emPATH Units as a Solution for ED Psychiatric Patient Boarding

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emPATH units report substantial improvements in outcomes, as well as safety and patient satisfaction, while dramatically reducing the need for coercive measures.
emPATH units report substantial improvements in outcomes, as well as safety and patient satisfaction, while dramatically reducing the need for coercive measures.

Patients with acute mental health issues stuck languishing for long hours, sometimes days, in medical emergency departments (ED) awaiting psychiatric disposition continue to be a major problem across the United States1. Many observers suggest the problem is due to a shortage of inpatient psychiatric beds. However, it should be noted that emergency psychiatric conditions may be the only cases presenting to EDs for which the default treatment is ‘admit to inpatient', and if this were also true for any other emergency condition (such as chest pain), all medical beds of hospitals would likely be full as well. It has been demonstrated that the great majority of psychiatric emergencies, like other medical emergencies, can be resolved in less than 24 hours with prompt, appropriate intervention2 — thus it would make sense to try to treat mental health crises in emergency settings as well.

However, resolving those symptoms in the standard ED can be a complicated task. The ED can be a frightening or agitating environment for patients in a mental health crisis, as they are often restrained to gurneys, or stuck in corners or cubicles guarded by a sitter, amid police and ambulance personnel, flashing lights, loud noises and hectic activity, and the cries of nearby others in pain. Paranoid or anxious patients, who might benefit from extra space or the ability to move about, may instead be restricted to a small, confined area. It has long been recognized that the standard ED setting may actually exacerbate the symptoms of a psychiatric crisis.3

Those suffering from acute psychiatric conditions will understandably do better in more calming, supportive settings with trained psychiatric personnel. However, until recently in most parts of the country, such environments have only been possible within inpatient psychiatric wards (perhaps after a long wait in an ED) or in community-based crisis programs. The community crisis clinics, however, are typically limited to lower-acuity clients, and exclude patients with aggression, dangerousness, acute suicidality, substance intoxication or withdrawal, vital signs abnormalities or other medical concerns.

As a result, mental health patients with the most severe and urgent symptoms are, ironically, often the most under-served behavioral health population.

Fortunately, a new and effective model — the “emPATH unit” — has emerged  nationally in recent years, now boasting state-of-the-art facilities in multiple states. Combining the soothing, home-like and supportive atmosphere of the community crisis clinic with the ability to accept even the most acute psychiatric patients, emPATH units report substantial improvements in outcomes, safety, and patient satisfaction, while dramatically reducing the need for coercive measures, decreasing episodes of agitation and physical restraints, and diverting unnecessary psychiatric hospitalizations, all at substantially lower costs than the status quo.4

emPATH unit stands for “emergency Psychiatric Assessment, Treatment & Healing unit,” and as the acronym implies, is modeled on empathetic, rather than coercive, care. These are hospital-based outpatient programs which can promptly accept all medically-appropriate patients in a psychiatric crisis, even those on involuntary psychiatric detention. Rather than being an alternative-to-inpatient destination for ED mental health patients, the emPATH unit is the destination for all the ED's acute mental health patients, a place where disposition decisions are typically not made until after a thorough psychiatric evaluation, treatment, and an observation period in the recuperative unit setting.

emPATH units can be widely diverse in their designs, staffing and floor plans, but all follow several basic tenets:

1.The programs feature a large, comfortable central room or ‘milieu' where all patients are situated. Rather than individual beds or rooms, in this short-term outpatient program each patient is provided their own recliner or ‘sleeper' chair, which can be positioned upwards for joining in socialization or group therapy, or folded flat if one wishes to take a nap. Recliners are arranged to maximize personal space, and there is also ample room on the unit for those patients who wish to walk about, pace or meditate; some units even feature a safe outdoor retreat. Stations with snacks, beverages, and linens are accessible to patients without needing to involve the staff. There are opportunities to read books or periodicals, watch TV, play board games, or chat privately with a therapist or peer support counselor.

The large milieu room is optimally airy, with high ceilings, windows, and ambient light. Soft colors and peaceful murals adorn the walls. The entire atmosphere is one of calming and healing, where needs can be met, frustrations are minimized, and therapeutic interventions can be allowed the time and space to be effective.

