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Special Report

No ED is Immune from Psychiatric Patient Boarding

Shaw, Gina

doi: 10.1097/01.EEM.0000554840.63260.ff
Special Report

How long does a psychiatric patient wait for a bed, discharge, or transfer in your emergency department? If your institution is like most, that number ranges between seven and 11 hours, and can be 24 hours or more if an outside transfer is required.

Just about every emergency physician has stories of much longer waits. Authors of a study from Johns Hopkins Hospital in Baltimore reported that their average length of stay for an inpatient psychiatric bed was more than 20 hours, with wait times “habitually surpassing 100 hours.” (Am J Emerg Med 2018 Jul 18.)

“In 2016, we had an 11-year-old boy with multiple behavioral diagnoses who boarded in the ED for over a week,” recalled Casey Clements, MD, PhD, the practice chair of emergency medicine and the director of emergency behavioral health at the Mayo Clinic in Rochester, MN. “He wasn't disruptive—he was just sitting there—but we couldn't find him placement and we couldn't do anything to make him better, so he stayed for a week in an acute assessment room not meant for a patient to stay in for more than four to five hours.

“I speak around the country on this, and every state thinks they have it the worst in terms of psychiatric boarding times in the ED,” he said. “It is a ubiquitous problem. Here at the Mayo Clinic, it is our single biggest problem with regard to patient flow. Between 2015 and 2016, we literally had people boarding for weeks on end.”

The problem is agnostic with regard to location, said Scott Zeller, MD, the vice president for acute psychiatry at Vituity and the previous chief of psychiatric emergency services at the Alameda Health System in Oakland, CA. “We see it everywhere: urban and rural settings, university tertiary care centers, and small community hospitals.”

A 2008 survey by the American College of Emergency Physicians found that 79 percent of surveyed ED directors reported regular boarding of psychiatric patients in their EDs, with 90 percent reporting weekly boarding and 55 percent reporting it daily or multiple times a week. (ACEP Psychiatric and Substance Abuse Survey, April 2008.)

No ED is immune.

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Complicating Factors

The lack of availability of psychiatric inpatient beds has been exacerbated by other factors, ranging from the opioid crisis to sometimes well-intentioned state laws. “For example, here in Minnesota, they passed a law requiring that a person in jail who had mental illness requiring treatment must be transferred to a state psychiatric hospital within 48 hours,” Dr. Clements said. “Decriminalizing mental illness is a good thing. But unfortunately, we only have two state safety hospitals who can take those patients, so the effect was to immediately deprioritize people with mental illness who were not in jail. We have had people commit crimes on purpose knowing that they would go to jail and get the mental health care they needed.”

A study found that the median ED LOS for patients admitted for psychiatric care at the Mayo Clinic increased by five hours between 2011 and 2015 in the wake of the law's implementation. (Am J Emerg Med 2018 Nov;36[11]:2029.)

The increase in ED wait times for psychiatric patients can be traced to a number of factors, but perhaps the most significant is the decline in the number of inpatient psychiatric beds available nationwide. Those dropped 35 percent between 1998 and 2013. (JAMA 2016;316[24]:2591; http://bit.ly/2BElqwg.) And the drop wasn't just confined to the late 1990s and early aughts; a June 2016 report from the Treatment Advocacy Center, a national nonprofit focused on making treatment available for severe mental illness, found that the United States had 37,679 state psychiatric beds in 2016, down about 13 percent from 2010. (http://bit.ly/2GPKUKt.) That comes out to an average of 11.7 psychiatric beds for every 100,000 people, a number far below the 40-60 beds per 100,000 people the center recommends.

At the same time, the number of patients presenting to the emergency department with psychiatric emergency conditions significantly increased, said Dr. Zeller. “We've seen an approximately 55 percent increase in the number of ED patients who have psychiatric emergency complaints as their primary presenting condition, and over a 400 percent increase in people presenting to EDs for reasons related to suicide.”

