Studies show that patients in psychiatric crises are entering hospital emergency departments at nearly double the rate of a decade ago, says Leslie Zun, M.D., president of the American Association for Emergency Psychiatry, and professor and chair of the department of emergency medicine, Chicago Medical School, Mount Sinai Hospital, Chicago. He discusses ways hospitals and health systems can help to meet these patients’ needs in the most appropriate care setting.
You’ve described the current situation regarding services for behavioral health patients as a “perfect storm.” Why?
ZUN: In the past, we’ve seen the closure of inpatient psychiatric units and the contraction of outpatient services. So, what’s the safety net for patients with mental illness? They go to emergency departments. Studies have shown that the number of these patients who go to EDs has gone from about 5 to 9.6 percent in the last 10 years or so. That is a huge number, and the reason this is going on is that we don’t have the inpatient or outpatient resources that we used to have for these patients.
What’s the alternative for patients in crisis?
ZUN: I don’t think that the ED is always the most appropriate setting for patients who have mental health issues. It’s appropriate when they have a psychiatric emergency, but a lot of patients have a crisis — such as having a dispute with someone they live with, losing their job, going through a divorce or having some stressor — and rather than going to a crisis center, they go to the ED because there’s nowhere else for them to go.
What’s needed to address this situation?
ZUN: There’s no easy solution to develop new resources to replace those that have been decimated over the last few years. The question is, how can emergency departments better treat and handle this influx?
We have to find other places where patients in crisis can go and work with our community crisis centers and community psychiatric services to see if there’s a better place to take these patients than the ED. We’re going to have to look at what we can do on both the front end and the back end. In the ED, can we be better-experienced, understand these patients better and have new protocols to treat them?
What are some of the best models that hospitals can adopt to treat emergency psychiatric patients in the most appropriate setting?
ZUN: First, you need a comprehensive plan to address what services are available in the community and to make sure all the services are integrated. There’s a great model in San Antonio in which the police, probation departments, courts, hospitals, those treating substance use disorders and other agencies came together to talk about the best way to treat patients who may be affected by substance abuse, homelessness, a psychiatric illness, a medical illness or all of these issues. They formed three integrated units that provide the gamut of services to these patients. One unit works with the homeless, a second site provides psychiatric services, and the last provides substance use treatment. There is significant cross-coverage of services.
How can the physical environment of the ED be improved for assessing and treating behavioral health patients?
ZUN: Currently, when a patient in crisis comes to the ED, there are five big, burly people waiting to greet him. It’s loud, it’s chaotic, and someone puts him in a room and tells him to take off all his clothes and asks him many complicated questions in rapid fire. Most people who don’t have a psychiatric illness are going to find this situation difficult, if not impossible, to deal with, and it’s very stressful.
We conducted studies showing that psychiatric patients feel most agitated when they enter the ED. So, the first thing we need to do is to treat them the same way we treat other patients — by being considerate and understanding of what they’re going through. For instance, we have a code stroke, a code heart, a code trauma, but we don’t have a code psych. We should be saying that this is an acute emergency, we need to address it and appropriately come to the aid of the patient.
We need to think about having a separate area designed for low stimulation that does a better job of serving the patient’s needs. Just as we have a trauma center where all the trauma equipment is located, we need to have all the people and resources for emergency psychiatric patients in a calm and comfortable, low-light environment.
Has Mount Sinai changed its ED design to address these considerations?
We have tried to be more understanding of the patients, and we’ve put in some distractions in their treatment rooms. We’ve added comfortable beds, and we have the ability to turn off some lights so it’s not as bright. We have discussed moving the assessment and treatment of emergency psychiatric patients into triage.
How can hospital leaders and boards assess current capabilities for treating behavioral health patients with acute problems?
ZUN: Health care leaders and boards need to ask themselves: What is reasonable throughput? What is a reasonable amount of time for these patients to be waiting? What services should they be provided? Do we want to help them get housing, insurance coverage or their medications? Do we want to help them navigate the system?
If we say we want something that’s on par with other types of patients, what do we need to do to reach that standard? It may take some creative thinking. It may take finding some creative dollars such as working on grants.
We’re working on a couple of things here. One is starting the patients who are on heroin- and opioid-addicted treatment in the ED and then getting them to a federally qualified health care center. That will get them connected to services much quicker, and there will be a better integration of services.
One other worrisome thing is that many clinics identify the patient’s mental health problems but then don’t know where to send them once they’ve identified their conditions. So, hospital boards and system boards need to think about where these patients are being sent, what resources are available and what services their organization needs to create for these patients.
On a slightly different matter, how can we improve the integration of psychiatric and medical care?
ZUN: We know that about 50 percent of patients who have a chronic mental illness also have a chronic medical illness. About 44 percent in that population have an active substance-abuse problem, according to the studies, and about 28 percent had a previous substance-abuse disorder.
So, first we need to identify that they have multiple problems, and we need to screen and understand what problems they’re having. If we don’t treat each patient as a whole person — meaning that if we don’t treat their multiple problems — then we are not going to adequately treat the individual one.
Once we’ve identified their psychiatric, medical and substance-abuse problems, the second thing is to treat them appropriately and integrate them in services.
What we see is that these patients will go to a clinic for their medical problems, they’ll go to a different clinic for their mental illness issues and they’ll go to a detox center for their treatment. Just think how inconvenient and difficult that is, especially for those patients who have limited resources and limited or no insurance coverage.
Those are the kinds of things that we’re not addressing that concern me. Their medical homes should be addressing all of their problems — the medical, psychiatric and any others — together in one place.
The Zun file
- System chair of the department of emergency medicine in the Sinai Health System, Chicago
- Chairman and professor in the department of emergency medicine and a secondary appointment in the department of psychiatry at the Rosalind Franklin University of Medicine and Science/Chicago Medical School in North Chicago
- President of the American Association for Emergency Psychiatry
What motivated you to select emergency medicine and psychiatric care as your field?
I chose emergency medicine because I wanted to work in a field where I could see the results quickly and feel as though I was making a positive impact on people’s lives. I chose behavioral emergencies because I’ve always had an interest in patients with mental health issues. While I care for them in the emergency department, I’ve been doing research and stayed focused on that area because it’s a huge unmet need. I am an advocate for improving care of the psychiatric patient in the emergency department.
What do you so when you’re not working?
You mean besides taking care of my twins and teaching them how to drive? I like gardening and running.