Emergency departments must aim for change

A little boy was brought into an emergency department (ED) 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 the boy would need to be admitted. He recommended painkillers 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. You already know that EDs have become the crisis management point for those with mental illness. 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. 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 healthcare interior designers is determining what the facility needs. Many psych ED projects are driven by a desire to improve throughput. Not much thought has gone 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.

Two models

Holding patients must be reconsidered in the ED. Instead of being restrained to a gurney, patients could be held in a safely designed secure room. Instead of chaos, patients could be in a calmer environment. This represents a substantial upgrade over the status quo and will improve throughput, but consider how big you want to make it.

Reimbursement for psych visits to the ED are not adequate to cover the costs of a three- or four-day stay in a holding area. If the some of the patients can be treated and released, throughput improves, costs are reduced, revenue increases.

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 the treatment. There are many ways to do this once you get past the question of whether you should adopt the model.

So, should you?

On one hand, it will cost more, both in space and staffing, and you probably won’t be reimbursed adequately for the treatment you provide. On the other hand, the more patients that can be treated and released, the more patients you can see. In other words, actually treating patients won’t make the hospital more money, but it will save on the cost of holding patients without treatment.

I will admit I am biased. I want facilities to choose the treatment model. It just seems like the right thing to do, and it looks like the numbers work.