EXECUTIVE SUMMARY

ED & UP, an initiative of the Institute for Healthcare Improvement, has been testing changes intended to improve the care and management of patients who present to the ED with behavioral health (BH) concerns. Among the early findings is recognition that providing trauma-informed care to these patients is critical to any improvement effort. Further, experts note EDs should find ways to provide early treatment to these patients rather than just focusing on ways to transfer them elsewhere.

Over the last decade, there has been an enormous increase in the number of patients presenting to the ED with BH concerns. Studies suggest that, on average, roughly one in every six patients presents with a BH emergency as their chief complaint.

The traditional thinking has been that it is not the ED’s role to work with these patients. Thus, the focus has been on finding an inpatient bed or treatment elsewhere, which leads to long lengths of stay and boarding problems.

Experts note the great majority of psychiatric emergencies can be resolved in less than 24 hours if one starts treatment right away.

After implementing a trauma-informed care approach at its ED in Newport Beach, CA, Hoag Memorial Hospital Presbyterian saw several improvements, including a 50% decrease in violent incidents.


Boarding continues to be a major issue for EDs across the country faced with increasing numbers of patients who present with behavioral health (BH)-related emergencies. Many of these patients sit for hours or days in the ED awaiting transfer to another facility, often without receiving treatment for their concerns. Meanwhile, other patients wait longer for care because of limited bed availability.

This problem is so widespread that the Institute for Healthcare Improvement (IHI) has spent the last 18 months collecting expert input on the issue and working with eight hospital systems to pilot improvements in the way BH patients are managed in the emergency setting. (See sidebar box at end of this article.) The creators of the initiative, called ED & UP, are readying the results of this effort so that other EDs can integrate the lessons learned into their own settings.

In advance of this report, several participants united to share some of their early findings in an IHI presentation entitled “The Benefits of Behavioral Health in the ED” on Nov. 14, 2019. While the experts highlighted a few steps that EDs can take to improve the way they manage their BH patients, they cited a change in culture as perhaps the most pivotal to achieving real progress.

Consider the Numbers

While most EDs seek to address their boarding problems by finding new and better ways to transfer these patients out of the emergency setting more quickly, it is a flawed approach when one considers the number of patients involved, according to Scott Zeller, MD, vice president of acute psychiatry for Vituity Healthcare, a multispecialty medical partnership based in Emeryville, CA, said during the IHI session.

“What we are seeing is an enormous increase in people with [BH] emergencies coming to the ED. It has gone from where it may have been something like one in every 20 patients a few years back to where, in some more recent studies, ... one out of every six patients is coming into the ED for a BH emergency as their chief complaint.” For instance, the number of people presenting to the ED for suicidal ideation or following a suicide attempt is up by more than 414% over the last decade, Zeller noted. This is a problem, considering the traditional thinking has been that it is not the ED’s role to work with these patients. Such patients might be provided with sedation, but then the approach would be to try to find them an inpatient bed, Zeller explained.

“When there were plenty of inpatient beds available, maybe that approach made sense, but currently it doesn’t make any sense at all,” Zeller stressed. “What is happening is psychiatric patients are staying in EDs often without any treatment at all, just waiting for transfer to a psychiatric facility or a psychiatric hospital. This is a long length of stay. Depending on where you are around the country, it could be anywhere on average from eight hours to 30 hours. Sometimes, we hear of patients waiting weeks in EDs for a transfer.”

While these patients sit in the ED, they are not receiving the help they require. This situation also is not good for patients sitting in the waiting room with other diagnoses who cannot enter the ED quickly because the beds are full of psychiatric patients awaiting transfer, Zeller observed. “It is not a good thing for hospitals, either,” he added. “They are, on average, losing about $2,500 for every patient they are boarding for psychiatric reasons.”

Take Ownership

Part of the problem is that there has been a prevailing notion that the ED is the not the right place for patients with BH emergencies. However, Zeller noted that even when there are outpatient programs or other crisis services in the community, these resources generally do not have the capacity to deal with high-acuity BH patients (i.e., those who are boarded most often). This includes patients who are acutely suicidal, acutely agitated, or patients with extreme symptoms of psychosis.

