SGEM#360: We Care a Lot – The EmPATH Study - The Skeptics Guide to Emergency Medicine

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Date: February 21st 2022

Reference: Kim et al. Emergency psychiatric assessment, treatment, and healing (EmPATH) unit decreases hospital admission for patients presenting with suicidal ideation in rural America. AEM February 2022.

Guest Skeptic: Dr. Kirsty Challen (@KirstyChallen) is a Consultant in Emergency Medicine and Emergency Medicine Research Lead at Lancashire Teaching Hospitals Trust (North West England). She is Chair of the Royal College of Emergency Medicine Women in Emergency Medicine group and involved with the RCEM Public Health and Informatics groups. Kirsty is also the creator of the wonderful infographics called #PaperinaPic.

Case: You are in discussion with your emergency department (ED) manager about the number of patients boarding for hours to days and you are both aware that many of these patients are attending with mental health crises. You wonder whether a model of care involving a specifically designed unit would improve their patient experience and ED boarding times.

Background: We have covered mental health issues only a few times on the SGEM. The latest SGEM Xtra was a very powerful episode with Dr. Tim Graham sharing his story of burnout, anxiety, and depression. This was based upon his article published in the Canadian Medical Association Journal (CMAJ). We also had Dr. Tyler Black on that episode to provide his expertise as a suicidologist.

ED visits in the US for mental health conditions has increased by 44% from 2006 to 2014. Inadequately resourced provision for emergency mental health care is familiar to health care professionals in multiple jurisdictions and patients can spend days in the ED waiting for inpatient admission.

We’ve talked about mental health issues in SGEM #252 in 2019. In that episode we concluded that clinician gestalt was likely to be as accurate and efficient in screening for suicidality as a specific tool (Convergent Functional Information for Suicidality screening tool). Also, in SGEM #313 we recognised that three or more ED attendances for alcohol-related issues was associated with a 1-year mortality risk of over 6%.

Clinical Question: Does the implementation of a dedicated interdisciplinary unit for mental health patients presenting to an ED with suicidal ideation or a suicide attempt reduce inpatient admissions and ED boarding time?

Population: Adults presenting to a single academic tertiary referral ED in Iowa with suicidal ideation or after a suicide attempt – determined using administrative data..
- Excluded: Patients that were medically unstable, needed co-management of a medical condition, were incarcerated, actively violent or judged by the provider to be intoxicated. Also, patients with mental health conditions other than suicidal ideation or attempt.
Intervention: Post-establishment of EmPATH unit Nov 2018 – May 2019.
Comparison: Pre-establishment of EmPATH unit Nov 2017 – May 2018.
Outcome:
- Primary Outcome: Proportion of patients admitted to inpatient psychiatric unit (direct from ED, via EmPATH Unit or by transfer).
- Secondary Outcomes: Any admission including psychiatry, intensive care, or medicine; complete vs incomplete psychiatric admission; hospital length of stay in those with a bed requested; ED length of stay; use of restraints in ED, scheduled follow-up, 30-day ED return; restraint use; code green

Dr. Allie Kim

This is an SGEMHOP episode which means we have the lead author on the show (Dr. Kim). And as a special treat we also have the senior author (Dr. Lee).

Dr. Allie Kim graduated from emergency medicine residency at the University of Iowa last July and now works as an attending physician at Unity Point Health hospitals in Des Moines, Iowa. We also have senior author Dr. Sangil Lee who is a Clinical Associate Professor of Emergency Medicine at the University of Iowa.

The state of Iowa has only a handful of inpatient psychiatric units. The University of Iowa, where the EmPATH unit was implemented, is one of them. We see patients from all over the state, plus even out of state, and with the increase in numbers of mental health presenting to our emergency department, the sheer percentage of our patients needing inpatient psychiatric care was high. And, as many of us have seen, patients may wait in their ER bed for days until an inpatient bed became available. This “boarding” of patients delayed their psychiatric care and left less room for us to see other patients.

Dr. Sangil Lee

The EmPATH program we created, in conjunction with the Department of Psychiatry, is an open concept unit with the capacity to treat 12 adults. Patients must be medically cleared first in the ED, and also be behaviorally appropriate, to enter the EmPATH unit. Once in the unit, there are psychiatrists, nurses, and social workers to help patients. Average stay is about two days and most patients go home after stabilization there; however, if they need additional time, they can be transferred to the inpatient psychiatry unit.

Authors’ Conclusions: “The introduction of the EmPATH unit has improved management of patients presenting to the ED with suicidal attempts/ideation by reducing ED boarding and unnecessary admissions and establishing post-ED follow-up care.”

