After tracking boarding times for 30 days, Zeller found that the average boarding time in the Alameda Model was less than two hours (107.6 minutes). Zeller also says he found out something else equally important from the study's results: Only 24.8% of patients actually needed an inpatient bed. "The one thing that has been missing over the concern of a dwindling number of inpatient beds is any alternative to inpatient beds," says Zeller. "All too often the default solution for every mental health problem is to admit a patient to the hospital first and start treatment later. It doesn't make any sense to me. Not nearly enough places are considering trying to do urgent treatment on arrival, seeing what they can do in those first 24 hours when so many patients can have their urgent symptoms relieved."
Success key No. 3: Telepsychiatry on demand
Seton Healthcare Family in Austin, Texas, an 11-hospital system that is part of Ascension Health, is trying to make a dent in helping psychiatric patients within the first 24 hours of their presenting in an emergency room.
It just opened a new stand-alone psychiatric ED at its downtown Austin location, University Medical Center Brackenridge.
"This is the Seton hospital which bears the brunt of psychiatric patients in the ED," says Kari Wolf, MD, vice president of medical affairs for psychiatry, who is overseeing the psychiatric ED. "It's located close to the local mental health center, and there's a large homeless population in the geographic area."
Wolf says Seton decided to include a 24/7 telemedicine suite in the new psych ED. She expects it to reduce the boarding time of psychiatric patients, inpatient admissions, and ED costs.
"We spend $30,000 a month at University Medical Center Brackenridge on sitters in the ED," says Wolf. "We anticipate that will be pretty much gone with new psychiatric ED because we're not going to need them. It's a safer environment."
Wolf says Seton began using telemedicine in its Brackenridge ED and then spread it to its more outlying hospitals in 2012.
"If someone gets brought in, we were able to get a psychiatric assessment right away and some were able to go home," says Wolf. "Before, if they came in Friday night, they would have had to wait until Monday morning for an assessment. Other times, we were able to treat people, so instead of waiting until Monday morning to start treatment, they could start Friday night."
The on-demand telepsychiatry even helped patients who were going to be admitted and were waiting for a bed, she says, because beginning treatment reduced their anxiety, which can be compounded by the chaos of an ED.
Success key No. 4: Behavioral emergency response team
Another aspect of treating psychiatric patients in regular EDs is the danger they can pose to staff. Furniture, IV poles, and trashcans that are typical in an ED room can become weapons if a patient is in an elevated state of agitation.
At SSM Health Care–St. Louis, a seven-hospital system, a new emergency response process is in place because of the results of a pilot program called BERT, for behavioral emergency response team.