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As emergency rooms fail in treating mental health, systems create new plans, centers

Extended boarding in chaotic emergency departments detrimental to patients and physicians, experts agree.

Beth Jones Sanborn, Managing Editor

Enloe Medical Center, a 298-bed standalone nonprofit hospital in Chico, California, is the only voluntary acute care mental health program for adults north of Sacramento all the way to the Oregon border.Enloe Medical Center, a 298-bed standalone nonprofit hospital in Chico, California, is the only voluntary acute care mental health program for adults north of Sacramento all the way to the Oregon border.

More than 80 percent of emergency room physicians say the mental healthcare systems in their regions are dysfunctional, and do not adequately serve patients, according to a survey done in December by the American College of Emergency Physicians involving 1,500 of its members.

Unfortunately, thousands of people in need of mental health treatment are often being dropped at the emergency departments of their local hospitals, where under federal law doctors must evaluate these patients despite the limitations on ER-based mental health treatment.

"The patients are clearly not getting the best care available if they are sitting in the emergency department for long periods of time." said Sandra Schneider, MD, director of emergency medicine practice for ACEP. "One of the biggest problems around psychiatric patients in the emergency department is that when we see a patient with a psychiatric illness, there are very few resources for us in the emergency department that are there on a 24/7 basis."

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One thing the ACEP study discussed was a lack of tailored education and training for dealing with mental health ER patients. It also pointed to data from the National Alliance on Mental Illness that showed 38 percent of mental health patients in the ER had waited more than 7 hours to see a mental health professional. And in 21 percent of cases, the wait was more than 10 hours. That's a long time in a hectic and stressful environment for someone who is already in crisis.

It's complex problem that isn't going away. If anything, it's growing. According to ACEP, one in 25 adults, or 13.6 million, experience a serious mental illness in any given year that significantly impedes one or more "major life activities."

The roadblocks

Schneider, who is also a practicing emergency physician, said one of the biggest challenges in dealing with mental health patients in the ER is after the initial consultation or first efforts at treatment. Doctors who are unsure whether that patient requires further care or should be sent home don't have much of a sounding board to work with because they lack instant access to a psychiatrist.

"If I had that same patient with an orthopedic injury or with a surgical injury, I can pick up the phone and I can talk to another physician and describe the case, have them look at the x-ray or the EKG, whatever, and they sometimes would even come in and see the patient. If I have a patient with a psychiatric illness, in general I can't get somebody. I might be able to get a social worker. I might be able to get a nurse. When we did a recent survey, the vast majority of people could not get a psychiatrist and could not talk to a psychiatrist about the patient."

That issue carries through to patients who might need outpatient care or just a psychiatric follow-up once they leave. Schneider said the system is complicated, and resources that are there one day are unavailable the next.

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"I've talked with several psychiatrists who say they can't figure it out. So just getting them to the next level of resource, the next follow-up is very difficult."

Experts also say boarding can create a dilemma both for patient and the hospital. Boarding is when patients are kept in the emergency department while waiting for an inpatient bed, and most healthcare professionals agree it is harmful to the patient.

If boarding is an issue among general medical patients, it is catastrophe when it comes to mental health patients, Schneider said. According to the ACEP study, 70 percent of their physicians said they'd boarded a patient during their last shift that was waiting for a mental health bed. Many of them had boarded for days, even 10 days or more.

"Imagine you went to the hospital with appendicitis and it took 7 hours for you to see a surgeon. No one in the world would say that was appropriate treatment and yet that's what happens a lot in mental illness. No one is taking this as a serious illness and a lot of it has to do with reimbursement. The reimbursement for taking care of mental health patients is poor."

In addition to the negative effect on a patient's health, there is enormous financial impact, too.

"The emergency department is like a restaurant. And if you have a restaurant that is turning over tables, you're doing good business. If you have a bunch of customers that would come in the morning for breakfast and never leave and just sit at that table, you'd never be able to make money. And that is exactly what's happening with the psychiatric patients when they're sitting in the emergency department."

Schneider said it is also costly in terms of staff resources. For one thing, it is required that a nurse supervise a mental health patient while they are in the ER, which is called a one-to-one, to make sure they don't run away or hurt themselves.

"You wouldn't see this at a psychiatric hospital but we have to do it because we're not a psychiatric facility," said Schneider.


The behavioral health unit of Enloe Health.

Enloe's approach

Enloe Medical Center is a 298-bed standalone nonprofit hospital in Chico, California. It is also home to the only voluntary acute care mental health program for adults north of Sacramento all the way to the Oregon border, according to CFO Myron Machula.

"We don't necessarily like that distinction, but there it is."

Enloe has run the Behavioral Health Unit  since 1998 after merging with Community Hospital to become Enloe Medical Center. As part of that transaction, they acquired the behavioral health program.

