Increasing visits by patients with behavioral issues raise emergency department concerns. Is the answer to build psych units right into the ED infrastructure?
A 34-year-old female arrives in your emergency room, showing symptoms of manic depression, yelling at other patients, and making threats and accusations about one of your nurses. How does your emergency room handle situations like this? Do you have a protocol for dealing with patients with severe behavioral issues? Do you have a dedicated emergency psych unit within the ED specifically designed for these kinds of patients? One thing is clear: Treating individuals who arrive at emergency departments seeking help for psychiatric or mental health problems is becoming an increasingly familiar — and difficult — problem for emergency departments.
Deconstructing the Data
From 2008 to 2010, almost 10% of ED visits in North Carolina had one or more mental health diagnostic codes (MHDC-DC) assigned to the visit, and the rate of MHD-DC-related ED visits increased seven times as much as the overall rate of ED visits during the same time, according to a 2013 Morbidity and Mortality Weekly Report. Patients with an MHD-DC were admitted to the hospital from the ED more than twice as often as those without MHD-DCs. Making matters worse: Stress, anxiety, and depression were diagnosed in more than 60 percent of MHD-DC –related ED visits, and those are particularly difficult conditions for emergency department to manage, according the health care experts.
Nationwide, there were more than 6.4 million visits to emergency rooms in the United States in 2010, or about 5 percent of total ER visits, involving patients whose primary diagnosis was a mental health condition or substance abuse, according to the Agency for Healthcare Research and Quality.
A study published in 2013 in the Western Journal of Emergency Medicine noted that mental health patients boarding for long hours, even days, in United States emergency departments (EDs) awaiting transfer for psychiatric services has become a considerable and widespread problem. Previous studies have shown average boarding times ranging from 6.8 hours to 34 hours.
And, in their landmark report, No Room at the Inn: Trends and Consequences of Closing Public Psychiatric Hospitals, 2005-2010, researchers found that the number of state psychiatric beds decreased by 14 percent between 2005-2010, concluding that “the continuous emptying of state psychiatric hospitals for the past half-century has decimated the number of public psychiatric beds available for the treatment of acutely or chronically ill psychiatric patients in the United States.” In the absence of need care, the report asserted, patients are increasingly gravitating to hospital emergency departments. “Hospitals emergency departments are so overcrowded that some acutely ill patients wait days or even weeks for a psychiatric bed to open so they can be admitted; some eventually are released to the streets without treatment,” the study concluded.
As a result of these developments, emergency departments must now face a multitude of issues when it comes to treating and perhaps subsequently boarding patients with psychiatric or psychological issues, including the dangers to other patients, their families, and hospital staff; overcrowding of emergency rooms; lack of inpatient psychiatric hospital beds; and the costs and liabilities of dealing with severely emotionally disturbed patients. In addition, ED beds occupied by mental health patients often result in longer waits by patients with medical problems to get out of the waiting room and into an ED bed.
The liability issue is an increasingly serious one for emergency departments, and why more emergency department are creating or considering separate, dedicated psych units. In 2009, for example, New York City agreed to pay $2 million to the family of a woman who died the previous year on the floor of the psychiatric emergency facility at Kings County Hospital Center after she had waited more than 24 hours for treatment. According to published reports, a videotape showed the 49-year-old woman, who was reported to have suffered a nervous breakdown, lay on the floor for about an hour while workers at the city-run hospital apparently failed to assist her. The incident resulted in widespread criticism of the hospital and led to efforts to improve procedures, starting in the emergency department.
There is no one size fits all solution to these problems, experts say, with options running from small dedicated units within emergency departments to more comprehensive emergency department units designed to treat larger geographic populations to establishment of regional units. There are no hard data on the number of dedicated psychiatric units in emergency departments in the United States. However, according to a survey of 61 EPM subscribers, about one-third (34 percent) of EDs have such dedicated units, while about two-thirds (64 percent) do not (see box).
