A little boy was brought into an Emergency Department with a broken arm. After being triaged by the nurse, a doctor examined him and determined that the broken arm was his only medical condition. He explained to the boy’s parents that he wasn’t trained to treat broken arms, but that he would try to get him seen by a broken arm doctor. After waiting 12 hours in the ED, the broken arm doctor arrived and declared that this boy had a very serious broken arm and would need to be admitted. He recommended that the boy be given pain killers as it could be several days until a bed would be available.
This story is horrifying. Nobody would allow a child with a broken arm to go untreated for days. Unfortunately, if you change broken arm to mental illness, this story plays out every day in this country. Emergency Departments have become the crisis management point for those with mental illness. There aren’t enough other options for them to receive timely treatment so they go to the ED. Once they are there, they wait for days until a bed becomes available.
Thankfully, hospitals are starting to react to this problem and look for solutions. Having a high number of mental health patients boarded in the ED has a dramatic effect on the throughput of the ED. Beds are unavailable. Staff are distracted. Resources are stretched. Until we achieve systemic change to the way we treat those with Mental Illness, the best we can do is improve the way we treat them at their most vulnerable point.
The challenge for designers is determining what the client needs. Many psych ED projects are driven by a desire to improve throughput. Not enough thought goes into what should happen in the psych area. The decision tree starts with one fundamental question. Are we holding patients or treating patients? There are many variations but most of the models seem to fall into these two categories.
Holding patients is a scaling up of what is already happening in the ED. Instead of being restrained to a gurney, patients are held in a safely designed secure holding room. Instead of chaos, patients are in a calmer environment. This represents a substantial upgrade over the status quo and will improve throughput, but how big do you want to make it? Reimbursement for psych visits to the ED are not adequate to cover the costs of a 3-4 day stay in a holding area, so the cost model is all about overall ED throughput. The more beds you build, the more you spend but if you build too few, you won’t see the improvements in throughput. One way to reduce the number of beds you need to build is to shorten the length of stay. If some of the patients can be treated and released, throughput improves, costs are reduced, revenue increases. Which brings me to option #2.
Providing actual treatment is the second model. In this scenario, the facility and the staff are organized around an operation paradigm of treatment. There may be additional spaces for patients to interact and be observed as well as additional clinical staff to oversee a basic level of treatment. Many patients have previously been diagnosed and treated but are in crisis because they stopped taking their medications or some other obstacle has interfered with their recovery. In a properly designed psychiatric ED, those patients can be stabilized, properly medicated and released with an updated safety plan, making room for other patients in need of support. This is an investment in staffing costs that won’t bring in revenue, but it may save enough money to justify the expense.
So, what is the right answer? It depends. Every hospital’s situation is different. Our approach is to analyze the available data and work with the clinical and operations teams to find the best combination of construction costs and staffing costs to achieve the most efficient and effective model for managing the throughput of the ED as a unit.
I will admit I am biased. I want my clients to choose the treatment model. It just seems like the right thing to do and it sure looks like the numbers work most of the time.
