Go to a hospital emergency department with symptoms of a physical emergency such as chest pain or a broken leg and you’ll be met by a team of doctors and nurses who know exactly what to do. They will assess you quickly and competently using established protocols. Most of them will be compassionate and kind, making you feel safe and cared for.
It’s a different experience if you walk into the same emergency department having an acute behavioral health crisis. Maybe you’re hearing voices or have attempted suicide. You’re upset and scared — probably agitated, irrational, and disoriented. You may have to wait hours in a crowded, noisy waiting room or worse — in a locked examination room, possibly restrained or monitored by a guard. You could be left on a gurney for hours, or even days, until the default treatment, a bed in an inpatient psychiatric unit, becomes available.
Here’s the bottom line: Psychiatric patients in the emergency department can end up being treated as less than human. All too often, I’ve seen the standard approach to care escalate what is already a tenuous, scary, and traumatic situation for everyone.
And we’re up against some frightening numbers. Emergency visits for suicidal thoughts and suicide attempts have increased by more than 40% since 2006, while behavioral health visits to emergency departments have increased by nearly 57% for children and 41% for adults. And every emergency department across the country has witnessed an explosion of opioid overdoses — another tragic manifestation of untreated mental illness.
In my 20 years as a hospital-employed physician working hand in hand with my emergency medicine colleagues, I know firsthand that addressing this need begins with changing the way we relate to these patients. This begins with listening and approaching patients as the human beings they are.
The most effective tools we can use are ones we already possess: empathy, kindness, and a mindset of treating people the way we would want to be treated. This is the essence of the EmPath model (short for emergency psychiatric assessment, treatment, and healing unit), which creates a safe space designed to calm and stabilize patients in behavioral health crises.
Here’s how physicians affiliated with Vituity, the company I work for, use the EmPath model in emergency departments across the country:
A calm environment. Instead of making a patient in crisis wait in the noise and chaos of an emergency department, offer a quiet, darkened space with comfortable chairs to help patients relax.
De-escalation. Patients may come in frightened, angry, or out of control on drugs. While some of them cannot be calmed down by simple dialogue, a surprising number can. Speaking slowly and quietly and assuring them, “We’re going to get through this together,” goes far in reducing aggression and building trust that the clinicians are there to help.
Immediate access to a psychiatrist. In the EmPath model, every behavioral health patient is seen right away by an emergency psychiatrist. If one isn’t available on site, patients are given access to one via video. These telemedicine consults work. In fact, many patients find it easier to open up, be vulnerable, and talk honestly when the person they’re talking to is on a screen.
This approach delivers substantial benefits. First, the focus on immediate care means patients get treated and discharged instead of being admitted. Emergency rooms employing the EmPath model have seen a 75% drop in hospitalizations. This helps to avoid boarding, the practice of leaving patients on gurneys while staff members try to find patients inpatient beds. Eighty% of patients seen at an EmPath unit go home within 16 hours.
Like most changes in care delivery, more humane treatment of behavioral health patients in emergency departments won’t be fixed from the top down. Physicians and administrators need to listen to the people on the front lines: nurses, most importantly, but also paramedics and social workers.
Modernizing outdated processes and procedures empowers providers to deliver quality care for all patients, improving outcomes and creating a better experience for patients while reinvigorating health care providers’ passion for their work. Most importantly, patients experience care on a human level which gives communities the confidence and comfort of knowing their local emergency departments can be trusted to handle any health care crisis.
Denise Brown, M.D., is chief strategy officer for Vituity, a physician led and owned multispecialty partnership that delivers acute care to patients in 14 states.
I have a long psych history. The Er has always treated me with respect and kindness. The have always recognized the crisis and helped me get calmed down. The nurses ands cnas have been helpful and made sure my needs were met.
YES! As someone who works in Health Care, but has a Veteran spouse with PTSD, Major Depression, and chronic health issues that leave him with physical pain resulting in 3 emergency surgeries in 2019 alone, I wholeheartedly agree. Patients are treated like prisoners. My husband reached some very dark places, he called the VA Hotline from a Hospital parking lot. The VA sent the local police to my home. My husband voluntarily walked into the ED to get help, as he was encouraged to do by the VA I’m sure… he was put on an involuntary hold. They made him change into a gown and kept him in the ER for hours until they transferred him to an Inpatient BH facility where they kept him against his wishes for 2.5 days! They stripped him of everything. He was also undergoing changes to his meds during that time. He did not get to talk to a Psychiatrist until almost Day 3. Visiting hours were restricted like a prison. He did nothing but sit around at this Inpatient facility. Staff treated him like he was crazy even though he kept telling them that he was fine. Naturally, he was pissed off even more being held hostage. My husband is getting help from a VA Psychiatrist, VA Therapist, and a private Psychotherapist all on his own. He is TRYING to get help. He did the RIGHT thing and what does he get? Imprisonment. Do you think he will ever reach out for help again when he actually needs it???? NO! The system treated him like a prisoner and did not handle him with care. It is horrifying!
“Patients may come in frightened, angry, or out of control on drugs. ”
This is correct. The drugs often were prescribed by their physicians and taken as directed. The prescribing of multiple psychoactive medications can cause serious illness. The custom is to add drugs to combat deleterious effects of the currently prescribed drugs. How often is an offending drug discontinued before adding additional drugs? What percentage of ER “behavioral health” patients are manufactured-mental-patients? Is there any effort to distinguish these iatrogenic mental cases from the more naturally occurring mental dysfunctions?
