Can Your County Be the Partner You Need to Solve Psychiatric Boarding?

Published May 03, 2017

About one in eight ED visits now involves a mental health or substance abuse disorder. Once screened and stabilized by an emergency physician, many of these patients endure long waits for a psychiatric consult or admission to an inpatient treatment facility. The results: crowded EDs, soaring costs, and prolonged distress to vulnerable patients and their families.

The ED team at Rideout Memorial Hospital believed they could do better for patients in crisis. Here's how a unique partnership between ED providers, telepsychiatry, and county health workers is providing faster, safer, and more humane care for psychiatric emergencies.

A Growing Need for Crisis Services

The Rideout Emergency Department is a 44-bed Level III Trauma Center located in Marysville, Calif. This busy ED serves over 70,000 patients annually from largely rural Sutter and Yuba counties. Since 2004, the department has been staffed and managed by Vituity.

Due to decreased funding and increased demand for local mental health programs, Rideout found itself treating more and more patients for mental health and substance abuse emergencies. The numbers of involuntary psychiatric patients rose 75 percent between 2015 and 2017, and total mental health visits rose from 40 per month to 145.

Often, these patients would be medically cleared but would then endure a long wait for a psychiatric evaluation. Those who were ultimately admitted were spending a median 25–27 hours in the ED, often under the care of a paid "sitter." "Psychiatric boarding" was costing the hospital an estimated $3 million a year while sorely exacerbating ED crowding.

It also wasn't ideal for the patients. Long waits in a noisy, chaotic environment only added to their stress. Many grew increasingly agitated as the hours wore on. A few lashed out with disruptive behavior and even violence.

The sad thing about all of this waiting was that it was often unnecessary. Patients who present to the ED in psychiatric crisis are twice as likely to be admitted compared to those with purely physical complaints. But it's likely that 70–80 percent of this population can be stabilized, discharged, and treated in the community.

"I find it strange and frustrating that this is the only illness (in EDs) where the default treatment plan is admission,” Scott Zeller, MD, Vice President of Acute Psychiatric Medicine at Vituity, told Hospital Peer Review.

The ED team, the hospital, and the county behavioral health department all agreed that things needed to change. So in 2016, they launched the Mental Health Emergency Collaborative. Sutter-Yuba is the first county mental health agency in California to partner with an ED in this way.

A Collaborative Solution

The collaborative takes an integrated team approach to mental health emergencies that involves:
  • Emergency medicine physicians, advanced providers, and nurses
  • Crisis workers from Sutter-Yuba Behavioral Health
  • Sutter-Yuba Behavioral Health's emergency psychiatrists
  • Vituity's telepsychiatry program

The goals of the collaborative are to provide faster, more effective treatment to mental health patients. Specifically, they aim to reduce the need for inpatient admissions by stabilizing patients in the ED. With early intervention, many patients can be safely discharged to continue treatment in the community.

To accomplish this, county mental health workers and stakeholders developed a crisis stabilization algorithm to guide evaluation and disposition. Separate versions were created for voluntary and involuntary patients.

The collaborative also benefited from the expertise of Zeller, who formerly headed the pioneering Psychiatric Emergency Services program at Alameda Health System in San Leandro, Calif. The Vituity Vice President regularly made the two-hour drive from the Bay Area to Marysville to help get the new program off the ground.

Finally, after months of preparation, the collaborative was ready to go live. Tremendous effort had gone into its creation. But could it really make a difference for patients?

A Fresh Approach to Psychiatric Evaluation

Today when a patient presents to Rideout's ED with a mental health emergency, the team swings immediately into action.
  • The emergency physician conducts a rapid screening on arrival and alerts the mental health team as appropriate.
  • A county crisis worker conducts an initial assessment and recommends a tentative clinical path (admit to an inpatient facility, evaluate further, discharge with support).
  • The ED team works to medically assess and clear the patient.
  • An emergency nurse, county crisis worker, and Vituity telepsychiatrist evaluate the patient according to the crisis stabilization algorithm.
  • When a patient requires inpatient admission, the crisis worker secures the necessary clearances, completes the paperwork, and arranges admission and transportation.
  • If the patient will be discharged, the crisis worker consults with the charge nurse to finalize a support and safety plan.
  • The county psychiatrist consults with the team as needed regarding final disposition. He or she also lifts involuntary psychiatric holds when appropriate.

With 24-hour support from county crisis workers and Vituity telepsychiatry, treatment can begin immediately. This expediency greatly reduces the probability of an inpatient admission. “If they need to, the patient can talk to a psychiatrist in minutes instead of waiting for a bed they might not even need," Theresa Hyer, RN, Rideout's Director of Emergency Services, told Hospital Peer Review.

Fast Care, Fast Results

Within six months, the collaborative was producing some amazing benefits for the patients, department, and hospital.
  • Median ED length of stay dropped from about 25 hours to 18 (for admitted patients) and 14 hours to 9 (for discharged patients)
  • The number of sitter hours required to manage boarded patients decreased — even as the total number of patients with mental health complaints rose
  • Use of restraints due to violent or disruptive behavior was cut by half (10 percent of patients to 4)

The program's benefits were also felt across the region. Fewer patients were admitted to mental health facilities, which saved the county money. It also freed beds and personnel for those most in need.

Finally, the collaborative was clearly the right thing to do for patients. It helped to reduce unnecessary admissions, keep patients comfortably at home, and connect them with community resources.

This spring, the Yuba-Sutter Chamber of Commerce recognized Rideout Memorial Hospital's efforts to improve mental health emergency care with the 2016 Business of the Year - Innovation and 2016 Rising Star awards.

Recognition is nice, but the Rideout ED team doesn't plan to rest on its laurels. Going forward, they hope to be a model for other hospitals that are struggling to provide timely, effective care to patients in mental health crisis.

“The best part about this is that it’s really treating the human needs of the psychiatric patient,” Hyer says.

Read more about the Mental Health Emergency Collaborative in this Hospital Peer Review article.

Partnering to improve patient lives

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