In addition, it includes patients with a history of violent behavior, comorbid substance use issues, or patients who are acutely intoxicated or are in withdrawal, Zeller explained.

“All of these things can end up meaning that these patients really need the ED, or at least a hospital level of care,” Zeller shared. “Federal law defines psychiatric emergencies where someone is dangerous to themselves or others as equivalent to a medical emergency. An ED can be, and in fact is, an appropriate place for people with high-acuity danger symptoms to go.” Another flawed notion, according to Zeller, is the idea that mental illness cannot be treated in the emergency setting. Rather than trying to find the perfect program for these patients, Zeller argued it is time to take ownership of these patients, and find the best way to treat them.

“If we do that, we are going to actually get a lot of better outcomes,” he stressed. “One thing we know from our research is that the great majority of psychiatric emergencies can be resolved in less than 24 hours if you start treatment right away.”

Streamline Care

For starters, Zeller noted there are some simple steps EDs can take to improve the way they manage psychiatric emergencies. First, he noted it important to approach BH patients in a trauma-informed, patient-centric way that will not stigmatize or risk making symptoms worse. For instance, he observed that at some EDs, the first place patients with psychiatric symptoms go is for a blood draw.

“Maybe there is an assumption that everybody needs to get a blood draw, but think about it: If we are going to avoid the need for hospitalization in the majority of patients, we shouldn’t be traumatizing patients by going after them with a needle before we even know if they are going to need it,” Zeller said. “A lot of people are afraid of needles, and that is one of the things ... that can make people’s symptoms worse.”

Secondly, there is no reason to conduct a medical clearance exam, and then conduct the psychiatric part, Zeller said. Instead, he advised EDs to perform both the psychiatric and medical parts simultaneously as part of the same medical evaluation. Further, instead of just holding someone or giving him or her sedation, find ways to start appropriate treatment.

“What is going to happen is a lot of these people are going to get better, and that is going to change your disposition decision,” Zeller said. “When you take a look at someone when they first come in, they may appear very acute. But if you start treatment, a few hours later they may appear much better. Instead of needing to be hospitalized on an inpatient unit, they may be able to go to a community program. That is a win/win for everybody.”

Zeller likened this kind of management to the way one might treat a patient who presents with difficulty breathing due to asthma complications. He noted one might first think the patient needs to be hospitalized. However, if one gives the patient a nebulizer, then he or she might be breathing clearly a couple hours later and be fine to go home. “The same thing can happen with an emergency psychiatric patient,” Zeller added.

Take a Patient-Centric View

To find different ways of improving how BH patients are managed in the ED, IHI has been working with eight participating sites in the ED & UP initiative to test changes recommended by experts. “The objective of this learning community was to really develop a theory and test that theory,” observed Marie Schall, MA, senior director of IHI who also is presiding over ED & UP, during the Nov. 14 IHI session.

Schall noted that the work has focused on what she calls the four Ps, or the aspects of care that the experts suggest are key to improving the way BH patients are managed in the ED. (See the sidebar box at the end of this article for more information.)

The participating sites have piloted different aspects of care outlined in the four Ps, Schall noted. For instance, some sites have focused on using assessment tools to ascertain patient needs more quickly, while others have studied de-escalation techniques. Still other teams have worked to strengthen relationships with community resources.

“Our teams have been working on things like streamlining the referral process, making it possible for patients to have appointments in hand when they leave the ED so they can follow up with a community provider,” Schall reported. “[This is] to tighten the care system so that people don’t fall through the cracks and then have to return to the ED unnecessarily.”

Schall emphasized that what the participating sites discovered is that instilling a trauma-informed culture has outsized influence in making strides in this area. To that end, the learning community tried to examine what the care process looks like from the patient’s perspective, and think about how EDs can best respond to such a person’s needs through changes in the care process. Considering these patients typically ask for comfort and safety, the learning community studied how EDs can deliver these basic needs. This starts with the initial patient interaction and continues all the way through to ensuring individuals receive the kind of support they need to manage their conditions or distress over the long term.

