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Recognizing an urgent need to improve the way patients with psychiatric needs are managed in the ED, the Institute for Healthcare Improvement has teamed up with Well Being Trust and nine participating hospitals to test and implement new approaches.
With limited care options, patients with psychiatric emergencies often present to the nearest ED where they may wait for hours, if not days, for some sort of disposition. The ED may get backed up as beds become scarce, wait times will increase, and all involved will be left frustrated and resigned that this scenario will repeat.
It’s happening in every region of the country. The call for solutions couldn’t be more deafening as frontline providers struggle to manage a patient population that many providers misunderstand and some even fear.
That’s why Boston-based Institute for Healthcare Improvement (IHI) has teamed up with Well Being Trust, a national organization focused on advancing mental, social, and spiritual health, to identify better approaches to the care of patients with behavioral health concerns in the emergency setting. IHI leaders established ED & UP, a learning community in which nine hospitals are working with expert faculty to test new ideas. Their goal is to better equip EDs and their community partners to meet the needs of patients with mental health concerns while also improving outcomes for patients and families.
In an online presentation, IHI leaders recently discussed what they have learned thus far from the project. Leaders included steps that administrators can take now to improve the way their facilities manage patients who present with psychological problems.
Scott Zeller, MD, the vice president of acute psychiatry at Vituity, is one of the faculty members working with ED & UP to formulate and test improvements. He noted that the dearth of mental health resources is contributing to the problem. “Even if [patients with psychiatric needs] are fortunate enough to have a psychiatrist or a clinician that they work with, they might call them up when they are having a difficult time and hear a voicemail that says ‘If you are having a psychiatric emergency, please hang up and dial 911 or go to your nearest ED,’” he explained.
However, Zeller noted that the nearest ED often is ill-equipped to work with such patients. These patients wait three times longer to be seen than patients with traditional medical concerns. “The staff in the ED spends tons of time trying to help these folks out, and get them the kind of treatment and dispositions they need. This interferes with their ability to care for other ED patients,” he said.
It is also important to consider financial implications. Psychiatric patients in the ED can cost hospitals more than $100 per hour in lost billing. The overall costs to the hospital are even greater, Zeller noted. “Each time a hospital boards a patient ... if you put everything together, [it costs] about $2,300,” he explained.
While the expense is high, the effect on a psychiatric patient who is boarded is far from optimal. Typically, such patients are just waiting for either a psychiatric evaluation or a psychiatric disposition, Zeller said. “Sometimes, these folks are [stationed] with a sitter in very close confines. Sometimes, they are strapped to a gurney in a hallway. Sometimes, they are in restraints. Many times, this is all going on without any kind of intervention or treatment,” he observed. “It can be very disruptive and very unpleasant for people having a psychiatric crisis. Sometimes, as a result, their symptoms get worse.”
Unfortunately, more of these types of patients are coming to the ED. Zeller noted that there has been a 55% increase in psychiatric patients visiting EDs in the past decade. In the same period, there has been a 414% increase in patients arriving for suicidal ideation.
“Boarding in and of itself can last a long, long time. It usually averages between eight and 34 hours for someone who is boarding in a regular ED. Sometimes, it can last for days and even weeks,” Zeller said.
What is the solution to such bottlenecks? There have been numerous calls in recent years for more inpatient psychiatric beds. However, Zeller argued that would be an unusual approach, as it would not be the default option for any other medical condition.
“If you come in with chest pain, high blood pressure, or an asthma attack, we are going to address that in the ED. We are going to find out what is going on, start treatment, and hopefully stabilize you in the ED, and get you back home,” he said. “But for some reason, in far too many EDs, the default treatment — if a person is having psychiatric symptoms — is to find him [or her] a psychiatric bed.”
Hospitalization for every patient with psychiatric symptoms is not a workable or affordable option, Zeller lamented.
“Even if we had tons of psychiatric hospital beds, we would use them all up if we were doing that,” he explained. “If you are at a place where the default treatment is hospitalization ... I can guarantee you that those psychiatric hospitals are having a lot of unreimbursed one- to two-day admissions where the insurers are coming back from Medicare and Medicaid saying that these persons didn’t really need to be hospitalized.”
Further, Zeller added that such a policy is disruptive for the patient and bad for the ED.
“It is just not a good situation for anybody,” he said.
Rather than looking for places to send all patients who present with psychiatric concerns, a better approach is to address the issues in the ED just like emergency personnel address most other medical problems, Zeller argued.
“What we found in our research is that the great majority of psychiatric emergencies can be stabilized in less than 24 hours in an emergency level of care,” he explained.
In fact, Zeller noted there are simple steps that EDs can take almost immediately to improve management of these patients. For instance, he recommended better training for emergency staff in behavioral health best practices so that personnel understand that psychiatric emergencies are, in fact, medical emergencies.
“These are people who are experiencing painful conditions that need our assistance,” he said. “If we can intervene appropriately, we are going to have phenomenal improvement and great outcomes.”
Zeller added that one focus of this training should be on eliminating the idea that people with psychiatric emergencies need to be treated in a coercive way, either with restraints or forced medication.
“Those things really draw out and create a lot of the boarding,” he said. “Once you put someone in restraints, or you have involuntarily medicated them, it is a lot more unlikely that your exit resources — psychiatric facilities — are going to be interested in taking them.”
Another innovation that can help EDs accelerate appropriate treatment to patients with psychiatric concerns is on-demand telepsychiatry, which has been initiated in many areas, Zeller noted.
