EXECUTIVE SUMMARY

Elliot Hospital in Manchester, NH, has unveiled a new $1.5 million psychiatric evaluation unit within the confines of its ED to boost resources and access to care for patients in psychological distress. The center is designed to offer an atmosphere more conducive to emotional healing. Administrators note that the added resources also should help ease crowding and boarding at the level II trauma facility.

  • The 1,780 square-foot facility includes a vestibule where staff can screen patients and visitors, six beds, a bathroom and shower to address the hygiene needs of patients who are experiencing long lengths of stay, and a separate interview/family room.
  • The unit is equipped with windows and plenty of natural light to create an area that is calmer and quieter than a traditional ED environment. The unit is heavily monitored with video and security 24/7.
  • Staff with behavioral health expertise take care of patients who are referred into the unit following triage and a medical screening exam in the main part of the ED.

Like most EDs across the country, Elliot Hospital in Manchester, NH, receives a steady stream of patients who present with behavioral health concerns.

“The census of our ED is about 60,000 patients [per year],” observes Matthew Dayno, MD, FACEP, associate director of emergency medicine at Elliot Hospital. “We are a level II trauma center. It is a busy ED in more of a central, urban environment that has a significant volume of behavioral health patients.”

However, even with some psychiatric resources on site, behavioral health patients tend to wait three times longer for a disposition than patients with traditional medical needs, a problem that contributes to crowding, boarding, and other ills. Further, administrators note that the atmosphere of a busy ED is hardly conducive to emotional healing.

“You go to the ED because you are anxious or depressed, and the environment is chaotic,” notes Heidi St. Hilaire, MSN, CNL, BSN, RN-BC, clinical nurse manager of adult behavioral health at Elliot Hospital. “People are coming and going with testing and emergencies.”

To address such concerns, the hospital has just opened what it calls a psychiatric evaluation unit within the confines of the ED, a 1,780 square-foot space that is designed specifically to meet the needs of patients who are psychologically distressed.

The new $1.5 million space contains a vestibule where staff can screen patients and visitors before they come into a safe area. There are six beds to accommodate patients, and the unit is equipped with a bathroom and shower.

“We find that patients in New Hampshire are staying longer in the ED, so we need to take care of their hygiene needs,” St. Hilaire says. “We also have a separate interview/family room where we can talk privately with family or do meetings with family and the patients. The family room is also a place that we will use for basic group sessions.”

The walls in the rooms of the unit are covered with a metal coating that makes them softer or squishier than traditional walls, although not in a way that is obvious or stigmatizing, St. Hilaire stresses. “If someone gets angry or punches the wall, it won’t hurt their hand as much,” she says. “These walls are more durable, and we won’t have to repair them as often.”

Further, St. Hilaire stresses that designers took care to ensure the inclusion of windows in the unit. “There is a large window in the family room. Four of the bedrooms have windows,” she says, noting that natural light can help improve patients’ emotional health.

With the new unit, psychologically distressed patients can be brought to an area that is quieter and calmer, St. Hilaire notes.

“We can control what is happening in the common areas, and it is safe,” she says. “It is highly monitored with video cameras and security.”

Finding the square footage to accommodate the new unit in the midst of a busy ED was difficult, Dayno acknowledges.

“We actually had to move administrative offices for nursing leadership out of the ED to a different area just outside the department,” he says. “We were restricted by square footage in terms of how the project was going to proceed. We had to make sure we were blending our objectives in terms of what we were trying to do.”

For instance, at the same time the ED was setting up the unit, the department was starting a physician-in-triage model for the general ED population. Administrators had to look at design and flow and ensure the unit processes would fit into the larger plan.

“It is much more of a team approach in terms of the process with emergency medicine, behavioral health, psychiatry, and then our community resources,” Dayno says.

Find Clinicians With Right Skills

To be sure, the new unit is not just about space. The hospital has added specialized nursing staff so that nursing ratios in the ED have improved. The care provided in the new unit is attuned more specifically to behavioral health patients who are waiting longer in terms of their disposition, Dayno explains.

“This is very important not only to the ED patients in that area, but also specifically to the entire environment of the department. We are trying to take care of those patients ... and they may be there for multiple days,” he says.

In fact, finding personnel with the right behavioral health expertise was one of the biggest challenges involved in opening the new unit. “Workforce is always an issue, and human resources had to do a lot of recruiting to find those specialized nurses,” St. Hilaire reports. However, she adds that there was no pushback from a financial standpoint, and that ED staff members have been very supportive of the initiative.