“This has really become the centerpiece to any of the changes the teams have made,” Schall added.

Examine the Numbers

One of the participating facilities in the learning community, Hoag Memorial Hospital Presbyterian (with sites in both Irvine and Newport Beach, CA), has worked to implement several improvements to the way it manages BH patients in the ED.

However, the most transformational change has involved instituting a trauma-informed culture among the ED staff, explained Scott Surico, BSN, RN, MICN, education coordinator for emergency services and neurobehavioral health, during the Nov. 14 IHI session.

On average, the EDs at the two Hoag hospitals see about 6,800 patients a month, roughly 6% of whom present with BH emergencies. “When you consider the fact that these patients have to be taken to a room and put on a hold — first a 24-hour medical hold, and then, if need be ... a 72-hour detention — then 23% of our ED beds are taken up by BH patients 24/7, 365 days of the year,” Surico shared.

The way such patients used to be managed was the ED staff would obtain labs, but no treatment would be provided, Surico explained.

Then, the hospital brought in psychiatrists to work in the ED Monday through Friday, which was helpful in terms of facilitating treatment for these patients and releasing the holds where indicated. However, the psychiatrists often were called to work on the inpatient side, too, resulting in more demand for their services than hours in the day.

Start With Training

It soon became clear that a new approach was needed.

“We found we had an increase in security calls, or code grays,” Surico reported. “Our frontline staff in every single survey said they don’t feel supported, they don’t feel safe.” Further, workplace injuries were on the rise, too.

“We weren’t treating the whole patient, and we knew that,” Surico continued. “We did not have the appropriate resources to transition these patients from the inpatient to an outpatient setting unless we could get them into an inpatient psychiatric facility. [Also], 33% of our inpatients had secondary mental health diagnoses that we weren’t treating.”

It was at this point Hoag became a member of the IHI learning community, and decided to pilot a trauma-informed care approach in the largest of its two EDs (Newport Beach). Surico took charge of the project, beginning with training into what trauma-informed care is all about. This concept was developed by the Substance Abuse and Mental Health Services Administration (SAMHSA).

This group contends 90% of BH patients have suffered from some kind of trauma or abuse early in their lives, which has changed their brain functioning and causes them to suffer from a BH diagnosis, Surico related.

“There is a lot of emphasis on the fact that [having such a problem] is a diagnosis. It is not a behavior or bad parenting or bad decisions in college, but an actual diagnosis just like a heart attack or diabetes,” he said.

Consequently, when these patients come to the ED, rather than asking what is wrong with them, the more appropriate question is to ask about what they have experienced. Surico said the focus should be on trying to learn as much about the patient as possible.

“Find out something personal about them that [you] can use to connect with them when they amp up or start to get aggressive,” he advised.

Increase Awareness

A trauma-informed approach also involves raising awareness about what happens in the ED that can trigger or retraumatize these patients, Surico observed. For instance, he realized that since security officers wear uniforms and badges that are similar to police officers, their appearance can trigger patients who have had run-ins with the police.

“Often, I have to move [the security guards] out of sight just to keep a patient from becoming agitated,” Surico reported.

Other potential triggers include alarms, overhead pages, or noises that may travel from room to room. “All of these things have been found to ... cause our BH patients to become aggressive, assertive, or anxious,” Surico noted.

When one looks for the cause of a patient’s behavior, it can be relatively easy to address the issue, Surico offered. For instance, he noted that if a bipolar patient is yelling and screaming because his mother just came in and indicated he cannot come home, the patient may be worried he will be thrown onto the street.

“If we can address that issue, and talk to the patient about what we are going to do to help him so that we are not just going to throw him out onto the street, that patient will [likely] de-escalate very quickly and accept our help,” he shared.

Trauma-informed care emphasizes what Surico referred to as empathetic communication. “It is acknowledging that it is stressful, scary, and hard to be in the ED on a hold,” he explained. “It is letting the patient know that if you were in that situation, you would probably be scared, too. Then, it is letting them know why they are there, what [you] can and cannot do, and then sitting down and trying to give them something they can hold on to.”

