In April 2018, NPR reported the story of a 22-year-old psychiatric patient who was escorted out of a Baltimore emergency department (ED) on a cold January night. The woman was visibly distressed, disoriented, and wearing only socks and a gown when security personnel left her at a bus stop.
The incident sparked outrage after a video captured by a concerned bystander went viral. But as the patient's mother told NPR, her mistreatment could easily have gone unreported.
The NPR story shed light on both the plight of patients in psychiatric crisis and the struggles hospitals face in caring for them. Until recently, most patients presenting with mental health and substance abuse emergencies were admitted to inpatient psychiatric facilities. Often, this required patients to wait many hours in the ED for an inpatient bed.
Fortunately, new models of care are emerging that help both patients and hospitals to relieve the burdens of long ED stays and unnecessary hospitalizations. In this post, we'll examine three ways that hospitals are transforming psychiatric emergency care.
While the Baltimore incident represents an extreme case, many EDs find it challenging to provide timely, appropriate care for a growing number of psychiatric patients.
Patients with mental health and substance abuse complaints are presenting to EDs in record numbers. Substance abuse-related ED visits have doubled since 2004. Meanwhile, ED visits immediately following a suicide attempt have risen by a startling 414 percent since 2006.
Unfortunately, ED providers aren't trained to treat and manage complex psychiatric illnesses. Less than 5 percent of questions on the American Board of Emergency Medicine certification exam focus on behavioral health. What's more, less than 20 percent of emergency physicians report having access to an on-call psychiatrist for consultations.
Providers' beliefs and biases can also impact care. "Patients with addiction issues are some of the most challenging we treat in the ED," says Stacie Solt, MD, an emergency physician who is fellowship trained in addiction medicine. "Their problems can be intimidating and overwhelming. It's easy to shy away from them or write them off, especially when they come back over and over."
Compared to all other patients, psychiatric patients are 2.5 times more likely to be admitted to an inpatient facility. This trend is driven by a number of factors, including:
Meanwhile, many areas of the country are experiencing a severe shortage of inpatient psychiatric beds. As a result, admitted psychiatric patients wait an average of 12 hours in the ED — three times longer than patients admitted with physical complaints.
Too often, these care delays lead to poor outcomes. The noisy, chaotic ED setting can increase patients' distress, increasing the likelihood of aggression. Providers often respond with coercive treatments like restraints and sedation that upset patients and extend ED length of stay.
Extended "boarding" of psychiatric patients is extremely costly. For every hour the patient occupies an ED bed, the hospital loses $130 in opportunity costs alone. The per-episode cost of boarding averages $2,264. Boarding also contributes to ED crowding and creates longer wait times for all patients, including those with life-threatening conditions.
Providers and administrators often blame psychiatric boarding on the shortage of inpatient beds. However, Scott Zeller, MD, Vice President of Acute Psychiatry for Vituity, says it's time to challenge that assumption.
"Psychiatric patients are the only population for which admission is the default treatment," he says. "If we hospitalized every patient who came into the ED with chest pain, we wouldn’t have any med-surg beds left either."
ED providers generally try to stabilize and treat patients with physical complaints before making an admissions decision. According to Zeller and other experts, it's time to apply this approach to psychiatric emergencies.
Research suggests that the vast majority of psychiatric emergencies resolve within 24 hours. Hospitals can therefore decrease admission rates by shifting the paradigm toward early assessment and treatment.
It's also important to recognize that the chaotic ED may not be the most therapeutic environment for patients with mental health and substance abuse disorders. Many of these patients benefit more from calm settings where they are free to move and seek support or privacy as needed.
In order to deliver on the promises of early intervention and patient-centered care, hospitals are increasingly drawing on three models:
Telepsychiatry services connect ED providers to board-certified consulting psychiatrists on demand. Through secure video conferencing, the psychiatrist can evaluate the patient and make treatment and disposition recommendations.
Telepsychiatry has been shown to reduce admission rates, improve outcomes, and satisfy patients. (Many patients actually prefer it to a live consult.) This approach is especially cost-effective for lower-volume sites that can't afford to pay an on-call psychiatrist.
More and more hospitals are establishing dedicated facilities or units for intensive, short-term psychiatric care. These services are sometimes called "psychiatric EDs" or "crisis stabilization units." At Vituity, we call them "EmPath Units," which stands for "emergency psychiatric assessment, treatment, and healing."
EmPath Units provide patients with a calm, comfortable setting to rest and recover. Providers can begin treatment and observe the patient's response for up to 24 hours before making a decision on admission.
EmPath Units are staffed by a team of psychiatrists, nurses, social workers, and peer counselors who form therapeutic bonds with the patients. Many hospitals also use telepsychiatry to cover gaps in staffing.
Dr. Zeller directed one of the nation's first EmPath Units in Alameda County, Calif., and has helped to establish similar units around the country. Almost every one of these units discharges 70 to 80 percent of its patients within 24 hours, freeing up inpatient beds for those most in need. Some of these programs have all but eliminated the practice of psychiatric boarding at local EDs.
With supportive training, ED providers can become much more effective at assessing and treating patients with psychiatric conditions. This in turn improves patient flow, reduces the demand for consults, and improves discharge rates.
In addition to improving clinical care, training can foster greater empathy for psychiatric patients. "Like patients with physical illness, agitated patients want to get better," Zeller says. "These people are suffering and need help, even if they don’t always act like they want it."
Zeller recently partnered with the Depression and Bipolar Support Alliance to produce a video training on de-escalation techniques.
"De-escalation helps patients who really need help getting care to be healthy and safe," he says. "It also gives ED staff the techniques to provide the best care for their patients. When providers have the tools they need to help, they feel safer and more satisfied in their roles."
For many patients, the ED is the only source of mental health care available. New patient-centered care models can therefore have a huge impact on patient lives. "I've personally seen patients make remarkable recoveries after struggling for years and making dozens of ED visits," Solt says.
Incidents like the one reported in Baltimore are disheartening. But there are also many success stories coming out of the nation's EDs.
"We had a former patient stop by on both Thanksgiving and Christmas last year with treats for the staff," Solt says. "He told us, 'You know, a year ago I was on my deathbed with liver failure because I was drinking so much. And you helped me get into a program and treatment.
'Now my health is much better. I'm celebrating another holiday, when a year ago, I didn't know if I was going to survive another few months.'
Really," Solt says, "I just can't think of a better thank you than that."
Visit Vituity's website to learn how innovative approaches to emergency psychiatric care can help your hospital:
Originally published June 12, 2018.