It is estimated that between 6% and 9% of all ED visits are from patients presenting to the emergency room with mental health problems. Unfortunately, many EDs have limited onsite mental health services, forcing many of these patients to endure long holding periods while ED personnel search for available inpatient psychiatric beds. “The problem of boarding mental health patients for long hours—sometimes days—in EDs is considerable and widespread throughout the United States,” says Scott Zeller, MD.
Recently published studies have shown that the average boarding time for patients with mental health issues ranges from about 7 hours to 34 hours (Table 1). The causes of boarding in these patients are wide ranging and include a lack of available psychiatric clinicians, requirements for insurance pre-authorizations, and few resources to conduct psychiatric evaluations, among others. Many solutions have been proposed, but these have generally focused solely on increasing available inpatient psychiatric hospital beds rather than considering alternative emergency care designs. “Changing the emergency care design has the potential to provide prompt access to treatment,” Dr. Zeller says. “It might also reduce the need for many hospitalizations.”
A Dedicated Psychiatric Emergency Services Model
In an effort to reduce average boarding times for patients with mental health issues, one suggested option has been regional dedicated psychiatric emergency services (PES). These units are stand-alone ED specifically for psychiatric patients. At PES facilities, patients are evaluated, receive intensive treatment, and are allowed time for observation and healing. “The goal of PES programs is to stabilize acute symptoms and avoid psychiatric hospitalization when possible,” says Dr. Zeller. “A PES unit can effectively treat patients to the point of discharge or provide alternatives to hospitalization, which in turn may reduce demand for psychiatric inpatient beds.” He adds, however, that few studies have examined the role of PES units in reducing psychiatric hospitalizations.
Alameda County in California has a population of 1.5 million people and spans a wide geographic area. To provide emergency psychiatric care for this area, the county developed the Alameda Model. It provides “round-the-clock” mental health services that can be accessed either via ambulance or by direct transfers from any county ED. Patients can also self-present for care. When patients arrive at the PES, they receive intensive treatment with psychiatrists, nurses, and other affiliated personnel for up to 24 hours onsite.
The Alameda Model has been shown to reduce psychiatric patient boarding times and decrease the percentage of patients admitted for inpatient care. In a study published in the Western Journal of Emergency Medicine, Dr. Zeller and colleagues tracked ED patients on involuntary mental health holds to determine boarding times and trends in patients admitted to inpatient psychiatric units after evaluation and treatment in the PES. After reviewing the total sample of 144 patients using the Alameda Model, the average boarding time was approximately 1 hour and 48 minutes (Table 2). Only about one-quarter were admitted for inpatient psychiatric hospitalization from the PES unit.
“Applying the Alameda Model may reduce psychiatric inpatient hospitalization substantially.”
Findings from the study were also compared with results of a similar analysis of boarding times in California EDs that was published in 2012. This study found an average boarding time of over 10 hours (Table 3). “The time difference between the Alameda Model and the one for California EDs was over 80%,” Dr. Zeller says. “Applying the Alameda Model may reduce psychiatric inpatient hospitalization substantially.”
The Alameda Model is a potential alternative for ED systems in which the volume of patients with emergency psychiatric conditions far exceeds the number of available psychiatric inpatient beds. “The Alameda Model avoids medical EDs altogether for most medically stable patients,” says Dr. Zeller. “For those who need stabilization, the PES allows patients to be transferred swiftly from emergency care to facilities designed solely for psychiatric care. Ultimately, unnecessary inpatient admissions are avoided, and inpatient psychiatric beds are reserved for those who truly need them.”
Developing Programs Psychiatric Emergencies
Many organizations have created PES or crisis stabilization units in the U.S., but finding ways to financially support such operations is challenging. Dr. Zeller says establishing a national billing code for these units may facilitate the development of more programs like the Alameda Model. “Such a code might encourage the development of self-sustaining programs without requiring new government projects or separate funding. Adding the code may enable healthcare systems to actually save dollars from using fewer psychiatric inpatient beds and by reducing boarding in medical EDs.”
Readings & Resources (click to view)
Zeller S, Calma N, Stone A. Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments. West J Emerg Med. 2013 Jun 11 [Epub ahead of print]. Available at: http://escholarship.org/uc/item/01s9h6wp.
Hazlett SB, McCarthy ML, Londner MS, Onyike CU. Epidemiology of adult psychiatric visits to US emergency departments. Acad Emerg Med. 2008;11:193-195.
Weiss AP, Chang G, Rauch SL, et al. Patient and practice-related determinants of emergency department length of stay for patients with psychiatric illness. Ann Emerg Med. 2012;60:162-171.e165.
Chang G, Weiss AP, Orav EJ, et al. Bottlenecks in the emergency department: the psychiatric clinicians’ perspective. General Hospital Psychiatry. 2012;34:403-409.
Zeller SL. Treatment of psychiatric patients in emergency settings. Primary Psychiatry. 2010;17:35-41.