In some cases, it might be enabling patients to watch TV, giving them a nicotine patch, or even just providing them with a sandwich, Surico noted. “Once you empathize with [patients] ... show them that you are with them and that you know who they are ... it changes the whole dynamic of that encounter in the ED,” he said.

Measure Outcomes

The positive results from implementing trauma-informed care have been borne out in the ED that piloted the approach. For instance, prior to implementing this new approach, the ED was seeing 12 to 18 incidents of violence involving patients every month. Then, in September and October 2018, every nurse, EMT, secretary, and clinical coordinator underwent training on how to provide trauma-informed care.

The results were immediate. Surico reported that in both November and December 2018, there were just five violent incidents reported each month. In January and February 2019, the monthly tally of violent incidents was just two.

“Since then, we have had an average of five to six workplace violence incidents every month. We have decreased our workplace violence incidents by more than 50%,” Surico shared. “That was [SAMSHA’s] theory, that when you change the way you view these patients and how you interact [with them] ... you are going to decrease workplace violence.”

However, the decrease in workplace violence was not the only positive result the ED experienced. Calls to security and the use of behavioral restraints also declined by 30% to 40%. When restraints were used, they were only on the patient an average of 15 minutes, Surico noted. “Before [implementing this approach], we would leave the restraints on for 30 minutes before we would even talk to the patients,” Surico said.

Furthermore, staff surveys validated these results, with nurses reporting they felt safer and better able to help this population of patients. “Our nurses are now engaged, and they are in there with the patients,” Surico shared. “They don’t just put them in a room; they are in there talking them down and letting them know we are here for them.”

The pilot was so successful that Hoag has implemented the trauma-informed approach in its Irvine ED. Meanwhile, Newport Beach is in the process of providing the same trauma-informed training to all inpatient nurses and staff working in ancillary services throughout the hospital, Surico reported.

“We do have a problem upstairs. We are being attacked by family members, visitors, and patients. We have never known how to talk them down or how to communicate and reach them,” Surico lamented. “We have changed our verbiage. We no longer use ‘psych patient.’ We use ‘behavioral health’ or ‘neurobehavioral health’ patient. We don’t say that we deal with them. It is an encounter.”

Even just those simple updates in terminology have changed the perspective of staff. Thus, outcomes are evolving positively, Surico said. “It really has been quite a successful program, and we are excited to share it with our sister hospitals,” Surico added. “I hope that others in the nation take this program and run with it because it ... can give your nurses ... the opportunity to help a patient population that, historically, we have not been able to help without specialized training.”

Secure Leadership Support

Working with the improvement teams from Hoag and the other ED & UP participants, IHI is in the process of synthesizing all the lessons and outcomes gleaned from their 18 months of work, Schall reported. She noted that IHI will release more details about outcomes and recommended changes soon.

Arpan Waghray, MD, a geriatric psychiatrist and chief medical officer of Well Being Trust, the national foundation that is funding the IHI learning community’s efforts in this area, commented that it is well-recognized that EDs have many competing priorities and that community resources for BH care are often scarce. Still, he noted during the Nov. 14 session that hospitals and EDs can bring about positive change.

“It is extremely important for us to change our culture and to stop talking about [BH] patients as those patients out there, Waghray stressed. “[Instead], try to think of them as our patients.”

ED & UP Participants

  • Abbot Northwestern Hospital
  • Cohen Children’s Medical Center
  • Hoag Memorial Hospital Presbyterian
  • Kaiser Permanente Sacramento
  • Maine Medical Center
  • Memorial Hermann Northeast
  • South Seminole Hospital
  • Providence Regional Medical Center Everett

Keys to Improving Treatment

During the Nov. 14, 2019, IHI session, Marie Schall, MA, senior director of IHI noted that the ED & UP work has focused on what she calls the four Ps, or the aspects of care that the experts suggest are key to improving the way BH patients are managed in the ED:

  • Process: standardizing ED processes related to the BH patient group;
  • Provider culture: creating a trauma-informed culture among ED staff;
  • Patients: engaging and activating patients and families;
  • Partnerships: finding ways to strengthen the ties between the ED and community partners.