Behavioral Health and Emergency Department Throughput
A behavioral health crisis and its impact on community hospital emergency departments.
At any given time roughly one third of evaluation rooms within our Emergency Department are occupied with behavioral health patients. This patient cohort is often cleared for medical complications while simultaneously assigned Involuntary Emergency Admission (IEA) status. IEA status entitles a patient a bed at the state run psychiatric facility external to our organization. Due to chronic lack of funding at the state level wait times for such an emergency psychiatric bed often runs several days in length. The net result is multi-day boarding of psychiatric patients in community based emergency departments, growing security concerns, increased pressure on staff trained in emergency medicine (not psychiatry) and an erosion of patient experience by the balance of patients who receive care in areas most proximal to disruptive patients.
Reflecting on the material contained in Module 1 “Design for Excellence” what programmatic, clinical and/or physical plant related recommendations would you consider to help improve the situation for our providers, patients and staff?
Participant comments on Behavioral Health and Emergency Department Throughput
It sounds like the root cause of increasing capacity in the state run psychiatric facility is beyond your control to address in a reasonable time frame, and so these patients will continue to be in your facility for the foreseeable future. Have you considered cohorting them in an inpatient unit while awaiting transfer? This might improve their care through availability of specialized psychiatric nursing and medical staff, and improve care in the ED for the reasons you outline. If admitting them is not an option, then perhaps creating a specialized and segregated “crisis” unit within the ED staffed by psychiatric nursing. The latter is an option we have chosen for these challenging patients.
We had the same issue several years ago. To address the concerns you state we built a Comprehensive Psychiatric Emergency Program in a separate building attached to our ER. Patients still come in through the ER, but are assessed and then directed to either the adult or child CPEP for a psychiatric evaluation. We have an entire floor for these group of people to stay while they are being evaluated. We also have added several programs to provide our patients support to help mobilize patients so they don’t have extended stays while waiting on state run psychiatric centers including Extended Observation unit, Mobile Crisis Outreach, Crisis Residency, and Home-Based Crisis intervention to help the throughput in the unit. It is important to note we are do have a behavioral health unit and this was built to help through put in the Er as well as support out In Patient Behavioral Health units. Maybe something on a smaller scale would work. Hopefully this helps!
We have a psychiatric crisis unit in our ED. This is staffed by a psychiatric RN and RPN. After being medically cleared by the ER physician, they are assessed by the psychiatric RN or RPN. Those patients that require admission or further assessment are seen by the on call psychiatrist, patient that do not require admission are discharged by the ER physician. The model allows for a separate area for these patients to be assessed. This unit has two interview rooms and three rooms with a bed. Some patients that need observation, or a period of de-escalation but not necessarily admission are held in this unit overnight.
We are a level 1 psychiatric hospital which means we get patients transferred from our surrounding 4 hospitals. Because we are often full, these patients often have delays in transfers as you are describing at yours. We are now using OTN (ontario telehealth network), where the psychiatrist can assess the patient via OTN and determine whether they actually need transfer to our facility. Not sure if this is an option for you and whether some of your patients are actually discharged once they arrive at your state run facility.
Until our country decides that we are going to subsidize a large portion of the care for these patients, I fear they problem is likely only going to get worse. These patients often do not have the means by which to pay for their own care. As per usual in the US system, we treat illness as an episode, and do a poor job at early education, prevention, and detection.
I would argue that the solution lies in a multi-faceted approach which would start with education. We need to remove the stigmata that is attached to mental illness. We need our adolescence and young adults to be educated about these diseases as much as they learn about the other politically charged health education curriculum.
A more educated public will help in creating the momentum to get programs established for these patients, and help establish new hospital solutions, both private and public, to serve the need. Until the public gets engaged through education, I fear we are going to continue with the screaming “crazy” person in the corner of the ER department.
We have a similar problem in Cincinnati. We currently have 142 inpatient pediatric mental health beds, which is the largest of any children’s hospitals in the country, but it is still often not enough. We board children in medical surgical beds, taking up space that other children at times need and delaying the start of true treatment. We are attempting a few things to modify the demand including putting psychologists in many of our primary care practices and in the local schools. We hope to help the parents and children with resiliency and head off problems before they are at the crisis stage. We have also opened partial day hospital at one location with another one planned. Finally, we have opened what we call a bridge clinic. If a child presents to the ED during the evening or night hours and is borderline on need for admission, we can discharge them home and have them seen in the bridge clinic the next morning. Also under consideration is putting pyschiatrists in our ED so that they can determine best course of action. Hard to stem the tide on our own, but the local community health budget is already stretched to the max with other priorities.
I think most Emergency services would face similar problems. Whilst it would be ideal to have close mental health support and services, the reality is that it is not cost effective. I would suggest more data is required. What are the common behavioural health presentations. Are there variations throughout the day/month/year.
Can the presentations be risk stratified? Minor cases can be handled by a counsellor, referral to an external provider or even the emergency staff. We found that emergency staff still need some basic trainings in mental health first aid and risk assessments.
For moderate to severe cases, if there are commonalities, some form of treatment algorithms/pathways may be possible. Thereby hopefully lessening the reliance on manpower.
We made and are still making a large structural change in our psychiatric services. We closed a couple of psychiatric hospitals and have opened or are opening psychiatric wards in each of our somatic hospitals – so in every emergency unit there are psychiatric nurses and psychiatrist on call as well as some acute psychiatric beds for acute situations; the heavier stuff is treated in our specialized central psychiatric hospital. The resources came from closing psychiatric beds. Our ER and psychiatric services are in the same organisation. I guess it would not be easy in a fragmented system.
I would agree with Bruce, if there is one area that needs more resources it would be mental health care. From a hospital standpoint I wonder whether it would be more cost effective to underwrite the cost of group and cognitive therapy outpatient services that are more accessible for patients. Outpatient services are not reimbursed to cover costs, but considering the resources consumed by a single inpatient boarding in the ER, it may be cost neutral for you. Trick would be getting several of the area hospitals to do the same thing….
We have similar problem but the solution that works to some extent is having a secure observation bay which is supervised by security personnel and psychiatry trained nursing staff. It is not a solution if you have continuous inflow of patients requiring psychiatric assessment and attention as you fill this space very soon and put strain on the rest of the ED.
We have similar issues in our ED, along with a lack of psychiatric beds in the region. Our psych unit is 20 beds, with very strict admission criteria and can only accept insured patients. Even with this rules, they are always full, with increasingly complex and sometimes violent patients. We have had psych patients in the ED for more than 5 days.
Psych consults on all psych patients in the ED and we have a full-time psych social worker. We use Mobile Crisis (which has 72 hours to respond) to aid in assessing patients. We implemented Team STEPPS across the organization over the past two years. ED was an early adopter. After everyone went thru training, Team STEPPS action council was formed by interdisciplinary team members. We extended the psych area in the ED, made some cosmetic changes (it was looking pretty bad), and implemented routine care for the patients such as offering a shower and change of clothes every 24 hours (this is done early in the morning prior to the ED getting busy as these patients often need close monitoring and cannot be left alone). We also worked with Dietary to have menus available and trays delivered to the ED for this population (they had been getting the standard ED turkey sandwich and ginger ale for 5 days!). All of this is a band-aid and doesn’t solve the real problem, of course, but the staff recognized that we could do better for the psych patients and provide them more dignity and a better environment.
We have looked at opening a short stay/observation psych unit also but many of the modification we would need to make to a vacant unit are somewhat cost prohibitive as we are building a new hospital to be completed by 2021-ish.