Case: You bring up the issue again of boarding mental health patients for hours to days in the emergency department (ED) monthly meeting. Multiple members at the meeting confirm your concern that these patients are not getting appropriate care in a timely fashion. You wonder if there could be a way to improve access to acute mental health care.

Clinical Question: Can an emergency psychiatric assessment, treatment, and healing (EmPATH) unit decrease hospital admission and boarding time for patients presenting with suicidal ideation or after a suicide attempt?

Background: There has been a 44 percent increase in ED visits for mental health conditions between 2006 and 2014.¹ In one decade, ED visits for suicide attempts have almost doubled.² The mortality rate by suicide is greater in this population than the rate of mortality for patients presenting with any other ED complaint.³

Inadequately resourced provision for emergency mental health care is familiar to health care professionals in multiple jurisdictions, and patients can spend days in the emergency department waiting for inpatient admission.⁴ Lack of access to care can have several consequences for the individual and also adds to the overcrowding issue in the emergency department.⁵

Reference: Kim AK, Vakkalanka JP, Van Heukelom P, et al. Emergency psychiatric assessment, treatment, and healing (EmPATH) unit decreases hospital admission for patients presenting with suicidal ideation in rural America. Acad Emerg Med. 2022;29(2):142-149.

Population: Adult patients presenting to the emergency department with suicidal ideation or after a suicide attempt

Excluded: Patients who were medically unstable, in need of co-management of a medical condition, incarcerated, actively violent or determined by the physician to be intoxicated; patients with mental health conditions other than suicidal ideation or attempt

Intervention: After the implementation of an EmPATH unit

Comparison: Before the implementation of an EmPATH unit

Outcomes:

• Primary Outcome: Proportion of patients admitted to inpatient psychiatric unit
• Secondary Outcomes: Any admission including psychiatry, intensive care or medicine; complete versus incomplete psychiatric admission; hospital length of stay for patients with psychiatric bed requested; ED length of stay (LOS); use of restraints in emergency department; scheduled follow-up; 30-day ED return; restraint use.

Study Design: Before-and-after observational study

Authors’ Conclusions: “The introduction of the EmPATH unit has improved management of patients presenting to the ED with suicidal attempts/ideation by reducing ED boarding and unnecessary admissions and establishing post-ED follow-up care.”

Results: There were 435 patients included before the establishment of an EmPATH stage and 527 patients included after. The median age was 32 years, with an almost a 50/50 male/female split. Close to two-thirds arrived as walk-ins, with the rest being brought by EMS or police, and 13 percent were identified as homeless.

Key Result: The EmPATH unit was associated with a significant reduction in psychiatric admissions.

Primary Outcome: Proportion of patients admitted to inpatient psychiatric unit (direct from emergency department, via EmPath unit or by transfer)

• 57.1 percent before versus 27.3 percent after EmPATH implementation
• Absolute difference of 29.8 percent and relative ratio of 0.48 (95 percent CI; 0.40–0.56)

Secondary Outcomes:There were multiple secondary outcomes. One that stood out was the reduction in ED boarding time from a mean of 16 hours to five hours.

EBM Commentary

Before-and-After Study: This was an uncontrolled before-and-after observational study.⁶ An editorial by Dr. Goodacre cautions against these types of studies. One way to address this limitation of uncontrolled before-and-after study design would be to perform a stepped wedge design. This would provide more robust information.⁷

Single Center: This was a single center study done at an academic tertiary referral emergency department in Iowa and may lack external validity to other nonacademic sites in other parts of the United States.

Length of Stay: There was an observed decrease in ED LOS from 16 hours to five hours. If confirmed, this could make a significant impact on ED flow. However, the total hospital LOS for patients who had a psychiatric bed request placed did not change with the implementation of EmPATH. Although this might just be shifting the boarding problem from the emergency department to EmPATH, patients will at least be getting the benefit of a wider scope of care provided in the EmPATH unit.

SGEM Bottom Line: The implementation of an EmPATH unit has been associated with a reduction in ED LOS and psychiatric admissions in this single Iowa hospital.

Case Resolution: You suggest that emergency department leadership should start a dialog with the psychiatric department and explore the idea of implementing an EmPATH unit at your hospital.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Thank you to Dr. Kirsty Challen, who is a consultant in emergency medicine and emergency medicine research lead at Lancashire Teaching Hospitals NHS Foundation Trust, for her help with this review. 

References

1. Moore B, Stocks C, Owens PL. Trends in emergency department visits, 2006-2014. HCUP Statistical Brief #227. Healthcare Cost and Utilization Project; 2017.
2. Ting SA, Sullivan AF, Boudreaux ED, Miller I, Camargo CA Jr. Trends in US emergency department visits for attempted suicide and self- inflicted injury, 1993–2008. Gen Hosp Psychiatry. 2012;34(5):557- 565. doi:10.1016/j.genhosppsych.2012.03.020
3. Crandall C, Fullerton-Gleason L, Aguero R, LaValley J. Subsequent suicide mortality among emergency department patients seen for suicidal behavior. Acad Emerg Med. 2006;13(4):435-442. doi:10.1197/j.aem.2005.11.072
4. Appelbaum PS. “Boarding” psychiatric patients in emergency rooms: one court says “no more”. Psychiatr Serv. 2015;66(7):668- 670. doi:10.1176/appi.ps.660707
5. Nicks BA, Manthey DM. The impact of psychiatric patient board- ing in emergency departments. Emerg Med Int. 2012;2012:360308. doi:10.1155/2012/360308
6. Goodacre S. Uncontrolled before-after studies: discouraged by Cochrane and the EMJ. Emerg Med J. 2015 Jul;32(7):507-8. doi: 10.1136/emermed-2015-204761. Epub 2015 Mar 27. PMID: 25820301.
7. Hemming K, Haines TP, Chilton PJ, Girling AJ, Lilford RJ. The stepped wedge cluster randomised trial: rationale, design, analysis, and reporting. BMJ. 2015 Feb 6;350:h391. doi: 10.1136/bmj.h391. PMID: 25662947.