Emergency departments are struggling to find new ways to treat mental-health patients, with a growing recognition that crowded waiting rooms are not the best place for a person struggling with suicidal thoughts or psychosis.
But what would a kinder, gentler – and safer – emergency department look like?
A new approach expanding across the United States – and currently proposed by an Ontario hospital hoping to become Canada’s first site – gives the emergency department for mental-health patients a complete open-concept makeover. It has comfortable reclining chairs and soft lighting, even board-game tables, and no locked rooms. More importantly, staff in the unit aim to begin treatment shortly after a person arrives, move patients more quickly out of emergency care and, when discharging, send them home with a planned next appointment.
That’s a big shift from what typically happens now. People coming to the emergency department with mental-health issues wait roughly twice as long as all visitors to the ED, according to the Canadian Institute for Health Information. Families describe sitting in open waiting rooms, their loved ones in obvious distress, sometimes even with injuries from self-harm for everyone to see. Across Canada, police are also responding to more mental-health calls, escorting more people to hospital and waiting longer with them – a presence that can be shaming for patients.
In the fall of 2018, Madison Croskery, then 16, was brought to the emergency department in North Bay, Ont., after a teacher noticed “she wasn’t doing okay.” It was her third visit in a year; the last one had been just 48 hours earlier. Madison, who struggles with depression, broke down sobbing in the school hallway after a fight with a friend. This time, hospital staff deemed her to be a suicide risk and locked her alone in a small room with plastic furniture. It was meant to keep her safe. It felt more like jail.
But being placed in a hospital room doesn’t guarantee safety. In March, 2019, a teenage boy died from suicide at North Vancouver’s Lion’s Gate Hospital after being kept overnight in the emergency department after an earlier suicide attempt brought him to the hospital. There were no beds available in a specialized unit, and he took his own life the next evening, between one-hour checks by staff, according to the coroner’s report. A spokesperson for Vancouver Coastal Health said the hospital had developed new recommendations after a review, including more staff training and additional mental-health nurses in the ED. It also modified two rooms in the pediatric wing for mental-health patients.
Across the country, many hospitals are working on changes to their emergency rooms, often by redirecting mental-health patients to separate areas.
The American innovation – know as EmPath units, which stands for emergency psychiatric assessment, treatment and healing unit – aims to go well beyond a fresh coat of paint and plush chairs to transform how the emergency room functions, so patients can get help faster and go home sooner. The units treat patients often excluded from community-based clinics – those dealing with a psychotic episode or suicide attempt, coming in with a police escort or under the influence of drugs.
Hospitals typically find unused space near the emergency department, says psychiatrist Scott Zeller, who led the first EmPath unit in California. Or they create some; one hospital in Sacramento adapted a portable classroom in the parking lot. Rather than sit behind counters or glass, nurses, counsellors and peer support workers interact with patients on the floor or meet with them in private rooms. “If you are suicidal and feel like you don’t have a friend in this world, getting put in a room alone is not a healthy option,” says Dr. Zeller, who now consults with hospitals to set up the units. “In this unit, nobody is going to tell you, ‘Get back in that room or I am calling security.’ ”
The Ontario Shores Centre for Mental Health Sciences in Whitby, Ont., hopes to become the first in Canada to have an EmPath unit; the hospital, which currently doesn’t have an emergency department, has submitted a proposal to the province as part of a larger expansion. The unit, which would have 32 recliners, would cost about $35-million to build, according to the proposal, and require an estimated $12-million a year to operate. By 2027, the hospital estimated in its proposal, it would be treating 9,700 patents annually, while saving more than $11-million in health care costs.
A 2014 study co-authored by Dr. Zeller and published in the Western Journal of Emergency Medicine assessed the performance of the first units in five California hospitals and found they significantly reduced wait time for patients, the number of hospitalizations and the need for restraints, compared with regular emergency departments.
The University of Iowa hospital, which opened its Crisis Stabilization Unit just over a year ago, reports similar positive results, says Taylor Ford, a social worker and the unit’s assistant clinical director. For example, she says, as mental-health patients were directed to the unit, wait times fell in the main emergency department. The amount of time people spent waiting on a stretcher for an in-patient bed dropped to five hours from 30 hours.
There have been growing pains, she concedes. Family members can’t easily visit in the unit because of the open space. The hospital also underestimated how many staff were needed in the 12-chair unit, leading the sole psychiatrist to quit after a few months, citing burnout. The unit has since doubled its staff, says Ms. Ford, including security guards who are also trained as counsellors.
Patients also stay for an average of 48 hours – longer than the one-day turnaround Dr. Zeller envisions. “We still have a backdoor problem,” Ms. Ford concedes. The unit’s staff book follow-up appointments for patients, and the hospital has opened a drop-in clinic as backup for the unit’s patients. But “anyone who needs an admission is here until a bed opens up,” Ms. Ford says. The advantage, she says, is that while those patients wait, they get food, a change of clothes, counselling and a treatment plan – far superior care to being left in an ED hallway or locked in a room.
And quite different than Madison’s experience. She spent two hours in the room, listening through the walls to the sometimes-volatile conversations between other patients and doctors. “It was so bright,” she recalled of the room. “It had a steel door and a small window. There was a security guard outside.” Her phone had been taken away. “You feel as if you have done something wrong.”
“She still talks about being in that room,” said her mom, Kris Croskery-Hodgins. “She says ‘Never again.' And that is frightening. Because where will she go when she needs help?”
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