Patients who present to the emergency department (ED) with psychiatric complaints are 2.5 times more likely to be admitted than all other patients. What's more, they then wait three times longer in the ED for a bed.
But providers at the Billings Clinic ED, which serves patients in Montana, northern Wyoming, and the western Dakotas, believe these patients deserve better.
On April 17, 2018, the clinic opened an EmPath Unit, a service that provides short-term crisis stabilization and treatment to psychiatric patients across the Upper Midwest. The program was established under the leadership of Eric Arzubi, MD, Psychiatry Chair, with a grant from the Helmsley Charitable Trust.
"Given our country's mental health crisis, and given the challenges faced by patients in rural America, we have to stop thinking of psychiatry in traditional terms and start thinking outside the box," Arzubi told HelmsleyTrust.org.
"Traditional models are not working. The EmPath model offers a vastly improved patient experience, which we believe will lead to improved treatment outcomes and become a model practice in rural areas across the nation." EmPath stands for emergency psychiatric assessment, treatment, and healing.
In today's post, we'll look at how EmPath Units can promote early intervention and help to reduce inpatient admissions by up to 80 percent.
Mental health- and substance abuse-related ED visits have increased by 50 percent since 2006. Unfortunately, many ED providers don't feel confident managing this population. And less than 20 percent of emergency physicians have access to psychiatrist coverage.
Due to these and other factors, psychiatric patients are admitted to inpatient facilities in disproportionate numbers. However, the U.S. is experiencing an acute shortage of inpatient psychiatric beds. As a result, psychiatric patients wait an average of 12 hours for admission — three times longer than all other patients.
"Boarding" of psychiatric patients awaiting admission is expensive for the patient, hospital, and community. Research shows that patients whose care is delayed by boarding experience poorer outcomes. The noisy, chaotic ED environment tends to exacerbate distressing symptoms. Patients who become agitated may be restrained, sedated, and subjected to other coercive treatments.
ED boarding also hurts the health of the hospital. According to the American College of Emergency Physicians, 55 percent of EDs board psychiatric patients on a daily basis. Each of these delayed admissions costs the hospital an average of $2,264.
Finally, boarding aggravates ED crowding and increases wait times for all patients. When beds are occupied by boarded patients, EDs have less capacity to respond to emergencies, life-threatening injuries, and illnesses.
To meet the growing demand for behavioral health care, EDs need to adopt new delivery models. One of the most promising of these is the EmPath Unit.
Scott Zeller, MD, Vice President of Acute Psychiatry at Vituity, believes hospitals can meet the needs of psychiatric patients despite a shortage of inpatient beds.
"Indiscriminate hospital admissions will almost inevitably strain our healthcare resources," Zeller says. "After all, if we admitted every chest pain patient who presented to the ED, we'd run out of general hospital beds, too. As things stand, relatively few chest pain patients are hospitalized, because the focus is on prompt assessment and treatment."
Evidence bears Zeller out. Studies suggest that most psychiatric emergencies can be stabilized within 24 hours with appropriate treatment and do not require inpatient care.
"We need to focus on early assessment and prompt initiation of treatment for psychiatric emergencies — just as we would for chest pain or asthma attacks," Zeller says. "And while we're at it, for maximum therapeutic benefit, let's deliver this emergency psychiatric care in the most supportive, healing, and least coercive way possible."
Before joining Vituity, Zeller led the development of one of the first EmPath Units in Alameda County, Calif. Depending on the location, these services are also known as "psychiatric EDs" or "stabilization units." The practice of establishing regional EmPath units like the ones headed by Zeller and Arzubi is sometimes called the "Alameda Model."
An EmPath unit is a dedicated psychiatric emergency service that provides intensive, short-term care to all patients. The unit accepts all comers, including patients on involuntary holds and those considered too high-risk for community-based treatment.
Patients are transferred to the EmPath unit after receiving medical clearance in the ED. Upon arrival, they undergo team-based assessment by specialized providers, including psychiatrists, mental health nurses, and social workers.
For the next few hours, patients are treated, observed, and reassessed in a homelike space with comfortable recliners. Throughout their stay, they have opportunities to relax and recreate, move around, engage with staff and peer counselors, and seek privacy as needed.
EmPath Units have demonstrated many benefits for patients, hospitals and communities:
Historically, patients with mental health and substance abuse conditions experienced considerable discrimination and stigma. However, the public is becoming more aware of the cost of untreated mental illness — and is increasingly eager to support innovative treatment programs.
The Billings Clinic's EmPath Unit has received considerable support from the community, including financial support from organizations and local businesses. "People recognize this is a national problem," E. James Duncan, President of the Billings Clinic Foundation, told the Helmsley Charitable Trust.
Going forward Billings Clinic unit will be closely studied as a model for other rural areas. Innovations developed by Arzubi and his team could change the lives of the most acute psychiatric patients, who ironically remain some of the most underserved.
Originally published July 24, 2018.