1. The EmPATH Model
Streamlining Care with Specialized Psychiatric Emergency Services
Kaiser-Steinberg Institute Forum
January 31, 2018
Scott Zeller, MD
Seth Thomas, MD

2. Scott Zeller, MD Seth Thomas, MD VP Acute Psychiatry CEP America
Director of Quality & Performance
Emergency Medicine
CEP America

3. Intake
Processing
Output
Throughput

4. Flow
Matters!

5. Definition: Psychiatric Boarding
Psychiatric patients in medical emergency departments who are medically stable yet waiting for evaluation or disposition
Often these patients are kept with a sitter, or in “holding rooms” or hallways on a gurney – some languishing for ours in physical restraints, often with no concurrent active treatment

6. Problem: Psychiatric Patients are Victims of ED Overcrowding
The typical ED experience:
Loud / Noisy
Auditory & visual overload
Untrained staff
Lack of specialists
Lack of correct medications
Error-prone environment
Lack of showers & exercise

7. ED Boarding… Increases frustration Decreases patient satisfaction
Decreases core measure compliance
Increases costs
Increases adverse outcomes
INCREASES MORTALITY

8. Nicks B, Manthey D. Emerg Med Int. 2012
Impact of Psychiatric Boarding
Boarding is costly, medically, ethically and financially
Symptoms often escalate & worsen in EDs
Average cost to board a psychiatric patient estimated at $2,264
Studies showing average psychiatric patient in medical emergency departments boards for an average of between 8 and 34 (!) hours
Psych patients boarding in an ED can cost that hospital more than $100 per hour in lost income alone (Treatment Advocacy Center, 2012)
Nicks B, Manthey D. Emerg Med Int. 2012

9. Psychiatric Patients are Disproportionately Affected
ED staff spend twice as long finding inpatient beds
2012 Harvard Study
11.5 hours per ED visit
15 hours waiting for inpatient beds
2012 CHA Study: Average adults wait over 10 hours until transfer after the decision is made
Studies showing average psychiatric patient in medical emergency departments boards for an average of between 8 and 34 (!) hours

10. Psychiatric patients are especially at risk

11. LOS Psychiatric Patients
Psychiatric Patients Pay the Price
3.2 x
longer
18.2 hrs
5.7 hrs
LOS Medical Patients
LOS Psychiatric Patients

12. 414.6% 44.1% 14.8% 6.9% General Population Emergency Department
ED Mental Health
ED Suicidal Ideation

13. Who’s the real Gomer? An unsophisticated person; a yokel. Origin
An acronym that stands for "Get Out of My ER". The term was popularized by the 1978 novel The House of God by Samuel Shem (pen-name of Stephen Bergman). In this book, the word is applied to patients who are frequently admitted with complicated but uninspiring and incurable conditions.

14. Intake
Processing
Output
Throughput

15. So what can we do?
We need to think and act in a proactive, innovative fashion

16. Modern
Solutions

17. Boarding Solutions Suggested
Most suggestions still follow concept that virtually all emergency psychiatric patients need hospitalization as the only disposition
Results in far too many patients being unnecessarily hospitalized at a very restrictive and expensive level of care
Roughly equivalent to hospitalizing every patient in an ED with Chest Pain (typically only 10% of such patients get hospitalized)

18. Wrong Solution: Treating at the Destination Instead of the Source
All these solutions call for more availability for hospitalizations, nothing innovative at the actual ED level
Change in approach needed – beginning with recognition that the great majority of psychiatric emergencies can be stabilized in less than 24 hours
To reduce boarding in the ED, shouldn’t the approach be at the ED level of care?

19. Zeller’s Six Goals of Emergency Psychiatric Care
Exclude medical etiologies and ensure medical stability
Rapidly stabilize the acute crisis
Avoid coercion
Treat in the least restrictive setting
Form a therapeutic alliance
Formulate an appropriate disposition and aftercare plan
Zeller, Primary Psychiatry, 2010

20. Allen MH et al. Journal of Psychiatric Practice, 2003
Moving Outside the ED
A 2003 survey of psychiatric consumers reported that a majority had unpleasant experiences in medical emergency facilities and would prefer treatment in a specialized Psychiatric Emergency Service location.
Allen MH et al. Journal of Psychiatric Practice, 2003

21. EmPATH Units Emergency Psychiatric Assessment Treatment & Healing
Crisis Stabilization Units (or “Psych ER”) provide a calming, healing, comfortable setting
completely distinct from the medical ED
where prompt access to a psychiatrist can help lead to timely and dramatic improvement for
patients experiencing a psychiatric emergency.
A Revolutionary Approach to Emergency Psychiatric Care

22. Physical Space Design
Key Take-Away: Calming environment separate from ER that prioritizes healing and access to care
Large, open milieu space where patients can be together in the same room – high ceilings and ambient light. All can easily self-access food, drinks, linens, phones, books, games, TV. Ample room for walking about or pacing.
Space to move about and engage in socialization, discussion, and therapy. Some feature outdoor relaxation gardens
“Per chair” model, outfitted with recliners. Space recommendation: 80 sq ft per patient; 36 sq ft patient area around the recliners
Open nursing station w/instant access to staff - No “bulletproof Plexiglas” separating the patients
1-2 Calming Rooms (unlocked spaces) - Avoid locked rooms or restraints

23. Physical Space Design

25. Patient Benefits
Immediate care setting change from chaotic ED to a calming, “trauma-informed” environment with restraint elimination
Coercion avoided, all about engagement and individual decisions; staff available around the clock. Peer support specialists onsite.
Multi-disciplinary team treatment and resources available, discharge planning, family contact, outpatient provider connections
Rapid evaluation by a psychiatrists after arrival, comprehensive care plan development; patients may stay up to 23 hours till dispo

26. Hospital Benefits
EMTALA-compliant for voluntary/involuntary mental health crises; take all medically-stable patients immediately from ER
Not alternative destination to inpatient, but a separate “psych ER” where all evaluation, treatment and dispositions are made
Move behavioral health care out of the ER into more appropriate space for healing, opening up beds in the ER for medical patients
Significant reduction in admission rates, up to 80%, as patients respond very well to site and interventions
Even inpatient units benefit -- eliminate unnecessary, denied pay day inpatient admissions

27. Thank You!
Questions?