The solution of choice is often dictated by the capabilities of the surrounding community to handle emergency psychiatric patients in general. For example, in April 2014, the Seton Healthcare Family in Austin, Texas, opened the Seton Psychiatric Emergency Department specifically to treat adults from throughout the community who suffer from psychiatric crises.
Jesús Garza, president and CEO of Seton Healthcare Family, explains that Travis County, where Seton is located, does not have enough properly equipped facilities to meet psychiatric patient needs. “The psychiatric ER is the most visible evidence so far that the Community Care Collaborative will improve health care across Travis County, whether patients have health insurance or not,” he says. The Community Care Collaborative (CCC) is a physician-led not-for-profit coalition of health care and service providers working to close gaps in the continuum of care, including emergency psychiatric treatment.
Kari Wolf, M.D., president of Seton Mind Institute and vice president, medical affairs, psychiatry at Seton Shoal Creek Hospital, says the project was “the result of years of community needs assessment and planning.” “There is not a single model for what a psychiatric emergency department looks like,” Wolf says. “We looked at the various models around the country and studied our own gaps-figuring out what gaps we most wanted to address for our community.”
As a result, the Seton psychiatric ED has an area designated for law enforcement to safely deliver patients through a back door “to protect their privacy and dignity,” Wolf explained.
It also has a front door to meet the needs of people who walk in to an emergency department in crisis, often because they are not able to access the outpatient mental health system,” she says.
From April 2014 through April 2015, the psychiatric ED had 6,842 patient encounters/visits, including walk-ins, transfers and law enforcement drop-offs.
Of psychiatric ED patients, 59 percent were discharged to home or an ambulatory care setting and remaining 41 percent were admitted to inpatient care within the community.
Preliminary data from the first year-end chart audit indicate that up to 36 percent of patients are eligible for community-based behavioral health services, but may not be connected to those services prior to an ED visit, Wolf reports.
The ED now is taking children and adolescents, although it originally was designed only for adults since the emergency department at Dell Children’s Medical Center of Central Texas suffers from the same over-crowding that adult EDs experience. The project also benefited from federal matching Medicaid Waiver funds, which may expire next year.
How much of a crisis are we really in? In July, the Sierra Sacramento Valley Medical Society (SSVMS) published a white paper, “Crisis in the Emergency Department: Removing Barriers to Timely and Appropriate Mental Health Treatment,”  with the goal of assessing the events leading up to the mental health care delivery crisis in the Sacramento region.
The paper proposed three overarching recommendations to improve the quality of care for those experiencing a mental health crisis: the implementation of a regional electronic health information exchange (HIE), the standardization of medical clearance protocol across all Sacramento area emergency departments and inpatient psychiatric treatment programs, and consideration of dedicated psychiatric emergency service.
Every month more than 1,600 children and adults experiencing a mental health crisis end up in one of the Sacramento region’s hospital emergency departments, and that the number continues to rise, according to the SSVMS. Those patients are frequently boarded in the emergency department, often for days, until inpatient psychiatric beds become available and the transfer process is completed, the society reports.
SSVMS says the influx of patients has strained the Sacramento region’s emergency departments, resulting in extended wait times for patients experiencing medical and/or psychiatric emergencies. “The emergency department is not the right setting for patients experiencing a mental health crisis,” says Seth Thomas, MD, ED medical director at Mercy San Juan Hospital, SSVMS board member and one of the white paper’s contributing authors. “Patients need the right care in the right place at the right time,” Thomas comments.
The study notes that psychiatric boarding “can have a significant impact on ED resources, and prevent ED beds from being used for new patients.” “Additionally,” the paper concludes, “there are increased costs associated with ED boarding, including costs for law enforcement, for the extra time spent in the EDs waiting on patients placed on (involuntary)…holds to be assessed; increased nursing and security staffing; and costs associated with unnecessary diagnostic and laboratory tests required by inpatient psychiatric treatment programs prior to accepting a patient from the ED for admission and transfer.”
