Hot off the press: We care a lot: The <scp>EmPATH</scp> study

Over 8 million emergency department (ED) visits with psychiatric or substance use–related diagnoses occurred in the United States between 2007 and 2016.1 This may reflect difficulties in accessing urgent psychiatric care2 and is often associated with prolonged delays in transfer to inpatient psychiatric facilities.3 Various models of provision of psychiatric emergency care, including a centralized psychiatric assessment facility,4 a dedicated psychiatric ED,5 and community crisis interventions,6 have been shown to reduce inpatient psychiatric admissions and reduce ED boarding times. The EmPATH unit was established at the Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, in October 2018. It provides stabilization and treatment for up to 12 patients from a team of psychiatrists, nurses, and social workers for 1 day to several days to include medication, referral for substance use disorders, and support with financial and housing problems. This article is a before (November 2017–May 2018) and after (November 2018–May 2019) assessment of the effect of establishing an EmPATH unit that provided care for up to 12 mental health patients at a single tertiary referral site in rural Iowa. The unit was staffed with psychiatrists, social workers, and nurses and patients had access to recliners, restrooms, laundry facilities, and a calming room. The authors assessed whether the establishment of the EmPATH unit was associated with a reduction in the proportion of patients admitted to inpatient psychiatric facilities (primary outcome) and altered ED boarding time, restraint use in ED, and 30-day ED returns (secondary outcomes). As a before-and-after design, this study has inherent limitations in that other factors that may influence outcomes such as changes in case mix, referral patterns, or other parts of the care system cannot be isolated from the effect of the studied intervention.7 However, the authors compared many important patient demographics (age, gender, race, homelessness, and insurance coverage) between the two groups and found no difference. They did not, however, compare rates of substance misuse or previous psychiatric diagnosis, which could potentially have changed the patient journey through care. The single-center setting of the study limits generalizability of the findings; as a tertiary referral unit with an annual census of 60,000 of predominantly White patients the University of Iowa Carver College may not be representative of other populations. As the senior author Dr. Lee said in discussion on the SGEM podcast, the establishment of the EmPATH unit required significant financial investment and buy-in from the psychiatric team and this would need to be considered by any clinicians expecting to replicate the unit. The authors included 435 patients in the pre-EmPATH stage and 527 in the post-EmPATH stage with a median age of 32 years and a near-even gender split. For the primary outcome of psychiatric admission, rates decreased from 248 (57%) to 144 (27%), resulting in a relative risk of 0.48 (95% confidence interval [CI] 0.40 to 0.56). Mean ED boarding time reduced from 16.2 to 4.9 h (95% CI −1.23 to −0.99), restraint use in ED was unchanged at 2.8% versus 3.8%, and 30-day ED returns reduced from 20% to 15% (relative risk 0.75, 95% CI 0.57 to 0.99). Joshua (@reverendofdoubt): We have one and it's amazing. Couldn't imagine not having one! Abhi “Searching for the Truth in the Universe” (@EMIMMD): We have created a virtual model of this and have recognized real outcomes in numerous outcomes. Suneel Uphadye (@SuneelUphadye): I have been fortunate to work in ER systems that have embedded emergency psych services for acute mental health crises… Vital and priceless service!! Establishment of the EmPATH unit was associated with fewer psychiatric admissions and a reduced ED boarding time in this unit in Iowa. Clinicians or administrators hoping to replicate this should consider how comparable their practice setting is to the site described here.

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