Emergency Department Psychiatric Observation Units: Good Care and Good Money?

Abstract

The boarding of psychiatric emergency department (ED) patients continues to be a crisis across our country. As health care leaders navigate the challenges of COVID-19 there is an amplified urgency for novel solutions to this complex problem. Congested waiting rooms and hallways, the unfortunate byproduct of boarding, result in EDs becoming a potential focal point for disease transmission. Given the financial losses that many health care institutions have incurred due to the pandemic, understanding the fiscal implications of any intervention is paramount. While prior work has demonstrated improvements in ED operational throughput with the opening of psychiatric observation units,1 there have been limited published data on the financial details of such intervention. In this Issue of AEM, Stamy et al. elegantly describe both the throughput benefit and the enhanced revenue generation that accompany the opening of an emergency psychiatric assessment, treatment, and healing (EmPATH) unit. The EmPATH unit effectively functioned as a space that provided a destination for observation level treatment of ED patients with behavioral health needs. The overall mean length of stay (LOS) along with psychiatric boarding LOS improved. In addition, the number of overall patients (including those with and without behavioral health presentations) who eloped or left without being seen (LWBS) demonstrated significant improvement. Accounting for the cost of the planning, building, and operating the EmPATH unit, net increases in total collections were noted at both the 6- and the 12-month postintervention period. From an ED throughput perspective, adult EDs are the most challenging to manage and measures of throughput must be benchmarked alongside similar EDs. This study was conducted in an adult ED that reports an annual volume 58,000 patients in 35 treatment rooms, representing 1,657 patients per bed per year. Based on recognized adult ED benchmarks this ED simply does not have enough space for the visit volumes seen each year.2 To that end, any intervention like the EmPATH unit to increase capacity should be expected to yield some improvements in LOS. Notably, however, prior work has shown that simply expanding ED bed capacity often has marginal effects on ED LOS in comparison to downstream interventions on hospital capacity.2 Our local team published promising throughput results after opening a psychiatric observation unit in December 2013.3 Improvements in throughput persisted for approximately 2 years until our additional resources appeared to become saturated secondary to ever-increasing demand. Interestingly, much of the economic benefit described through the development of the EmPATH unit was likely the result of emergency care delivered to patients without psychiatric emergencies. The intervention resulted in reductions in the number of patients who either elope or LWBS. Using similar logic, it would seem that any operational intervention focused on these measures could generate the desired secondary revenue production. Specifically, ED front-end redesign interventions including both a physician in triage and split flow models have been studied with similar results.4 Alternatively, additional care space may not need to be specialty specific; adding a general ED observation unit may well have accomplished similar results. However, the evaluation of any intervention should consider outcomes beyond the narrow lens of facility revenue. From that perspective, there are likely several unmeasured outcomes that warrant the creation of a treatment area dedicated to acute behavioral health services. Patients with acute behavioral health presentations often have different needs that can be met in space that is differently resourced and remote from the traditional, general ED. In this study, the EmPATH unit was located on the eighth floor, presumably where the hospital had appropriate space. Additionally, a unit that is less crowded and calmer and staffed with mental health specialists is likely to meet the needs of psychiatric patients better than a more general ED. There are known gaps in acute psychiatric care provided in the ED setting and the ability to more rapidly transition patients to a care space and care team focused on behavioral health likely improves the quality of several care processes such as medication management while reducing the risk of adverse events.5 Patient satisfaction and related quality metrics were not measured in this study but would also be of interest in evaluating the comprehensive effects of an EmPATH unit. While authors comment that no other administrative intervention occurred during the study period, ED operational changes do not occur in a vacuum. By its nature, operations within an ED are not a controlled environment. Rather than acknowledging no intentional significant interventions other than EmPATH internal to the ED, a broader description of changes in the community, hospital, or post–acute care setting that may have had indirect yet substantial effects on ED throughput should be discussed for context when interpreting real-world evidence. Such confounders may limit the internal validity of these findings, but that may be outweighed by depicting an external environment that more closely mirrors other EDs and hospitals across the nation seeking to replicate the clinical and economic outcomes of this work. Emergency departments represent the last resort for patients in crisis. Overcrowded EDs boarding behavioral health patients simply represent a symptom of a broken psychiatric care infrastructure. While investigation of hospital-based solutions remains novel, future areas of study should examine the intersection of social determinants of health care and the need for emergency psychiatric care. Interventions specifically addressing housing and food security may prove both humane and cost-effective in addressing our psychiatric boarding dilemma. Alternative care settings such as telemedicine or care at home have been rapidly accelerated amidst the COVID pandemic and represent an opportunity for investigation. Investment in post–acute care infrastructure dedicated to behavioral health also remains largely unexplored. A national shortage of psychiatric providers highlights the inadequate care afforded to patients in crisis. Research examining the expansion of the scope of practice of ancillary providers or alternative methods to augment the psychiatric labor supply is desperately needed. Over the past 20 years the demand for acute behavioral health services has steadily risen. Preliminary trends suggest that ED visit volume for behavioral health emergencies are less sensitive to pandemic related changes in volume when compared to the general medical presentations. The mantra of “if you build it they will come” is commonly referenced in health care and the success of the EmPATH unit is likely no exception. The data by Stamy et al. are promising and should adequately support ED leader’s need to demonstrate a financial justification to develop a focused behavioral health intervention. Only time will tell if the operational and economic benefits of this intervention can withstand America’s behavioral health epidemic.