All patients still go through the standard triage process. They will receive a medical screening exam and visit with an emergency provider in the main ED. There is no set formula for which patients will be directed to the new unit for care, St. Hilaire explains.

“It is really day-to-day triage in terms of who we put in that area,” she says. “We tend to choose the patients who are higher acuity or have the likelihood to be violent because we want to put them in the safe area.”

Further, patients can be moved in and out of the unit based on their own needs as well as the needs of the ED. For example, St. Hilaire notes that if the patients who are currently in the unit are calm and doing well, they may be moved back to the main ED to accommodate other patients who come into the ED in an agitated state.

“The unit has specialized behavioral health nurses who are attuned to managing agitation and de-escalating patients,” she says. “We also have counselors, we have psychiatrists, and we have security there 24/7.”

Other factors can figure into placement decisions as well, Dayno observes.

“There may be patients who present with acute depression, but they may also have a self-induced medical overdose,” he says. “At that point during the triage process, we are treating the acute medical need with regard to the overdose. When [patients] are stabilized, they may be moved into the behavioral health area.”

Typically, placement decisions are determined during a discussion between the charge nurse on the medical side of the ED and the charge nurse on the behavioral health side, St. Hilaire says.

While the new unit has not been designed for patients with substance use disorders, there may be patients assigned to the unit who are dual diagnosed.

“We may take a patient who has bipolar disorder and is also using substances,” St. Hilaire offers.

However, if the diagnosis is primarily a substance use disorder, the patient will go into the general ED and receive his or her evaluation. If the medical provider determines the patient requires detoxification, the patient may be admitted to the ICU, St. Hilaire says.

“The decision point with substance use is often with the provider as far as what the patient needs,” she says. “In the psychological evaluation unit, the patients are already pretty much medically cleared. When they require detox, it needs to be [cases] where it is mild to moderate, where the patients are just getting oral medications, or there is IV hydration.”

Integrate Resources

The types of diagnoses that St. Hilaire anticipates treating in the new unit include depression, bipolar disorder, schizophrenia, anxiety disorder, and personality disorder.

“We work very closely with the local mental health center. In fact, some of the clinicians from the center’s assertive community treatment teams are credentialed to come and see their own patients in our ED. We do get some significant, persistently mentally ill patients that are being managed in the community,” she says.

In addition, crisis counselors from the community mental health agency are embedded in the ED. These individuals help arrange for strong outpatient treatment when behavioral health patients do not require inpatient care.

“Having access to [these counselors] and getting them plugged in to the ED ... helps the emergency physician feel comfortable that a discharge plan is going to stand up,” Dayno explains.

Administrators will be looking at quality metrics to measure the new unit’s performance.

“We are hoping we will have improved patient satisfaction for our population. We also want to decrease the use of restraints and to decrease assaults,” St. Hilaire says. “We want to prevent [escalation] before it even gets to the point that we are having to use restraints or [respond to] assaults.”

The ED also would like to reduce the length of stay (LOS) of behavioral health patients, but that will be challenging, St. Hilaire acknowledges.

“What we know is that a medical patient goes through the ED in three to five hours, and it takes a behavioral health patient 14 to 17 hours,” she says. “We have had patients get stuck in the ED while they are waiting for a bed in our state hospital. Those patients can stay with us for three days to three weeks. When we talk about LOS, we are looking at decreasing the weeks or the days versus the hours.”

While more than two dozen inpatient beds are available for psychiatric patients at Elliot Hospital, many patients are waiting for admission to other inpatient psychiatric facilities. However, with the specialized care provided in the new unit, there is the potential to improve the treatment and outcomes for behavioral health patients. For example, St. Hilaire notes that the status of an involuntary patient who comes into the unit can improve during the ED stay.

“We will be giving the patient medications and treating him for a few days,” she explains. “Sometimes, the acuity changes, and we can send him to a voluntary facility. Sometimes, [such patients] get better, and we can discharge them to the community.”

SOURCES

  • Matthew Dayno, MD, FACEP, Associate Director, Emergency Medicine, Elliot Hospital, Manchester, NH. Phone: (603) 669-5300.
  • Heidi St. Hilaire, MSN, CNL, BSN, RN-BC, Clinical Nurse Manager, Adult Behavioral Health, Elliot Hospital, Manchester, NH. Email: SFier@Elliot-HS.org.