An idea whose time has come? EMS and local communities should investigate transformative models to reduce psych holds in local EDs – something hospitals and EMS agencies often say contribute to EMS offload delays.

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Mental Health Crisis Leads Hospitals to Create a New Type of ER

Recliners and games in “Empath units” are helping move patients with psychiatric ailments out of emergency rooms.

ByJohn Tozzi

September 26, 2022

https://www.bloomberg.com/news/articles/2022-09-26/hospitals-empath-units-replace-the-er-for-mental-health-patients

With mental health treatment in short supply, Americans experiencing a psychiatric crisis frequently land in a hospital emergency room—brought in by the police or loved ones—and usually stay there until they can be safely discharged or transferred. That means patients can spend hours or even days stuck on a gurney until a spot opens in a psych ward, the only other setting deemed appropriate.

The approach rarely offers any real treatment for mental health conditions, and it ties up scarce ER beds. That’s spurred some hospitals to try a new idea: mental health crisis units designed to treat people quickly in a more serene setting, so they can stabilize patients and send them home. “There’s no other emergency in the ER where the default treatment is to find them a bed,” says Scott Zeller, assistant clinical professor of psychiatry at the University of California in Riverside. Zeller developed the model, called Empath (emergency psychiatric assessment, treatment, and healing), to improve care while avoiding unnecessary time in the emergency department.

The idea is an open room with recliners, soft lighting, TVs, and card tables. At the two dozen or so Empath centers in the US today—with dozens more on the way—patients who are medically stable are seen by a psychiatric specialist within an hour and quickly start any needed medication. By speeding up treatment and observing the response, doctors can send more patients home with recommendations for follow-up care, rather than automatically placing them in a psychiatric hospital.

Since the 1950s, most US psychiatric beds have vanished under the policy of “deinstitutionalization” that followed budget cuts and exposés of inhumane conditions in mental hospitals. The number of public psychiatric beds per 100,000 people dropped from 340 in 1955 to 12 in 2016, according to the nonprofit Treatment Advocacy Center. After the institutions emptied out, hospitals and jails became the de facto replacements.

Covid-19, which strained hospital capacity while exacerbating Americans’ mental distress, amplified the problem. A study of one pediatric facility found the average length of psychiatric boarding more than doubled, to 4.6 days, during the first year of the pandemic. A survey by the Massachusetts College of Emergency Physicians showed that at the average hospital, almost 30% of ER beds are occupied by people experiencing a behavioral health emergency, with some patients remaining there for weeks.

Zeller developed what became the Empath model when he was medical director of a psychiatric emergency center in Alameda County, Calif., which served as a regional destination for psychiatric transfers from local emergency departments. Most patients were brought in involuntarily by the police, and the county aimed to move those who were medically stable to the center as quickly as possible. The approach, Zeller found in a 2014 study, meant patients spent less than two hours in the ER waiting for treatment, and only 1 in 4 needed to be admitted for inpatient psychiatric care.

Part of the solution was getting people out of a setting that can aggravate mental distress. “That environment itself, within the ED, can be very frightening,” Zeller says. “It’s claustrophobic, there are lights and noises and scary equipment and uniformed personnel running all around, and they’re not allowed to move.”

The setting for the Alameda study was essentially a big waiting room. The hospital bought recliners to make patients more comfortable, organized group activities such as board games, and added stations where patients could get water, snacks, and linens so they wouldn’t have to ask a nurse for basics. “That allows the treatment to work a little better, if people aren’t feeling adversarial, but rather engaged,” Zeller says.

As the Alameda study got more attention, other hospitals sought to replicate the approach. Zeller and his colleagues started talking about redesigning the concept. “If we were going to be able to build something from scratch, what would we do?” he asked. Hospitals envisioning new facilities could make them feel less clinical and more inviting than the waiting room, with more space, higher ceilings, natural light, and fresh air.

M Health Fairview Southdale Hospital in suburban Minneapolis opened an Empath unit in March 2021. Lewis Zeidner, director of clinical triage and transition services, says it’s more like a living room than an ER, though it’s adjacent to the emergency department. The unit has 15 recliners and a staff of psychiatrists, psychiatric nurses, and therapists—one clinician for every two patients—around the clock. Hospital admissions for mental health crises have fallen to 14% from 40%, and there’s been a dramatic drop in repeat visits.

The unit sees 250 patients a month with depression, anxiety, PTSD, and substance use problems. “They’re everyday people who get to a place in their life where things feel more out of control,” Zeidner says. The setting opens a window to evaluate patients and determine whether they should be admitted for inpatient treatment. Before the Empath option, that was usually the only destination if a clinician was worried about a patient’s security. “We want to keep people safe,” he says. “You can’t reverse suicide.”

After University of Iowa Health Care opened an Empath unit in its main hospital building in Iowa City, the number of suicidal patients admitted and the length of time they waited in the ER dropped dramatically, researchers found. “Once we had it, we were like, ‘Oh my gosh, how did we do this without it?’” says Heidi Robinson, director of behavioral health services for the hospital’s nursing department.

A separate Iowa study looked at the economics of the approach and found that revenue in the emergency department increased as fewer patients left before being treated. But the boost wasn’t enough to cover the cost of the Empath unit—$1.4 million to open and $2.6 million in annual operating expenses. Zeidner says hospitals tend to lose money on inpatient mental health beds anyway, and the advantages to patients of avoiding those admissions are clear. With the success of its suburban Southdale Empath unit, M Health Fairview is considering another at its downtown Minneapolis location, with room to treat adolescents as well as adults. “There’s a growing understanding,” Zeidner says, “that this crisis is not going away.”