Long waits in the emergency department (ED) are a problem for both patients and hospitals. For psychiatric patients, the problem is even worse.
A 2012 study by Harvard University found that psychiatric patients spend an average of 11.5 hours in the hospital during an ED visit, about three times as long as patients with other medical conditions. The wait can cost a hospital more than $100 per hour in lost billing, an expense exacerbated by a 55 percent increase in psychiatric visits to the ED in the past decade.
Current recommendations are rooted in the belief that all emergency psychiatric patients should be hospitalized.
But Scott Zeller, MD, a guest on the July 12 WIHI audio program, questioned whether this is the best way to care for these patients. Zeller noted that, if followed, these recommendations would cause bed shortages due to excessive numbers of hospitalized patients. And treatment for many other conditions does not require expensive and disruptive hospitalizations following an ED visit: for example, only 18 percent of emergency patients with chest pain are hospitalized.
Zeller proposed, instead, that solutions should be centralized in the ED, since most psychiatric emergencies can be stabilized within 24 hours. Reforming ED practices, he added, can ameliorate patient experience and reduce unnecessary visits. How? Along with Zeller, three other experts — Robin Henderson, PsyD, Vera Feuer, MD, and Mara Laderman, MSPH — shared three ways organizations can improve psychiatric care within the ED:
- Create a Trauma-Informed Culture
According to Henderson, ED staff should be trained to build a trauma-informed culture. Here are a few specific suggestions:
- Help ED staff understand that psychiatric emergencies are just as serious as medical emergencies.
- Work with staff to process their own experiences with trauma and how they may inform their view of patients in crisis.
- Reframe the way staff ask questions to patients to avoid sounding judgmental, such as “What’s wrong with you?”. Focus on sending the message that providers recognize the influence of trauma by changing the language to inquiries such as, “What happened to you?”
- Improve ED Practices & Processes
Henderson pointed out that the best of intentions, often based in fear or an outlier incident, can lead to detrimental practices in the ED. Here are a few ways that emergency departments can improve the quality of care for psychiatric patients:
- Avoid restraints and coercive treatment when possible. In addition to traumatizing patients and families, this can shorten their visit by more than four hours and allow treatment to be started more quickly.
- Utilize psychiatric medications in the appropriate dose and for the indicated purpose, rather than using them to chemically restrain patients.
- Implement on-demand tele-psychiatry through video conferencing if there is a shortage of psychiatric care available in the ED. This can provide psychiatric patients emergency care within an hour.
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- Improve connections with outpatient care and community-based services
Feuer offered insights from her experience at the Cohen Children’s Medical Center that are applicable to young patients and children. And Laderman, the content lead for IHI’s work in behavioral health, provided additional pointers on follow-up care from the IHI Integrating Behavioral Health in the ED and Upstream Learning Community, an initiative with the Well Being Trust that seeks to improve patient experience and ED staff safety.
- Provide a comfortable outpatient space that provides urgent psychiatric care to help prevent the need for ED visits.
- Collaborate with community partners and primary care providers to develop streamlined referrals from the health care system to behavioral health resources.
- Ask for family feedback to improve the care referral system. At Cohen Children’s Medical Center, this feedback reveals a common need among families for more follow-up care.
- Equip family members to support patients following their ED visit.
To learn more about improving behavioral health care in the emergency department, download the July 12 WIHI: How to Build Better Behavioral Health in the Emergency Department broadcast.
Scott Zeller, MD, is the Vice President of Acute Psychiatry at Vituity and an Assistant Clinical Professor at both the University of California-Riverside and Touro University medical schools.
Robin Henderson, PsyD, is the Clinical Liaison to Well Being Trust and serves as Chief Executive of Behavioral Health for Providence Medical Group in Oregon.
Vera Feuer, MD, is the Director of Pediatric Emergency Psychiatry and Behavioral Health Urgent Care at Cohen Children's Medical Center (CCMC), Northwell Health and the president-elect for the New York City Council on Child and Adolescent Psychiatry.
Mara Laderman, MSPH, is a Director at the Institute for Healthcare Improvement. She is the content lead for IHI's work in behavioral health.