Quality Checklist for Observational Study:

Did the study address a clearly focused issue? Yes
Did the authors use an appropriate method to answer their question? Yes
Was the cohort recruited in an acceptable way? Yes
Was the exposure accurately measured to minimize bias? Yes
Was the outcome accurately measured to minimize bias? Yes
Have the authors identified all-important confounding factors? No
Was the follow up of subjects complete enough? Yes
How precise are the results? Fairly precise for the primary outcome
Do you believe the results? Yes
Can the results be applied to the local population? Unsure
Do the results of this study fit with other available evidence? Yes
Funding of the Study: Department seed grant

Results: There were 435 patients included in the pre-EmPATH stage and 527 patients included in the post-EmPATH stage. This gives a total cohort size of 962 patients presenting to the ED with suicidality. The median age was 32 years, it was close to a 50/50 male/female split, almost two-thirds arrived as walk-ins with the rest being by EMS or police, and 13% were identified as homeless.

Key Result: Psychiatric admissions were reduced significantly after the introduction of the EmPATH

Primary Outcome: Proportion of patients admitted to inpatient psychiatric unit (direct from ED, via EmPath Unit or by transfer).
- 57.1% in the pre-EmPATH stage vs 27.3% in the post-EmPATH stage
- Absolute difference of 29.8% and RR = 0.48 (95% CI = 0.40 to 0.56)
Secondary Outcomes:
- ED boarding time was reduced from a mean of 16 hours to a mean of 5 hours

We asked Allie and Sangil 10 nerdy questions to better understand their research. Listen to the SGEM podcast to hear their responses.

Retrospective Observational Study – You acknowledge this as your first limitation. Why do you think it is important to caution readers about this type of study design?
Administrative Data – You used administrative data (admitting diagnosis) to identify the patients to include in this study. Particularly with patients presenting after suicide attempt, who may have a diagnosis involving injury or poisoning, how sure are you that you can capture all these?
Before and After Study – This was an uncontrolled before and after observational study. An editorial in the EBM_BMJ by Goodacre cautions against these types of studies.
Stepped Wedge Design – One way to address this limitation of uncontrolled before and after study design would be to perform a stepped wedge design. A multi-centred cluster RCT would provide more robust information. Have you considered this as a future project?
Single Centre – That is a great Segway into another nerdy point. This was a single center study. How representative is your center of US EDs in general and academic EDs in particular?
Confounders – We mentioned in the quality checklist that you haven’t presented rates of substance misuse or previous psychiatric diagnosis in the paper. Do you think they have changed or might have had an effect on the EmPATH unit?
Washout – You had a washout period from May – Nov 2018. Can you explain to listeners why this was important for your study design and what was happening in the ED and EmPATH units during that time?
Length of Stay – In the United Kingdom they have a goal to try to disposition emergency department patients within 4 hours. The decrease ED length of stay (LOS) decreased from 16 hours down to 5 hours. If confirmed, this could make a significant impact on ED flow. However, the total hospital LOS for patients who had a psychiatric bed request placed did not change with the implementation of EmPATH. Might you just be shifting the boarding problem from the ED to EmPATH, or do you think patients still benefit from the wider scope of care provided in the EmPATH unit?
Long-Term Data – Why did you not follow-up on the long-term patient outcome such as suicide related using national data as you had done in previous studies?
Anything Else – Is there anything else you would want the SGEM listeners to know about your research that we have not asked or was not published in the manuscript?

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree that in this case the EmPATH unit has been associated with a reduction in psychiatric admissions and ED boarding times.

SGEM Bottom Line: The EmPATH unit has been helpful in this setting in Iowa but generalisability will depend on how similar other centers are to the one studied.

Case Resolution & Clinical Application: You agree with your manager that you need to look more closely at your local data to work out what are the rate-limiting steps locally, and then to address them with your psychiatric and social work teams.

Keener Kontest: Last episode’s winner was Dr. Steven Stelts (again). He knew Douglas Wilmer was the actor who portrayed Sherlock Holmes on TV died from pneumonia? Listen to the SGEM podcast for this weeks’ question. If you know, then send an email to thesgem@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.

SGEMHOP: Now it is your turn SGEMers. What do you think of this episode on having and EmPATH unit? Tweet your comments using #SGEMHOP. What questions do you have Allie and Sangil? Ask them on the SGEM blog. The best social media feedback will be published in AEM.

Also, don’t forget those of you who are subscribers to Academic Emergency Medicine can head over to the AEM home page to get CME credit for this podcast and article.