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Strategies for ED Psych Patients

Jacqueline Fellows, for HealthLeaders Media, May 13, 2014
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"The key idea is that there is a lot that can be done for a psychiatric patient in an emergency situation in the first 24 hours, and in too many places around the country, they're just sitting, waiting, when hospitals could probably have most of them much improved and on their way back home or somewhere less restrictive than an ER," says Zeller, who is also past president of the American Association for Emergency Psychiatry.

At AHS, Zeller developed what he calls the Alameda Model. In this approach, psychiatric patients are transferred from general hospital EDs to a regional psychiatric emergency service facility, which can receive direct transfers from other hospital EDs and assess and treat patients who are presenting with mental health emergencies. In this case, the PES is the John George Psychiatric Hospital, an 80-bed AHS facility in San Leandro.

Fewer than 10 of California's 58 counties use the PES model, something both Zeller and the California Hospital Association are hoping will change with the release of Zeller's 2013 study of the Alameda Model, published in the Western Journal of Emergency Medicine.

"This is a model that's evolved over several years," says Zeller, who wanted to prove that what AHS was doing as a PES would work for even the more difficult psychiatric patient emergencies, such as when police have an adult under an involuntary mental health hold. "We decided to set up a study and see if our assumptions were correct."

Zeller says 90% of psychiatric patients come into the John George Psychiatric Hospital because of an involuntary hold by law enforcement. In California, this type of psychiatric hold is called a 5150, which is short for the state code governing the treatment of psychiatric patients. Hold times also vary from state to state; in California, the limit is 72 hours. Ambulance crew members are the first point of triage for these patients (police who initiate this order call an ambulance for transport; they do not bring in patients) and will determine a patient's medical stability. If the patient needs medical care first, the ambulance will take the patient to one of the county's 11 EDs. If patients are considered to be medically stable, then they are taken to John George Psychiatric Hospital.

In the study, Zeller tracked the boarding times for psychiatric patients who were under an involuntary mental health hold. The study took place over 30 days and tracked patients from five area hospitals. He wanted to measure the difference in how long a patient was boarded. The comparison data he used was from a 2012 CHA study he also worked on that showed the average boarding time of these psychiatric patients as 10 hours.

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