Individuals with mental health conditions or substance use disorders frequently seek care at hospital emergency departments (EDs), yet many EDs lack the capacity to adequately support these individuals. The Abbott Northwestern Hospital of Minneapolis, Minnesota (Allina Health) has tested a short-term observation unit where patients can transition home or to an inpatient program in a space that is quieter than the general ED environment. The following is an excerpt from IHI’s Improvement Stories: Improving Behavioral Health Care in the Emergency Department and Upstream.
“Ted” is a 38-year-old man with severe mental illness who lives in the Twin Cities area in Minnesota. He is in outpatient treatment, but every few weeks he experiences an increase in paranoia, anxiety, fear, and suicidal ideation. When this happens, he usually comes to the emergency department (ED) at Abbott Northwestern Hospital in Minneapolis. He has often been admitted to the hospital for three to seven days for minor medication adjustments and then discharged. Occasionally he has stayed in the ED for a day or two before stabilizing and returning home.
When Abbott Northwestern Hospital joined the ED & UP Learning Community, one major motivation was to help patients like Ted. The team felt that Ted and other patients with mental health conditions and substance use disorders — who presented in the ED but didn’t require emergency or inpatient care — were not getting their needs met in the optimal way. “What do they need?” asked Jackie Cooper, DNP, APRN, PMHNP-BC, a psychiatric nurse practitioner who works in the ED. “They need a space where they can come and talk to somebody. They need to get out of the general ED space into a quieter environment.”
To meet this need, the ED team established a new six-bed observation unit (called the HOPE unit) in an area adjacent to the inpatient psychiatry unit for patients who do not require an inpatient referral, but who do need some immediate care prior to discharge. The goal was twofold: to avoid unnecessary inpatient admissions and alleviate demand on limited ED staff and resources.
The first challenge in creating the HOPE unit was to establish admissions criteria — to cast a net that was neither too wide nor too narrow. The team determined that patients with mental health conditions and substance use disorders who were expected to stabilize within 24 to 48 hours were appropriate for admission to the unit. Patients who had significant medical issues or had exhibited aggression were not admitted and stayed in the regular ED.
The team engaged patients and their families in designing processes for the unit, asking them for feedback during several workshops. Before the unit opened, patients and families participated in walk-through simulations of the processes and identified opportunities to help patients feel safer in the environment.
From January through July 2019, 128 patients were admitted to the ED’s HOPE unit. “A lot of them didn’t want to be hospitalized,” said Cooper. “They felt like avoiding a prolonged admission was a good [arrangement] for them, so they could get back to work.” The unit was much calmer than both the ED and the inpatient environment, with much more one-on-one contact with staff. The new unit “encouraged patients to take more ownership of their care,” Cooper noted, prompting patients to consider, “What can I do in the next 24 to 48 hours to get myself well?” The majority of patients admitted to the HOPE unit were discharged home, while a smaller number were admitted to inpatient care or to longer-term residential mental health treatment.
One patient who benefited from the new observation unit was Ted. On two occasions, he was transferred from the ED to the HOPE unit, where he was able to access increased support and supervision. He was able to make contact with his mother and other outpatient supports before stabilizing and returning home.
The ED team encountered several challenges in creating the new observation unit. One was the isolated and small location of the unit, on the opposite side of the hospital from the ED. The unit is considered an “extension of the ED” and its remote location, apart from other hospital units, makes it difficult to deploy resources (i.e., security, certain medications, additional staff) in a timely manner, posing a safety risk in the event of behavioral incidents or needs for emergency response.
Another challenge involves staffing on the HOPE unit, which has a dedicated staff of one social worker, one registered nurse, and one mental health associate. However, when the unit has no patients, the unit staff float to other hospital departments. Since the number of patients admitted to the observational unit greatly fluctuates, the ED team encountered challenges with immediately reallocating staff resources when even one patient was admitted to the HOPE unit. Another significant challenge was determining the right mix of patients in the unit. “It was really difficult trying to balance the type of patients that might benefit with being a small, six-bed unit with one [team of] staff,” said Cooper. The unit consists of three rooms with two beds each. The team set rules against placing an adult in the same room with an adolescent, or a male in the same room with a female. These restrictions presented obvious barriers to taking full advantage of the unit.
Despite these challenges, the team saw promising results. One was a reduction in ED boarding time for patients with mental health conditions and substance use disorders. “Even if it was one or two patients, it did have a positive impact on boarding time and patient flow,” said Dana Alston, Clinical Operations Manager. Moreover, preventable readmissions have decreased. The HOPE unit is currently on hiatus, with an evaluation underway to determine the next steps.
Ted and his mother have both expressed appreciation for the HOPE unit. They are able to engage with the small observation care team, as opposed to a larger inpatient team, and are grateful for the closer engagement with unit staff compared to the chaotic inpatient environment. Ted is treated in a less restrictive environment and able to more quickly transition back to where he wants to be — home.
Editor’s note: For more on this topic — including practical tips, tools, and more Improvement Stories like this — download the full Improving Behavioral Health Care in the Emergency Department and Upstream white paper.