CHPR: Dr. Nordstrom, please tell us about yourself.

Dr. Nordstrom: First and foremost, I am an emergency psychiatrist. I have been working in this field for years and have a passion for it. I am also drawn to healthcare policy and administration, especially when it comes to models of care. As a past president of the American Association for Emergency Psychiatry and past chairperson of the Coalition on Psychiatric Emergencies, I have had opportunities to tour many emergency/crisis psychiatric facilities and learn about different models of care.

CHPR: Let’s start by reviewing what EmPATH stands for.

Dr. Nordstrom: EmPATH stands for “Emergency Psychiatric Assessment, Treatment, & Healing unit.” EmPATH units provide prompt, empathetic care to patients in psychiatric crises. Their goal is to help patients improve quickly, and they have the added benefit of reducing emergency department (ED) boarding and overcrowding.

CHPR: What led to their development?

Dr. Nordstrom: In recent years, there’s been a movement to transform the way mental health emergencies are handled in the US. In 2010, the American Association for Emergency Psychiatry embarked on a huge project to identify best practices in the evaluation and treatment of agitation. It was called Project BETA (Holloman GH Jr and Zeller SL, West J Emerg Med 2012;13(1):1–2), and it shook up the system and is now being used around the world. It taught clinicians the steps to provide empathetic care to help de-escalate an agitated patient. Dr. Scott Zeller worked in a psych emergency service (PES) in Alameda County at the time and created a model that incorporated Project BETA’s principles. It was called “the Alameda Model” and provided an alternative to EDs where the local EMS and police could take psychiatric patients directly. When I visited this PES, I saw about 40 patients in an open milieu. I could tell they were quite ill, yet the unit felt calm and healing. That was, in effect, the first iteration of an EmPATH unit. Since then, the model has evolved so that it can be implemented in any type of hospital—urban, rural, academic, or community.

CHPR: Open milieus are a central feature of EmPATH units, right?

Dr. Nordstrom: Yes, the open-milieu model is a key part of the EmPATH units. Patients can easily get their basic needs met, such as grabbing a blanket or snacks. The most important part, I think, is that patients can walk around. Most psychiatric EDs keep people in their rooms. When a person is feeling out of control and just wants to pace or look out a window and instead they’re stuck in a room, that just makes them feel worse.

CHPR: But what happens if a patient is assaultive? Some of our patients can be highly agitated and psychotic. Won’t staff and other patients potentially be in danger?

Dr. Nordstrom: The open milieu helps prevent those behaviors in the first place. Unlike most psychiatric EDs, where the staff are in a “fishbowl” behind glass because of their belief that they need protection, EmPATH staff are out engaging with the patients. They chat, play board games, or just sit there with the patients, and they are always monitoring for agitation. They catch it in its earliest forms when it is mild and staff can do something about it. The whole atmosphere of an EmPATH unit is quiet and calming, with soothing art, comfortable seating, board games, TVs, books, magazines, and snacks. And EmPATH units have quiet rooms for patients who want some privacy. These rooms can also be used for seclusion and restraints (S&R) if necessary (Editor’s note: See Q&A on S&R in this issue).

CHPR: It would be hard for nurses in my hospital’s psychiatric ED to find the time to play board games with individual patients. How do EmPATH units provide sufficient staffing for this one-on-one time?

Dr. Nordstrom: Peer support specialists help, as well as nursing aides who are on-site around the clock. It’s not always one-to-one; often you’ll see two or three EmPATH patients at a time playing dominoes with one of our staff members. These interactions help patients relax, to the point that they often become more forthcoming about their current crisis.

CHPR: These units sound much less hectic than typical EDs.

Dr. Nordstrom: Think about how easy it is to be frustrated in a typical ED. If you have ever been a patient in an ED, you probably had a long wait, became hungry, and just wanted to get back home. EDs are also quite noisy, putting the average person on edge. Now add on to that a person who is in a mental health crisis. One hallmark of agitation is a heightened responsiveness to internal and external stimuli (Lindenmayer JP, J Clin Psych 2000;61(Suppl 14):5–10). You can see how easy it is, just from the nature of a typical ED, to exacerbate symptoms.

CHPR: And patients are seen promptly in a EmPATH unit, right? I’m sure that helps reduce their frustration.

Dr. Nordstrom: That’s the other reason why agitated patients tend to do better in EmPATH units. Treatment is initiated within one hour of arrival. That’s not always the case in an ED or in a PES.

CHPR: Right, patients sometimes wait hours to be seen in an ED. What do the data show about how EmPATH units compare with traditional EDs?

Dr. Nordstrom: To start with, the use of S&R is low in EmPATH units even though most patients are on psychiatric holds. Dr. Zeller made a presentation to the California State Senate and Assembly Health Committee in December 2021, where he reported the rate is 0.1%–0.2%. That’s significantly less than the rate in traditional psychiatric EDs, where it’s in the realm of 14% (www.tinyurl.com/ymts5kkf; Simpson SA et al, Gen Hosp Psychiatry 2014;36(1):113–118). However, there are no peer-reviewed, published data on this yet.

CHPR: What else do the data show?

