The opioid epidemic, a 400% increase in suicide attempts, and fewer inpatient psychiatric beds are sending more behavioral health patients to hospital emergency departments (ED).
Volumes have tripled in the last decade, says Scott Zeller, MD, vice president of acute psychiatry at Vituity. “These factors combined with a lack of trained emergency department staff are impacting the care delivery for every patient that walks through the emergency room doors,” he says. “While some say adding more beds is the answer, unless we change the paradigm of how we treat psychiatric patients in the ED, we won’t change anything.” Instead, Zeller says most patients can be treated successfully in the ED without hospitalization through better collaboration with highly trained psychiatric and emergency care professionals. Here, he discusses how health systems and communities are creating new treatment protocols that raise care standards for behavioral health patients in emergency settings.
Q: Tell us about the biggest problems you see facing our healthcare system today.
Scott Zeller, MD: A lot of people are having psychiatric crises or emergencies and having little alternative but to go to hospital EDs. Unfortunately, EDs haven’t been able to help a lot of these folks because they default to discharging the patient or holding them until they can transfer them to an inpatient bed. These patients typically don’t receive a mental health evaluation or treatment in part because providers are not properly trained to handle behavioral health emergencies and because there is a nationwide shortage of psychiatrists. This has resulted in a lot of patients getting stuck in ERs for hours, days and even weeks waiting for a transfer to an elusive inpatient bed. Often their symptoms become worse and they even become violent. This method of treatment impacts the entire system, fueling the ED overcrowding problem and unnecessarily wasting resources.
Q: What are the best solutions for addressing the issues faced by our nation’s emergency departments?
Zeller: There has been great improvement in emergency psychiatry treatments, medications, and approaches over the last few years. We need to help physicians and ED staff shift how they handle mental health emergencies. It is important to acknowledge that some mental health emergencies are legitimate medical emergencies. When someone is suicidal or having hallucinations, it isn’t different than other medical emergency. Patients with behavioral health problems should be evaluated and treated promptly the same as you would for someone with asthma, diabetes or heart problems.
According to research, a great majority of psychiatric patients don’t need to be hospitalized, if we do the right interventions, start medications, and have the proper personnel treating them. With basic medication philosophy, ED physicians are able to treat patients, see them improve, and avoid hospital admission. At the same time, on-demand emergency telepsychiatry is available for more serious cases. These medical professionals can provide consultations on treatments and medications. This is being done with amazing outcomes.
Q: What are some advanced solutions for EDs experiencing higher volumes of patients with psychiatric emergencies?
Zeller: Some hospitals are also creating a separate wing of the ED called emergency psychiatric assessment treatment and healing units (EmPath). They are hospital-based, home-like settings away from the lights, sirens and people in uniforms, which can elevate psychiatric symptoms. Patients are treated on a recliner instead of a gurney by trained psychiatric staff, including psychiatrists, nurses, social workers, and peer support professionals. They can stay in these units up to 24 hours before we decide if they should be hospitalized. We are seeing positive results in this calming, supportive environment. In the units I have been involved with, less than 1% of patients need to be restrained compared to 50% in the regular ED. Patients also respond well to treatment, with 75% of EmPath Unit patients being discharged home or somewhere less restrictive, where in typical models 100% might be hospitalized. Also, for that fraction who still go to inpatient care, since patients are properly treated and vetted on the EmPath unit before being admitted to the hospital, there is less violence or agitation when they arrive and the reimbursement process is much smoother with fewer denials.
Q: What makes Vituity uniquely qualified to address this challenge?
Zeller: Vituity started in traditional emergency medicine 40 years ago and has since grown into a multispecialty company that has expanded into 14 states. Vituity embraces innovation. Over the last few years we recognized there is a major issue around emergency psychiatric care and so we have created a new acute psychiatry division. Our emergency psychiatry and hospital medicine experts along with hospital leadership have been working on different models that address misperceptions about the way mental health patients should be treated and have solutions that can solve what has become a problem for every ED in the country. We offer everything from consulting services to developing and operating care delivery programs, which include EmPath units and telepsychiatry as part of an integrated approach. The real value above and beyond our experience is we are offering something that is different and unprecedented for most organizations.
Scott Zeller, MD, Vice President of Acute Psychiatry