However, the fact that the author is earnest enough to write that piece is encouraging.
I agree! I am a retired psychiatric/ mental health nurse practitioner who’s career included emergency room coverage ( on call). As a NP I had broader perspective & experiences. I could perform the tasks of multiple professionals and consequently completed the whole MSE, re treatments, and dispositions in an expedient manner. And I was paid less! ( I’m sorry to say).
Dr Brown is on target & needs to be heard! I have witnessed this callous behavior repeatedly & consistently! It’s past time for a change!
Marge, thanks so much for reading – and for your many years working to help patients in crisis. For those who suffer from mental illness, having someone like you with the experience to quickly and effectively navigate the process makes a big difference. I hope that more awareness and education of new approaches can help more patients get the care they need faster.
Patients with pain conditions are also discriminated against at ERs, they are labeled and dehumanized. This is after their long term physicians just stopped treating their pain. There is a lot of misinformation in healthcare, and why the ER is the only real option for many people. Physicians are under no obligation to return phone calls, or even arrange an appointment, when patients are in distress, or need an appointment. Of course all of this falls on the lower reimbursing patients, while patients with better insurance don’t have that much of a problem.
Our state cut funding to behavioral health, leaving many people with no options, and there is little accountability for the few remaining mental health providers. This left only the local ER as an option. People are quick to jump in and claim that the ER is not an appropriate place of any of this, as cuts are made to any system that was in place.
The ERs have worked very well to protect their profits and bottom line which includes turning away people with serious mental health issues, and over the years they referred a lot of people in distress to the criminal justice system. Evidence tells us that this is costly and only increases mental health issues. One young man with schizophrenia in my community was shot 17 times by police after he was refused treatment at our local ER. He was brought in by the sheriffs department, which indicated there was a serious problem. The hospital, a religious non profit, had their million dollar a year spokesperson claimed that “Some people just don’t want to be helped.” This was not an unusual situation at this ER or many others, the only thing unusual was that the poor guy did not go off an die in a ditch somewhere, like most of the people they turn away.
Our healthcare system is much too broken to expect that a proprietary software program will improve behavior. There is no accountability, and when the hospital is faith based, no expectation of decency or empathy can be expected. There is no way to track how many people had a medical condition worsen due to the lack of empathy or humanity at an ER. Of course when profit is the only motivator, these things very likely happen every day. It is like a slow Genocide!
Dr. Brown:
Thanks for your thoughts.
May I add another in the form a question:
Is the ER the right place for a behavioral crisis?
Perhaps what we’re seeing is a shift in coping skills at the same time as society not knowing how to cope with this self-same change.
The ER may not be the right place for everyone who feels a need.
To paraphrase Paul Seward, the ER can do anything, it just can’t do everything.
Tom, thank you for your question. Patients in behavioral crisis often have no place for treatment other than their local ED. In our experience, one effective way to deliver compassionate care and decrease the burden on EDs is by having a separate space designed for de-escalations and equipped with an experienced team skilled at handling acute behavioral crisis. For example, here are some results for one in Iowa City: https://www.press-citizen.com/story/news/2019/04/12/new-psychiatric-crisis-unit-iowa-city-creating-improved-outcomes/3446650002/
I had a few more thoughts on why EDs are the best place for behavioral health emergencies, shared on LinkedIn [https://www.linkedin.com/pulse/eds-best-place-treat-behavioral-health-emergencies-denise-brown-md/].
As a nurse with 40 years under my belt, I as so interested in this approach in the ED…I am currently an ED nurse and would welcome additional information, support and education on how I can be a part of this transition. Thank you
Hi Denise,
I work closely with Dr. Brown and our behavioral health experts. I’d be happy to share some additional information with you and perhaps connect you directly with somebody on our team. Please feel free to send me an email to get the conversation started.
Best,
Erin
My daughter is autistic and it frightens me that the psychiatrist can send a child/young adult to a psych ward if they feel the individual is a danger to themselves or others without the consent of parents. There will be a great need for emergency care like this because so many individuals have been diagnosed with autism. We need medical personnel who will be capable of handling meltdowns or people who self inflict. Ther needs to be personnel who can provide support and counseling to parents and family members of the patient. Its scary to think of what could happen to my child when i am no longer able to care for her or im dead. Nobody will love her and care for her like her father and i.
As a former psych patient, this really resonates with me. The times I’ve been in the ED, I’ve waited hours to see a doctor. Even after telemedicine became a thing in my local ED, I’ve waited hours for one. And it wasn’t with a doctor. In on ED visit, I was put in a room and told to put on a gown (fine) minus my socks, bra and underwear (not fine). I felt…. I don’t know. I don’t have the words to describe it. I was completely alone. Nobody came to check on me. I had no call button. I had to go to the nurse’s station to ask to go to the bathroom.
Thankfully, my illness is in remission. But the way I was treated the last time in the ED (what I described above) makes me less likely to seek help should things go south in the future.
Kathryn, I’m so sorry that you didn’t get the empathetic care you needed, when you needed it. With the shortage of trained emergency psychiatrists and the resulting lack of understanding about mental illness your story is unfortunately very common. But I’m hopeful that as patient-centric approaches become more adopted, longer waits and negative experiences happen less and people get the care they need and deserve. Good luck in the future, I’m glad to hear you are well. – Denise