The white paper reports that the average cost to board a psychiatric patient has been estimated at $2,264 and comments that “significantly, the ED is not conducive to the healing of patients with mental health needs.” “One clear issue that we can act upon at this time is the lack of effective coordination and communication between healthcare providers of mental health patients.” To this end, the study recommended a regional Health Information Exchange (HIE) platform to facilitate improved provider communication, improved access to mental healthcare services, and reduced ED overcrowding.
Standardizing the medical clearance process across all EDs and inpatient psychiatric treatment programs would facilitate the timely transfer of patients to appropriate treatment centers, according to the study. In the Sacramento region, the paper noted, patients are frequently brought in or present at one of the area’s EDs for mental health reasons without presenting problems requiring medical evaluation and treatment.
To facilitate medical clearance, SSVMS brought together specialists in emergency medicine and psychiatry to develop a standardized medical clearance form, which includes a series of questions under the acronym SMART. A score of ‘0’ on the form indicates no further workup is necessary, and would allow for prompt transfer of patients from the ED to a more appropriate inpatient setting, the white paper says. “Adoption of the SMART Medical Clearance Form…by each of the Sacramento region’s EDs, as well as by all inpatient psychiatric facilities, would vastly expedite the transfer process of mental health patients to an appropriate inpatient treatment program, reduce costly and unnecessary diagnostic tests, and ensure that patients receive timely treatment,” the study stated.
A third recommendation is that county officials consider alternative treatment design for new facilities, such as dedicated psychiatric emergency services (PES) to ensure that patients experiencing a behavioral health crisis receive care in an environment that is conducive to healing.
Many proposed solutions have focused solely on increasing available inpatient psychiatric beds, rather than considering alternative designs that provide access to care and may reduce the need for hospitalization, the white paper commented, adding that best practices and evidence-based programs may provide an option to reducing the cost of services and lessening the need for costly inpatient hospitalizations. An example of this type of a system is a dedicated PES, a stand-alone ED specifically for patients experiencing a behavioral health crisis, the study noted.
The ED aims at providing timely, specialized care to patients with mental health emergencies, a dedicated psychiatric ED, a PES accepts patients who are either transferred from a regular ED, taken there directly by ambulance or law enforcement or who walk in, the white paper explained, and “PES essentially accepts all patients.” A regular ED is “conducive to healing…is not secure, presents special risks for suicidal patients, and increases the risk for elopements. The PES, on the other hand, provides a comfortable, calm environment for patients as they are evaluated,” the study concluded
The Future: Concerns for the Elderly
The situation involving psychiatric patients and emergency departments is likely to get worse, not better, going forward, experts predict, and particular attention should be paid to addressing the burgeoning mental health needs of Baby Boomer sand the elderly. In a study, based on the MMWR article, scheduled to be published in an upcoming issue of the Western Journal of Emergency Medicine, Judith Tintinalli, M.D., professor in the Department of Medicine at the University of North Carolina, and her colleagues found that older adults with MDH account for more than one-quarter of ED patients with MHDs, and their numbers will continue to increase as the boomer population ages, concluding: “We must anticipate and prepare for the MHD-related needs of the elderly,” the article asserts.
Is Telemedicine the Answer?
Telemedicine also may be an option for reducing wait times for patients with psychiatric issues. Last September KentuckyOne Health instituted a mental health telemedicine collaboration between Our Lady of Peace and Sts. Mary & Elizabeth Hospital, both part of the KentuckyOne Health organization.
The collaboration connects mental health professionals from Our Lady of Peace with the emergency department at Sts. Mary & Elizabeth Hospital to provide a “level of care” assessment for patients who come to the hospital’s emergency room with mental health or psychiatric conditions.
The secure videoconference system allows professionals from Our Lady of Peace to respond to requests for a consultation in approximately 15 minutes — and to consult with the emergency room physician and make recommendations for immediate care.
Prior to the use of telemedicine, hospitals without on-site psychiatric services could either contact a provider, like Our Lady of Peace, and wait for a staff member to be able to respond in person or send written evaluations electronically for review and input.