“There is nowhere near enough psychiatrists to drive over to your site. We may be able to have psychiatrists come and see your patient almost immediately over high-definition video conferencing,” he said, noting there have been some good outcomes reported from such interventions.
Busier EDs that see four or more psychiatric patients a day might want to consider creating an emergency psychiatric assessment, treatment, and healing unit (also known as an emPATH unit), Zeller suggested.
“It is basically a separate section of the ED, or an adjacent section ... that is just for emergency psychiatric patients who otherwise might have been boarding in the ED,” Zeller explained. “It is a much more home-like, supportive setting with experienced psychiatric personnel to work with these folks for up to 24 hours.”
Instead of gurneys, patients sit in recliners. Patients can move about in an emPATH unit freely, Zeller explained.
“We are seeing amazing results with these units, not the least of which is that physical restraints and involuntary meds occur in less than 1% of patients,” he added.
Initiative leaders understand that improvements in the care of patients with mental health concerns require work in the ED, explained Mara Laderman, MSPH, a director at IHI and the content lead for the organization’s work in behavioral health. But, she added, leaders also know that improvements are needed in some of the levers upstream that are driving patients to the ED.
“We have developed a change package that is focused on the theory that we will have greater impact by intervening at multiple points ... than we can in working on isolated parts of the system,” she shared. (Editor’s Note: Learn more about the change package in the sidebar at the bottom of this page.)
Robin Henderson, PsyD, the clinical liaison to Well Being Trust and the chief executive of behavioral health for Providence Medical Group in Portland, OR, noted that emergency personnel typically respond quite differently to psychiatric trauma than physical trauma.
“Normally, when we are looking at someone coming in to the ED with a minor trauma like a broken arm or a broken finger, we will take them back and let them stay in their own clothes. We may let them have a family member with them. They keep things like their cellphone and their wedding ring,” she explained. “But when we have someone coming in, and they are hearing voices, or they may be actively psychotic, we will take those things that are a comfort to them ... we don’t understand the unintended consequences of our best intentions.”
Sometimes, such practices stem from an unfortunate event in the past that resulted in serious consequences, Henderson explained. For example, she recalled working in one ED that was the site of a suicide four years earlier. “They created an entire series of activities for every psychiatric patient who presented based on that one aberrant event,” she said. “It changed their entire culture.”
Henderson explained this kind of thinking and practice stem from a hospital culture where everybody is always looking to fix defects. For example, instead of acknowledging that a practice is working well 97% of the time, hospital staff will focus on the tiny percentage of times things did not go well, she observed.
“When we apply that same thinking to a trauma-informed culture, what we create are environments that are very based on fear, the false evidence that appears to be real as opposed to basic facts,” Henderson offered. “And 97% of the time, when a psychiatric patient presents to an ED, there won’t be violence, there won’t be harm to staff, and there won’t be a self-harm incident. Yet, we have created cultures, processes, and policies around the 3% of the time that [something bad will happen].”
To address this disconnect, Henderson advised ED leaders to review their policies to see what can be done to ensure that they are based on what actually happens in the ED with psychiatric patients as opposed to what might happen. She also suggested clinicians reevaluate their own perspectives. For example, instead of wondering what is wrong with a patient, think in terms of what happened to the patient or what matters to the patient, she said. These changes regarding thoughts, questions, and attitudes are the building blocks of a trauma-informed culture within an ED, Henderson added.
Vera Feuer, MD, the director of pediatric emergency psychiatry and behavioral health urgent care at Cohen Children’s Medical Center in New Hyde Park, NY, one of the participating hospitals in the ED & UP program, noted that, on average, U.S. children are hospitalized more frequently for psychiatric issues than for medical problems.
“In most of the country, kids get seen either by adult emergency medicine providers or psychiatrists. Only a few places have pediatric psychiatric expertise present,” she explained.
This frequently results in adult-level concerns about safety, which leads to overuse of inpatient resources. Another problem, according to Feuer, is that kids are sent to EDs often purely because there is no outpatient alternative available. “Let’s say a child draws a picture of a person hanging from a tree [at school], and nobody is sure what that means. The child might end up in the ED for a suicide assessment. [He or she] might be right next to a child who is there for a very different and much more serious reason,” Feuer explained. “In pediatrics, in many ways, the solution ... is providing access to expertise quickly in an ambulatory setting for those kids who don’t necessarily need the ED, but require an assessment.”
To address this problem, Cohen Children’s Medical Center is developing an urgent care program that is staffed by a child psychiatrist.
“It allows immediate access to expertise that is often needed when schools or therapists have concerns about kids, and [those kids] need to see a physician,” Feuer said. “It helps to avoid revisits to the ED. If there are issues that come up for the kids that we see in the ED, we have them come to urgent care for follow-up. If they are not in care and need the transitional space, it can also help avoid an inpatient stay or serve as an alternative.”
As part of the ED & UP collaborative, Feuer explained that the hospital is working to better educate patients, families, and hospital staff on how to manage things like agitation and other psychiatric issues while minimizing the use of coercion and medication. Also, Cohen Children’s Medical Center is collaborating with primary care physicians, schools, and community partners to establish streamlined referrals and provide more overall wraparound care for families.
Financial Disclosure: Physician Editor Robert Bitterman, MD, JD, FACEP, Nurse Planner Nicole Huff, MBA, MSN, RN, CEN, Author Dorothy Brooks, Editor Jonathan Springston, Editor Jill Drachenberg, and Editorial Group Manager Terrey L. Hatcher report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.