Some might question why patients would be all together in the milieu rather than the more traditional emergency psychiatry strategy of individual rooms, perhaps also wondering if highly-acute patients might be more likely to become combative when among other patients. But for a person in crisis, human interaction can be very beneficial, while an individual room can seem bleak and cell-like, with little hope for recovery.

For example, a person who feels distraught and in despair might continue to harbor such feelings in a private room. In the ‘group campout' environment of the milieu, however, he or she might instead be able to speak with a nearby peer about their issues, make a new friend, or enjoy a game of dominoes, and then suddenly, things might not seem quite so bad. Similarly, even individuals with paranoia or hostile thoughts can be soothed by the collegiality and mutual respect of the patients in the milieu setting.

2. All staff are intermingled with the patients on the milieu — there is no glass-enclosed ‘fishbowl' nursing station. Nurses, social workers, therapists, and peer support counselors are always available and close by. Because of this of this set-up, any patient having difficulties or escalating symptoms can be quickly assisted in a supportive and non-coercive way. Unlocked enclosed areas are available should an individual need temporary privacy to decompress.

3. All patients see a psychiatrist as quickly as possible, and have treatment implemented promptly. It has been shown the more early the assessment in a mental health crisis setting, the better the outcome. 5 Similarly — especially given the fact that emPATH units, being outpatient, typically have a limit of 23 hours, 59 minutes — the best chances for a speedy recovery in the unit occur when treatment is employed as soon as possible.

The combination of a prompt assessment and treatment with a supportive, healing environment can lead to impressive results, especially in safety and symptom relief. emPATH units report the use of physical restraints and/or forced medications in less than 1% of patients, even when the majority of patients are on involuntary psychiatric holds, 6 an improvement over more traditional emergency psychiatry programs (one of which recently published physical restraint use at 14%).7 Avoidance of inpatient hospitalization in highly-acute populations via treatment in an emPATH unit can be 75% or higher, sparing those available inpatient beds for those who truly have no alternative. 4

emPATH units can help mental healthcare systems achieve the Triple Aim of health care —enhancing patient experience, improving population health, and reducing costs.8 By minimizing boarding, which can cost EDs an average of $2264 per patient8, and avoiding unnecessary hospitalizations, which can cost $8000 to$10,000 or even more, the financial benefits of an emPATH unit are clear; in addition, these units are often able to operate self-sufficiently at far less than the costs of the status quo. And moving crisis individuals out of the ED opens up ED beds for other medical emergency patients. Further enhancing the fiscal advantages, emPATH units can often be created in a cost-effective way by simply remodeling available, unused hospital spaces.

Best of all, emPATH units are truly a win for mental health patients, providing swift relief and recovery for those who traditionally have been under-served, and have too often been detained with minimal care in improper settings.

References

  1. Castellucci, M. ER wait times, length of stay far longer for psychiatric patients. Modern Healthcare. http://www.modernhealthcare.com/article/20161017/NEWS/161019918 October 17, 2016. Accessed August 30, 2017. .
  2. Zeller SL. Treatment of psychiatric patients in emergency settings. Primary Psychiatry. 2010;17(6):41-47.
  3. Garriga M, Pacchiarotti I, Kasper S, et al. Assessment and management of agitation in psychiatry: expert consensus. World J Biol Psychiatry. 2016; 17(2):86-128.  
  4. Zeller S, Calma N, Stone A. Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments.  West J Emerg Med. 2014; Feb;15(1):1-6.
  5. Balfour M, Tannner K, Jurica PJ, Llewellyn D, Williamson RG, Carson CA. Using lean to rapidly and sustainably transform a behavioral health crisis program: impact on throughput and safety. Jt Comm J Qual Patient Saf. 2017;43(6):275-283.
  6. Zeller, SL. Data presented at the American Psychiatric Association 2017 Annual Meeting; May 22, 2017; San Diego, California.
  7. Simpson SA et al. Risk for physical restraint or seclusion in the psychiatric emergency service (PES). Gen Hosp Psychiatry. 2014; 36(1):113-8.
  8. Berwick DM, Nolan TW, Whittington J. The Triple Aim: care, health, and cost. Health Aff (Millwood). 2008. doi:10.1377/hlthaff.27.3.759
  9. Nicks B, Manthey D. The impact of psychiatric patient boarding in emergency departments [published online July 22, 2012]. Emerg Med Int. 2012;2012:360308.
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