Jennifer Nolan, president of both hospitals, said the concept “is for patients to have access to assessors, therapists and other mental health professionals at a location close to home.”
Telemedicine allows that access to assess the patient and provide guidance to the emergency room staff, Nolan explained. KentuckyOne also reported it would expand the telemedicine program other parts of its system.
Does Your ED Have a Dedicated Psych Unit: An EPM Survey
In August, EPM conducted a brief survey of subscribers to obtain input from emergency physicians on the establishment of separate psych units as part of emergency departments in the United States.
Based on the responses from 61 subscribers, 22 EDs (36 percent) had established a separate unit for patients with behavioral and psychiatric issues while 39 (64 percent) had not yet set up such units. The size of the units varied considerably, between 3 and more than 40 patients. Those that established separate units were generally very pleased with the results for the initiative. “I can’t imagine living without it,” said one respondent.
However, as expected, establishing such units is not without its own set of problems, according to the respondents, citing staffing and capacity issues.
Other survey results:
- By a wide margin (41 to 17), respondents indicated that the number of patients being seen in their emergency departments with behavioral and psychiatric issues was increasing in recent years.
- There were a multitude of reasons for creating separate ED units, including segregating patients with behavioral problems from those with other conditions; establishing a safe, secure area to handle patients with behavioral issues, especially those prone to violence; dealing with an increasing volume of patients in the emergency room; streamlining care; and attempting to eliminate patients remaining in emergency department for lengthy stays.
- Almost one-third of the respondent indicated that emergency department staff were concerned about the risks posed by patients with behavioral issues to other patients. Of those reporting no concerns, however, 17 had independent units established to deal with patients with behavioral problems. (One respondent reported having three dedicated beds under the direct line of sight by local law enforcement officers and under video surveillance for patients under involuntary holds.)
- The separate units are usually staffed by an ED physician, but some also include a psychiatric nurse, social worker or aide.
- About two-thirds of respondents indicated that they were covered by specific regulations dealing with physical interventions regarding psychiatric patients in emergency rooms.
One respondent was particularly frustrated with the entire situation, commenting: “The mental health system is beyond broken—psych patients should be in a state-funded secure facility, not in emergency rooms. Spineless politicians.”
The Alameda Model
In addition to creating dedicated psych units within the emergency department, hospitals also are exploring establishment of regional dedicated emergency psychiatric facilities to evaluate and treat all mental health patients for a given geographical area, and can accept direct transfers from other EDs.
The study reported in the Western Journal of Emergency Medicine assessed the effects of a regional dedicated emergency psychiatric facility design known at the “Alameda Model” on boarding times and hospitalization rates for psychiatric patients in area EDs. Over a 30-day period beginning in January 2013, five community hospitals in Alameda County, California, tracked all ED patients on involuntary mental health holds to determine boarding time — defined as the difference between when the patients were deemed stable for psychiatric disposition and the time they were discharged from the ED for transfer to the regional psychiatric emergency service.
Patients also were followed to determine the percentage admitted to inpatient psychiatric units after evaluation and treatment in the psychiatric emergency service. In a total sample of 144 patients, the average boarding time was approximately one hour and 48 minutes.
Only 24.8 percent were admitted for inpatient psychiatric hospitalization from the psychiatric emergency service.
The results indicated the Alameda Model of transferring patients from general hospital EDs to a regional psychiatric emergency service reduced the length of boarding times for patients awaiting psychiatric care by more than 80 percent versus comparable state ED averages.
In addition, the study concluded, the psychiatric emergency service can provide assessment and treatment that may stabilize more than 75 percent of the crisis mental health population at that level of care, thus dramatically alleviating the demand for inpatient psychiatric beds. The improved, timely access to care, along with the savings from reduced boarding times and hospitalization costs, “may well justify the costs of a regional psychiatric emergency service in appropriate systems,” the study noted.
Michael Levin-Epstein, J.D., M.Ed is a Maryland-based freelance writer who contributes to EPM, Telemedicine and other health care and business-related publications.