It's an unlocked unit separate from the medical center where mental health patients from the community and the emergency department are referred for treatment. It houses 30 licensed beds and discharges 750 to 800 patients annually, about 10 per day. Machula estimates that about 20 percent of those patients are coming from the emergency room. So, instead of boarding in the emergency department for hours or days until they see a psychiatrist, mental health patients are sent to the BHU, which is quieter, less chaotic, and more suitable for their care.

Molly Schneider, an emergency physician at Enloe, said she sees at least one mental health patient every day. Not only does the BHU offer a better environment for them, it gets them started on treatment sooner and it opens up beds for medical emergencies. While she admits it's not a perfect situation or system, she pointed out that it is at a minimum a much-needed "release valve" for what would otherwise be an overcrowded emergency department where beds were taken up by mental health cases instead of the strokes, heart attacks and other immediate needs that demand their attention as ER physicians.

"The behavioral health patients can get lost in the ED. You have a nurse that has to look out for them but when she gets a person that is having a heart attack or whatever she has to direct her attention to that individual. You want the behavioral health patient to get the level of care they need ongoing. That's how we got to what we do and we're very lucky that we have that pop-off valve."

Lucky, Molly Schneider said, because the 16-bed county facility is full more times than not, so the patients that end up at Enloe wouldn't have anywhere else to go if not for the BHU.

"As the government sponsored entities for housing mental health patients has slowly gone away over the last many decades, mental health patients have nowhere to go. Many of them are on the streets, many of them are in jail and we in emergency medicine are sometimes the safety net for things in society that don't go well, and that includes mental health," she said.

Beyond patient care, the BHU model also helps Enloe do better financially because they are able to see more patients. And for a stand-alone nonprofit hospital, that's crucial. Machula said the BHU's operating costs total about five to six million a year; a staff ratio of one nurse to every six patients does make the unit pricey to run. Machula said they just about break even.

"I'm not saying it saves a huge amount of money but it puts it in a context where the care is correct. It's certainly not putting us at a deeper level of expense. This indeed does offset a certain amount of cost. We're winning no matter which way we go with this."


The Calming Labyrinth at Alameda's John George Courtyard gives patients a place to walk, meditate or focus.

The Alameda model

"If you intervene promptly in an emergency setting you can usually stabilize a psychiatric emergency in less than 24 hours and therefore avoid hospitalization all together. It ends up costing less than the status quo of boarding to do this, and then it ends up saving untold millions for every system by avoiding unnecessary hospitalization. On top of it all, it's much much better for the patients to get on-demand emergency care with proper personnel when they need it, rather than just being put on a gurney in a back hallway and saying, 'We'll find something for you in the next couple days.'"

That philosophy is what drives Scott Zeller, MD, chief of psychiatric emergency services for Alameda Health System in Oakland, California, and a former president of the American Association for Emergency Psychiatry. After seeing community after community dealing with rampant boarding issues, Zeller led a study in 2014 on how to end the vicious cycle. What he found was having a dedicated regional psychiatric emergency room reduced boarding times by over 80 percent compared to the rest of the state, and overall hospitalization by 76 percent, all for less cost.

Zeller said the Alameda process has run for 10 years now and is unique from other programs. If police respond to a 911 call and find they are dealing with a psychiatric emergency, they immediately contact an EMS crew. Upon their arrival, law enforcement hand over the reigns to them, at which point a medical evaluation is performed to see if any medical services are needed or if the patient is medically stable enough to go right to the county psychiatric emergency services.

The criteria include no chest pain, no abdominal pain, patients have to be conscious, can't be bleeding much, and vitals have to be within a reasonable range.

"Psychiatric emergencies are defined by federal EMTALA laws as medical emergencies, equivalent to having a heart attack or being in a car accident. We certainly don't have police transport heart attacks or car accidents so why are we doing that with psychiatric patients? It's also very stigmatizing for a psychiatric patient," Zeller said.

Zeller says roughly two-thirds of those on psychiatric hold will be cleared to go right to the county psych ER, and therefore never even see a hospital or take up an emergency department bed.

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Those that do need medical treatment first are taken to the nearest ER, treated and then cleared for transport to the psych ER, which is centrally located in Alameda County. Zeller said ambulance crews have less than a 20-minute turnaround in transporting patients to the psych ER and getting back out in the field.

"Essentially, there's no such thing as boarding in our county. The time it takes for somebody to get from their ER to us once they're considered medically cleared is just the time it takes for them to arrange transportation," Zeller said.

While he knows his exact model won't work for every system, the philosophy behind it is what's key to more successful treatment of mental health emergencies: the majority of psychiatric patients can have their emergency condition resolved in less than 24 hours if you start treatment right away.

"Get people into the right place, at the right time with the right personnel. If you do that, no matter how you adapt your model, you have a great chance of getting the great majority of people the help they need and getting them somewhere outside of the hospital much more quickly," Zeller said.

Twitter: @BethJSanborn

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