asthma attack. “Under any other medical emergency, when you come to the ED, we are going to do an initial evaluation. Then, if there is an emergency condition present, we are going to try to stabilize,” he says. “That is the missing part we have with BH emergencies.”
Zeller maintains that if treatment is initiated promptly, most patients with psychiatric emergencies can be stabilized and discharged, negating the need for a psychiatric bed, and freeing up resources in the ED. This belief formed the basis of a solution Zeller developed that dozens of EDs are modeling.
EmPATH (emergency psychiatric assessment, treatment, and healing) consists of a designated space where patients with psychiatric emergencies will be taken as soon as they are medically cleared in the ED. Here, they will be evaluated promptly and treated by psychiatric specialists.
“We initiate a treatment plan, start medicines when they are indicated, and try not to make a decision on disposition until we see how people respond to the treatment,” Zeller explains. “If the treatment is successful — and it is 75% to 80% of the time — then 75% to 80% of these folks are going to be able to be discharged in less than 24 hours.”
The benefit with respect to ED boarding is only about 25% of patients who would have been referred to inpatient psychiatric care now require that level of care, according to Zeller. “That means there are going to be fewer referrals and more beds available — hopefully, because we are not sending as many of the patients along as we did before,” he offers.
Further, Zeller notes even when patients in EmPATH do require a higher level of care, these individuals are more attractive to inpatient wards or facilities because of all the care that has been completed. “These patients are going to have comprehensive evaluations and treatment under their belts and a lot of documentation. It is going to be a real game-changer.”
Zeller says EmPATH is scalable to fit an ED’s specific needs and resources. “It can be done within a wing of an ED, or more commonly ... it is a separate observation unit, which is adjacent to the ED, elsewhere in the hospital, or sometimes elsewhere on the hospital campus,” he explains.
Since EmPATH units were introduced in 2016, several dozen have been created across the United States, although they do not all go by the EmPATH moniker. For example, the University of Iowa established an EmPATH unit at its academic medical center in 2018, but it is referred to as a crisis stabilization unit (CSU). The goals for the new unit were to improve access to mental healthcare, offload the burden of caring for psychiatric emergencies from the ED, and to alleviate the need for inpatient psychiatric care.
“Our hospital actually has [many] psychiatric patients coming to the ED. But because of a shortage of inpatient beds, especially for psychiatric patients, we were having to rely on transfers,” explains Sangil Lee, MD, MS, an emergency medicine physician at UI and co-author of two studies of the performance of the unit.
However, considering potential transfer hospitals often were dealing with the same situation, Lee notes patients with BH concerns were spending a long time in the ED. Once the new unit was developed, patients presenting with BH emergencies began shift to the CSU as soon as they were medically cleared in the ED. “Patients with suicidal ideation are the dominant patient population, but the CSU actually treats a lot of other [diagnoses],” shares Lee, noting these include psychosis, dementia, and acute anxiety.
Upon entry to the CSU, a psychiatrist will see the patient, then initiate a stabilization process that often includes starting appropriate medicines. “The psychiatry team has access to a psychotherapist and a social worker in the CSU. Brief psychotherapy can be provided, and the social worker can assist with placement following the CSU stay,” Lee says. “Often times, these patients stay overnight in the CSU, but a lot of them get stabilized so that they can be discharged home.”
Looking at data before and after the CSU was introduced, Lee and colleagues found the new approach shortened the average length of stay (LOS) in the ED for patients presenting with psychiatric emergencies from an average of 16.2 hours to just 4.9 hours. The CSU lowered inpatient psychiatric admission rates from 57% to 27%. The researchers also found the CSU reduced ED recidivism rates by 25%, produced a 60% improvement in outpatient follow-up, and shortened inpatient LOS for patients who did require inpatient psychiatric admissions following their care in the CSU.1
In a study of the economic impact of the CSU, researchers found it added $861,000 to the ED’s fiscal bottom line by opening department beds for non-psychiatric patients, preventing the need for sitters to observe psychiatric patients and reducing the number of patients who leave the ED without being seen.2 “At our institution, it took about a year to offset the [CSU] costs,” Lee reports.
Lee believes the abundance of psychiatric expertise in the CSU is key to the outcomes observed. “It is not just an on-call psychiatry resident or an advance practice provider who is caring for these patients. It is actually a staff psychiatrist who has [extensive] expertise in the care of psychiatric conditions. The care recommendations are more definitive,” he says.
Lee also says most psychiatric patients who present to the ED with severe symptoms can manage these conditions after spending the night in the CSU. “That stabilization process makes a difference,” he adds.
Another center that is based on the EmPATH approach is the Behavioral Health Crisis Services Collaborative (BHCSC) unit, which sits adjacent to the ED on the campus of Mercy San Juan Medical Center in Carmichael, CA. The BHCSC is a partnership between Dignity Health, the parent company of Mercy San Juan Medical Center, and Sacramento County. The unit provides multidisciplinary mental health evaluation and crisis stabilization for patients who present with psychiatric emergencies to several hospitals in the county, explains Celeste Sweitzer, LCSW, the northern division director of behavioral health at Dignity Health.
On average, the ED at Mercy San Juan sees 5,000 patients per month, 350 of whom are there for a BH concern.
“The ED was so busy that BH patients were often lined up in the hallways,” Sweitzer says. “The average time that patients stayed in our ED while waiting for an inpatient psychiatric facility [admission] was 33 hours.”
After implementing the model, the average time from initial triage in the ED to the BHCSC is 3.6 hours. “That means within four hours, patients are having a psychiatrist address whatever needs they have,” Sweitzer adds.
Further, while the volume of adult patients going to the BHCSC has expanded every year since the unit opened, the number of patients referred to inpatient psychiatric care has decreased steadily. “The patients going to [the BHCSC] are getting stabilized, opening up beds for the patients who really need to be in an inpatient psychiatric unit,” Sweitzer says.
Sometimes, there are many tasks to handle in 24 hours, especially if patients present with significant psychosocial issues or disparities that are triggering mental health crises. Here, Sweitzer says adding social workers to the unit can be invaluable. She notes social workers can stabilize patients faster when working alongside the psychiatrists and nurses on the team.
REFERENCES
1. Kim AK, Vakkalanka P, Van Heukelom P, et al. Emergency psychiatric assessment, treatment, and healing (EmPATH) unit decreases hospital admission for patients presenting with suicidal ideation in rural America. Acad Emerg Med 2022;29:142-149.
2. Stamy C, Shane DM, Kannedy L, et al. Economic evaluation of the emergency department after implementation of an emergency psychiatric assessment, treatment, and healing unit. Acad Emerg Med 2021;28:82-91.
Some departments have designated space where patients with psychiatric emergencies will be taken as soon as they are medically cleared in the ED. Here, they will be evaluated promptly and treated by psychiatric specialists. This model has prevented boarding, opened more beds, made transfers smoother, and produced better outcomes.
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