In May 2022, the New York Times reported on a heartbreaking situation unfolding at a local emergency department (ED). Fifteen adolescents in mental health crisis (many of them experiencing suicidal ideation) were essentially living in the ED, sleeping there night after night. These kids desperately needed intensive residential treatment. However, wait times for a pediatric psych bed averaged 10 days across the region.
This shocking story drives home a hard truth. If any patient group is overdue for a compassionate, patient-centered approach, it's the emergency psychiatric population. Ironically, this group encompasses both the highest-acuity mental health patients and the most underserved.
Up to 15% of emergency department visits now involve behavioral health emergencies, including substance use and mental health crises. Yet in managing these patients, too many hospitals adhere to historically inefficient care models that benefit few—and may actually cause patients' symptoms to worsen.
Just as we strive to provide timely and compassionate care to other medical patients, we must work to extend this approach to those with behavioral health crises, which, according to federal EMTALA law, are considered to be medical emergencies. By approaching care from a patient's perspective, we can offer effective and efficient emergency psychiatric care that truly improves the health of our communities.
A better way
As healthcare leaders, our imperative is to deliver care to patients where, when and how they need it. This may mean traditional care within the hospital building or via virtual care models that have proliferated in recent years. At Vituity, we call this concept Health in Place, and we believe it has the power to significantly improve equity, access and quality of life in our communities.
To improve emergency psychiatric care, we must first challenge the assumption that most behavioral health patients require inpatient admission as their disposition. Our experience at Vituity suggests that with urgent interventions, as many as 80% of patients in behavioral health crisis can be stabilized and returned home or to outpatient care within 24 hours (that is, in less time than many are sitting waiting in EDs today). Based on my career managing over 90,000 psychiatric emergencies, I pioneered a solution-focused care model for this population: the EmPath Unit.
EmPath Units serve medically cleared ED patients who require further behavioral health treatment. A psychiatrist evaluates arriving patients and initiates therapies. A multidisciplinary team then provides continual observation and reevaluation for up to 24 hours. Care takes place in a calming, spacious, comfortable and homelike setting outside the chaotic ED.
EmPath Units have proven to be the most compassionate and cost-effective way to care for patients in crisis. For example, a typical ED has little choice but to admit every patient who arrives under an involuntary psychiatric hold. By contrast, hospital EDs with affiliated EmPath Units stabilize 75% of the involuntary patients they receive. This drastically reduces admissions and frees up scarce inpatient psychiatric beds for those who truly need a lengthier stay.
Vituity's experience designing and implementing over two dozen EmPath Units across the country supports many benefits for patients:
- An 80% overall decrease in psychiatric admissions.
- A 70% decrease in length of stay at University of Iowa Hospitals & Clinics.
- Only 0.2% of patients restrained or secluded at both Billings Clinic, Montana and Providence Little Company of Mary Medical Center, California (compared to as many as 30% in general EDs).
Hospitals also benefit from EmPath Units:
- University of Iowa Hospitals & Clinics achieved a 90% decrease in boarding hours and added an estimated $861,000 to the ED bottom line by moving patients into more appropriate care in EmPath. This approach also dramatically improved outpatient follow-up while reducing ED recidivism and decreasing inpatient lengths of stay.
- ED recidivism decreased 30% at Mercy San Juan Medical Center, California, after EmPath implementation.
A Joint Commission surveyor praised the EmPath Unit model, calling for it to become a "national best practice."
Changing a paradigm one patient at a time
Stigma toward mental health and substance abuse patients too often leads healthcare organizations to overlook their needs. EmPath Units offer compassionate, targeted treatment that relieves suffering promptly while reducing strain on EDs and hospitals. This is another sterling example of Vituity's innovative approach to meeting patients when and where they need care the most.
About the Author
Scott Zeller, MD, is Vituity's Vice President for Acute Psychiatry. He previously served as Chief of Psychiatric Emergency Services at the Alameda Health System in Oakland, Calif. In his 29 years of practice, he has personally cared for over 80,000 patients.
Dr. Zeller is known across the nation and around the world as a leading expert in psychiatric emergencies. He has authored multiple textbooks and numerous peer-reviewed articles and book chapters and lectures internationally as a keynote speaker.