You’re starting your day shift with a full waiting room and encounter a patient with a chief complaint of “psychiatric evaluation.” You talk with the patient and realize they are struggling with suicidal ideations and auditory hallucinations. You provide a medical evaluation, discuss the case with psychiatry, and decide to admit them to an inpatient psychiatric unit for medication optimization and psychiatric management. You message the inpatient psychiatry team, and they notify you that the patient is in queue but, due to lack of bed availability, the patient might be boarding in the ED for the foreseeable future.
The steady increase in the number of psychiatric patients boarding in EDs has been a persistent challenge for health care systems nationwide. In the past decade, the number of patients presenting with psychiatric diagnoses has significantly increased, with an estimated prevalence of 10.9% in 2017 rising to 21.9% in 2020.1,2 Patients presenting with suicidal/homicidal ideations, debilitating mental illnesses, and/or psychiatric crises often face prolonged wait times and uncoordinated care due to the increased demand for psychiatric services. Without proper avenues to safely provide care for these patients, many end up boarding in the ED, unable to receive ideal comprehensive psychiatric care.These situations further strain the already stressed resources in the ED.
One potential answer to this challenging issue may lie in the development of Emergency Psychiatric Assessment, Treatment, and Healing (EmPATH) units. Proposed as part of the 2022 Hospital and Outpatient Guidelines, EmPATH units represent a unique and innovative approach to address the challenges of psychiatric patient boarding.3
An EmPATH unit is a clinical space designed as a treatment zone with the goal of enhancing ED efficiency and patient flow, specifically tailored to address behavioral health crises. It is a specialized facility within or adjacent to an emergency department, staffed with mental health professionals, and equipped to provide immediate and comprehensive psychiatric assessment, treatment, and stabilization for patients presenting with psychiatric emergencies.
Patients are assessed promptly upon arrival, enabling rapid identification of the severity of their condition to coordinate and deliver appropriate interventions. The care team aims to be multidisciplinary and includes psychiatrists, psychiatric nurses, social workers, and other mental health professionals with expertise in acute intervention. Moreover, patients receive care within a more therapeutic and secure environment, potentially improving their overall experience and willingness to engage in treatment. There is also the goal of close collaboration with outpatient mental health providers. This helps ensure a seamless transition to ongoing care, after the crisis requiring acute intervention has been mitigated.
By better coordinating care of patients with acute psychiatric conditions, health care systems can allocate resources more efficiently — which benefits all patients. In a study by Kim et al, implementation of an EmPATH unit in an academic medical center for patients presenting with psychiatric crises reduced boarding time for medically cleared psychiatric patients by 66% and increased 30-day follow-up care by 60%.4 Similar studies by Zeller et al and Parwani et al also demonstrated reduced boarding times and less need for psychiatric hospitalization after implementation of EmPATH units.5,6
Take-Home Points
- Most EDs are not designed to provide comprehensive psychiatric care, leading to suboptimal treatment for psychiatric patients, particularly those with suicidal ideations.
- Boarding in the ED often results in prolonged delays in accessing specialized psychiatric services, potentially exacerbating patients’ distress.
- EmPATH units offer a unique solution by providing specialized, timely, and comprehensive care to these patients, with the potential to decrease the need for inpatient psychiatric care.
References
- Theriault K, Rosenheck R, Rhee T. Increasing Emergency Department Visits for Mental Health Conditions in the United States. J Clin Psychiatry. Published online July 28, 2022.
- Wang S, Shafique S, Xiao D, Barker K, Wang K, Xie X. Clusters of substance use and mental health variables with emergency room visits in U.S. adults: The 2020 National Survey on Drug Use and Health. J Affect Disord. 2023;339:683-690. doi:10.1016/J.JAD.2023.07.017
- Guidelines for Design and Construction of Hospitals.; 2022.
- Kim AK, Vakkalanka JP, Van Heukelom P, Tate J, Lee S. Emergency psychiatric assessment, treatment, and healing (EmPATH) unit decreases hospital admission for patients presenting with suicidal ideation in rural America. Academic Emergency Medicine. 2022;29(2):142-149. doi:10.1111/acem.14374
- Parwani V, Tinloy B, Ulrich A, et al. Opening of Psychiatric Observation Unit Eases Boarding Crisis. Academic Emergency Medicine. 2018;25(4):456-460. doi:10.1111/acem.13369
- Zeller S, Calma N, Stone A. Effect of a regional dedicated psychiatric emergency service on boarding and hospitalization of psychiatric patients in area emergency departments. Western Journal of Emergency Medicine. 2014;15(1):1-6. doi:10.5811/westjem.2013.6.17848