Some interventions aimed at this growing crisis have briefly shown promise, only to revert back to the mean over time. That was the case at Yale New Haven Hospital, which in December 2013 added a locked, 12-bed observation psychiatric unit to reduce boarding and improve ED throughput of psychiatric patients. The psychiatric observation unit shares coverage with the psychiatric emergency department, which is staffed 24 hours a day by a board-certified psychiatrist, advanced practice providers, nurses, and social workers. The psychiatric observation unit provides rapid psychiatric assessment, treatment, and referrals for adults experiencing a psychiatric emergency.

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Insatiable Demand

The unit initially achieved its goals, said Vivek (Vic) Parwani, MD, an assistant professor of medicine and the medical director of the adult emergency department at Yale New Haven Hospital. The median ED LOS for psychiatric patients in the preintervention period was 155 minutes, declining to 35 minutes (p<0.0001) post-intervention, according to a study he and his colleagues published last year. (Acad Emerg Med 2018;25[4]:456; http://bit.ly/2DSzti9.) Similar reductions were observed in crisis intervention unit LOS (865 minutes vs. 379 minutes, p<0.0001) and total LOS (1,112 minutes vs. 920 minutes, p=0.003). Psychiatric admission rates also declined significantly, from 42 percent to 25 percent (p<0.0001).

“We saw a pretty abrupt improvement in our psychiatric boarding rates immediately after the unit opened in 2013,” Dr. Parwani said. “We went from more than 14 hours down to six or seven hours. But the demand for psychiatric services has been insatiable. Six years later, we've seen the problem come back, and honestly, I think we are probably in a worse situation. ED boarding is at an unprecedented level. Had the psychiatric observation unit not been created, of course, I think we might be a bit worse, but just how much worse, I don't know. I still believe that the project was a success, but the demand for these services is so high we cannot build and staff observation units fast enough. Community hospitals are having a harder and harder time managing this patient population, so understandably they get taken to larger academic centers with more frequency.”

Dr. Zeller piloted a slightly different solution, one that he said he thinks has lasting potential. Called EmPATH Units—for Emergency Psychiatric Assessment, Treatment, and Healing—these aren't temporary waystations for psychiatric patients destined for inpatient beds. Instead, they are the destination for most patients presenting to the ED with behavioral health emergencies: a hospital-based, high-acuity ED specifically for psychiatric patients.

“Our work has shown that with prompt intervention and treatment with the right kind of modalities and with the rubric that we've put together, the vast majority of psychiatric emergencies can be resolved in less than 24 hours and don't need an inpatient bed,” Dr. Zeller said. “If we assess and treat at the emergency level of care, we only admit to inpatient about 25 percent of the high-acuity, involuntary patients we're currently treating, who all would be admitted to inpatient in traditional systems. So we don't need to find a bed for most of these people, leaving a lot more spaces open for people who really need them and have no alternative.”

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The Empathy of EmPATH

Each EmPATH unit is based on the specific needs of its hospital, but fundamental components include:

  • A focus on early assessment and prompt treatment with the least amount of coercion possible; restraints and forcible medications are rarely used.
  • Open design that allows patients to move about freely, with access to food, drink, and clean clothes.
  • No walls or “fishbowl” nursing stations. The nurses, social workers, and peer support counselors mingle with patients.

“Our EmPATH units are focused on getting these patients to see a psychiatric prescriber as quickly as possible once that's deemed medically appropriate and starting treatment immediately while putting them in a separate area that's more comfortable and homelike than a standard ED,” Dr. Zeller said. “It's an open space with recliners for people to sit in instead of beds, where they can sit up and participate in therapy or lie flat and sleep. They're given room to move about since many patients do well by pacing. If your needs are met, you're more likely to cooperate voluntarily.”