Dr. Nordstrom: A recent study showed that ED length of stay dropped from an average of 16 hours to five hours when patients were transferred to an EmPATH unit. The study also found that inpatient psychiatric admissions dropped from 57% of patients in the psych ED to 27% of patients in the EmPATH unit. The 30-day rate of psych patients returning to the ED dropped by 25%, and outpatient follow-up of patients improved by 60%, from 39% to 63% (Kim AK et al, Acad Emerg Med 2022;29(2):142–149).

CHPR: Those are impressive statistics. About one in eight patients in EDs are psych patients, right? So, if we can get more widespread use of EmPATH units, that could help us reduce overcrowding and provide better care.

Dr. Nordstrom: Right. Patients in behavioral health crises really add to ED overcrowding. One of the problems is that if they call their outpatient provider and it’s after hours, they’re told, “If you feel like you’re in an emergency, dial 911 and go to your nearest ED.” That can be tricky, as many times patients are unclear as to what constitutes an urgent versus emergent issue. Another problem is that those patients often don’t receive any care for their underlying mental health issues. They’re just boarding while they wait for an inpatient bed. If those patients instead received care in the ED, we might turn that person from an inpatient to an outpatient because the crisis may have abated. This is how other medical conditions are typically handled. If a patient shows up with an asthma attack, they get treated in the ED. They’re not told to wait in a room until an inpatient bed becomes available. But for mental health patients, emergency physicians often see the disposition options as binary: It’s either traditional outpatient treatment, or the patient is in a crisis and needs an inpatient admission.

CHPR: What mental health services do EmPATH units offer?

Dr. Nordstrom: They provide several treatments: medications, family counseling, psychoeducation, therapy, and safety planning. They are able to provide those services and divert about 80% of patients that come into a PES and not have to admit them into a hospital (Zeller S et al, West J Emerg Med 2014;15(1):1–6).

CHPR: Over what time frame do patients improve?

Dr. Nordstrom: Patients typically get better within 14–18 hours. The goal of an EmPATH unit is to keep stays shorter than 24 hours.

CHPR: Are there separate units for children?

Dr. Nordstrom: Yes, it’s important to not commingle children with adults. Some places might not be able to truly have them in separate spaces, but they keep kids sequestered on one part of the unit. The University of Minnesota is building a pediatric EmPATH unit specifically for children and adolescents that’s opening in 2022.

CHPR: Are EmPATH units usually housed next to an ED?

Dr. Nordstrom: They can be either in a hospital by an ED or elsewhere on the campus, or even elsewhere in the community, like the Alameda Model. But they are always affiliated with a specific ED or EDs, and they are under a hospital license, as opposed to being a community-based program.

CHPR: And that affiliation with EDs helps in cases of high-acuity and violent involuntary patients who are not able to tolerate the open-milieu environment because those patients can then be transferred to the ED, right?

Dr. Nordstrom: I believe that would be a rare occurrence, as the specialists for helping the severely agitated patient are at the EmPATH unit. They can treat severe agitation in the unit. The affiliation is more important for cases of agitation that result from medical emergencies. The person may start at the EmPATH unit, but the medical and psychiatric workup may reveal that there’s a medical etiology for their agitation.

CHPR: So much of what happens in EDs and psych EDs is just boarding, and often nothing is being done to heal the patient. EmPATH units seem like such a good alternative. But we do have mental health urgent care centers and crisis stabilization units (CSUs). How are EmPATH units different from those?

Dr. Nordstrom: Urgent care centers are usually set up like walk-in clinics and generally handle minor issues, such as patients who’ve run out of their medications or who are feeling a little down. They might occasionally be placed on a mental health hold, but this is rare. CSUs are for higher-acuity patients, and they can stay for as many as five days. The CSUs can’t do medical workups, but they can provide some medications and supportive therapy, and some of them have groups. So, depending on the location, they may be similar to EmPATH units, but the primary difference is that EmPATH units are for high-acuity patients who would otherwise be in an ED awaiting care. EmPATH units are an “emergency path” to the most appropriate level of care. Also, EmPATH units can more thoroughly evaluate the presenting issue and offer a larger array of treatments.

CHPR: Could EmPATH units completely replace psych EDs?

Dr. Nordstrom: The units do many of the same things that a psych ED does, but they go further in terms of trauma-informed care and in having a healing aspect. I would love for psych EDs to all evolve to this, but not everyone is comfortable with the open-milieu model.

CHPR: It might just be a matter of staff becoming more comfortable with the idea of being out there mingling with the patients.

Dr. Nordstrom: Right. If staff feel comfortable with performing de-escalation, they’ll have a lot less fear.

CHPR: We ran an article with Janet Richmond on principles of de-escalation and the Project BETA principles (Editor’s note: See CHPR Jan/Feb/Mar 2022 for this Q&A).

Dr. Nordstrom: Yes. She was the lead author on the de-escalation article (Richmond JS et al, West J Emerg Med 2012;13(1):17–25). Once frontline staff understand de-escalation, they’ll be a lot more comfortable with mingling with patients in open milieus like EmPATH units.

CHPR: Thank you for your time, Dr. Nordstrom.