A resource document from the American Psychiatric Association offers some solutions to the problem of boarding psychiatric patients.1

“We give practical ideas on treatment interventions in the ED [emergency department],” says Kimberly Nordstrom, MD, JD, the lead author and an emergency psychiatrist at University of Colorado Anschutz.

The idea is for the psychiatry and emergency medicine fields to work together on solutions and “get both groups talking,” Nordstrom says. “We also wanted to think broader. What can the hospital do?”

One example is designating a quieter area for those with psychiatric issues. “That in itself can help to stabilize the patient,” Nordstrom offers.

Some EDs are taking steps to reduce medical/legal risks by preventing the need for boarding in the first place. Scott Zeller, MD, has been working with several hospitals to rapidly create separate emPATH (emergency Psychiatric Assessment, Treatment, and Healing) units. The emPATH units handle all the ED’s acute mental health patients.

“We are looking at what they can do for the psychiatric patient who might be a little different so they don’t have people boarding and taking up beds that might be needed for other patients,” says Zeller, vice president of acute psychiatric medicine at Vituity in Emeryville, CA.

The emPATH units treat highly acute psychiatric patients without involvement of law enforcement or jail. “Relying on police to detain for involuntary holds, as we know, sometimes can have unfortunate outcomes,” Zeller observes.

Some ED psychiatric patients are on involuntary holds when they arrive on the emPATH units. Staff try to convert them to voluntary status as soon as possible. “The staff focus on collaboration and engagement rather than coercion,” Zeller explains. Quick access to a psychiatrist means more patients become willing participants in their care, rather than staff forcing treatment. Moving psychiatric patients to a designated area, says Zeller, “is not pushing these people out the door. It’s putting them into a much better, more therapeutic environment that’s going to improve their situation.”

The idea is to stop holding psychiatric patients indefinitely in noisy, crowded EDs, exacerbating agitation and anxiety. Instead, there is a chance to stabilize the emergency medical condition, as required by the Emergency Medical Treatment and Labor Act (EMTALA).

“This is much more in line with EMTALA, rather than just boarding them, and trying to transfer that responsibility elsewhere,” Zeller notes.

Many hospitals were looking at implementing emPATH units. Concerns about overloaded EDs during the COVID-19 pandemic hastened this research. “With necessity being the mother of invention, we’re able to ramp up the creating of these units in a much shorter time frame — less than 30 days,” Zeller reports.

If psychiatric patients are boarded, it means all ED patients are going to wait longer. “That takes a bed completely out of commission at a time when [clinicians] are looking at how to increase capacity during a surge,” Zeller says.

EmPATH units free up beds while putting treatment of psychiatric patients more in line with how all other ED patients are treated. “If you come to the ED with an asthma attack, they will not sit you in a back room until they find you an asthma hospital,” Zeller says.

Some patients improve so much that there is no longer a need for an inpatient bed after all. Many end up discharged home or to an outpatient community setting. “That preserves those beds for the patients who truly have no alternative,” Zeller notes.

In the ED, there usually is not much time to start treatment, see how the person responds, then use that to guide the next stages and disposition. In an emPATH unit, there is plenty of time (usually up to 24 hours) to handle all this.

“Somewhere in the range of 75% of the patients who are thought to need inpatient care actually improve enough to be discharged,” Zeller reports. These data refute the common misconception that it takes days or weeks to resolve highly acute psychiatric symptoms.

“The great majority of psychiatric emergencies can be treated to a subacute level in less than 24 hours,” Zeller adds.

REFERENCE

  1. Nordstrom K, Berlin JS, Nash SS, et al. Boarding of mentally ill patients in emergency departments: American Psychiatric Association resource document. West J Emerg Med 2019;20:690-695.