So far, Dr. Zeller said, EmPATH units have opened at a dozen hospitals and health systems across several states, ranging in size from the small Huntington Beach Hospital in California to the University of Iowa Hospitals and Clinics and the Billings Clinic, the largest health care organization in Montana. Many more systems are in the implementation pipeline.

Because of its large service area, the Billings Clinic previously had an average eight-hour wait for psychiatric patients in its ED, but that time decreased to less than five hours in the 30 days after opening the EmPATH unit, made possibly by funding from the Leona M. and Harry B. Helmsley Charitable Trust. The percentage of psychiatric patients admitted from the ED declined from 55-60 percent to 40 percent.

The University of Iowa saw similar results in the first few months with its EmPATH unit, which opened in October 2018 in a space vacated by a former PICU that had moved to a new children's hospital. “In September 2018, the month before the unit opened, our average psychiatric boarding time in the ED was 28.4 hours. By December, it was just 3.1 hours,” said Jodi Tate, MD, the vice chair for clinical services and a clinical professor of psychiatry. “Prior to opening the unit, we admitted about 50 percent of ED patients with psychiatric diagnoses, and that percentage is now down to about 27 percent. And our overall left-without-being-seen percentage for all adult patients went from 6.35 percent to 2.48 percent. That's only three months of data, of course, but those three months look really good.”

Establishing such a unit takes full institutional buy-in. “Our whole hospital wanted this to happen,” said Dr. Tate. “Both psychiatry and emergency medicine wanted to do things differently, and working with Dr. Zeller we were able to get the leadership on board that we needed to do this. They were willing to invest what was needed to set up the unit for the return of better care both in psychiatry and in the ED, where more patients are able to be seen, treated, and discharged.”

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Noncoercive Approach

Dr. Tate called the EmPATH unit “amazing” patient care. “I've been in psychiatry for more than 20 years, and this is probably one of the most rewarding things I've done. We're able to get interdisciplinary care to people in crisis right away in a patient-centered, team-based, noncoercive approach. I love it, the patients love it, and the staff love it.”

Don't underestimate the staffing required, she cautioned. “It's a lot of work. When you're there, you're hopping. We didn't realize how many providers we would need, so we have had to staff up a little bit.”

Dr. Zeller recommended at least one psychiatry-trained nurse on duty per shift, along with mental health specialists, psychiatric technicians, and trained peer counselors. “You want a psychiatrist on duty for a certain number of hours a day, as well as on-demand telepsychiatry so a patient can be seen quickly, even at 2 a.m.”

On-demand telepsychiatry can also alleviate psychiatric wait times for institutions that don't have enough traffic to justify a separate unit, Dr. Zeller said. “You also can train [emergency physicians] to have some medication algorithms for certain diagnoses.”

Dr. Clements said he liked the idea of the EmPATH units and that the Mayo Clinic is now exploring an intermediate-level crisis care center in the community, although not necessarily following that exact model. “It would be a drop-in facility where patients could receive mental health care when they need it,” he said.

Currently, the Mayo Clinic has separate space on two otherwise unused units in the hospital staffed by trained ED nurses where certain emergency psychiatric patients can safely stay. “We also created a hospital-based unit we call the complex intervention unit, in cooperation with hospital medicine where we sometimes will board patients. They are safer there, and outcomes improve,” Dr. Clements explained.

He also advocated for emergency clinicians to receive top-notch training in de-escalation techniques. “Our providers need to know what they need to do to stay safe,” he said. “We also need standardized guidelines in each institution for medication management of agitation and anxiety that should be based on the underlying cause to decrease variability and maximize effectiveness. But we really need to look at multidisciplinary approaches at a health system level to determine how the hospital is going to respond in the best interests of the patients. This issue keeps ending up in the ED, but it's not just an ED issue.”

Ms. Shawis a freelance writer with more than 20 years of experience writing about health and medicine. She is also the author of Having Children After Cancer, the only guide for cancer survivors hoping to build their families after a cancer diagnosis. You can find her work atwww.writergina.com.

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