Behavioral Health’s Impact on the Emergency Department

It’s no secret that emergency department overcrowding is hitting crisis levels. What’s less talked about, however, is yet another ripple effect from the COVID-19 pandemic that’s contributing to this growing problem—the admission of behavioral health patients to the ED. Already facing reduced staffing along with the collision of RSV, flu and COVID-19, overextended emergency departments simply don’t have the resources to handle the current influx of this growing patient population that is not only showing a rise in the geriatric baby boomer population moving beyond retirement, but is also experiencing a disproportionate increase in self-harm among the 0-24 age demographic.

As the majority of emergency departments are not staffed with mental health professionals, the practice of boarding behavioral health patients in the ED is at an all-time high, yielding financial, operational and clinical implications that are far reaching. As ED staff are often ill-equipped to address behavioral health needs, it can increase a patient’s length of stay, significantly slowing throughput. For example, a patient with a behavioral health emergency requires more than three times longer than a patient with non-psychiatric needs, blocking at least two medical patients from receiving more timely care. 

The Advisory Board reports that behavioral health patients who require extended specialty care in the ED—sometimes in excess of 30 days as they wait for a behavioral health bed to become available—can result in an additional health-care cost of $2,265 per stay, as compared to medical patients who are treated in the ED. Moreover, one in eight patients, and one in five pediatric patients, require mental health services in the ED. Respectively, 55% and 84% of these populations will be discharged without ever seeing a mental health professional. Given such statistics, it’s welcome news for EDs that the government’s Fiscal Year 2023 Budget includes the allocation of $7.5 billion for a new Mental Health Transformation Fund. 


Opportunities Without Capital 

It’s important to note that there are also significant opportunities that don’t require an infusion of capital. These center around health-care providers creating a network of local community partners, including social services, first responders and law enforcement, which underscores a key takeaway with this trend—bringing a person in the middle of a mental health crisis directly to the ED may not be the right avenue to take. There are other solutions available to help avoid an unnecessary ED visit, such as mental health crisis centers and walk-in clinics that can effectively treat the patient and provide a therapeutic environment suited for immediate intervention. At best, the ED can only prevent the patient from harming themselves or others.


Opportunities With Capital   

Although you don’t need to design a brand-new inpatient psychiatric facility to help mitigate the impact of behavioral health admissions on the ED, understanding design flexibility is critical to weathering this current issue. It can start with making some small, low-cost changes internally, and with potentially more involved capital investment opportunities:

  • On the lower side of the cost scale, health-care facilities can make minor modifications to ED exam rooms, like providing psych-safe rooms that feature secure anti-ligature headwalls and med-gas covers that enhance patient safety. 
  • A mental health outpatient clinic where patients can connect to mental health providers via telehealth is another lower-cost option that avoids ED admission while providing walk-in capacity and campus connectivity. 
  • An intervention support facility represents a mid-cost option that delivers a therapeutic environment and the necessary resources to treat a behavioral health patient. 
  • Segregated from the core ED, a psychiatric emergency department is a high-cost opportunity that includes behavioral health staffing in and near the main ED for interventions. 
  • At the top of the cost scale, a crisis stabilization unit offers 24/7, intensive, short-term stabilization for someone experiencing a mental health emergency. The average length of stay in a CSU is three days. 


Shifting Outcomes

Regardless of the solution that aligns best with your facility, a systematic approach to planning and designing an emergency department, as well as supporting behavioral health treatment strategies, requires an in-depth understanding of the operational challenges that accompany each area of treatment. Gresham Smith, for example, targets design drivers as a common language to assist our clients in optimizing staffing and operational resources. In the emergency and mental health space, we engage subject matter experts with operational and clinical backgrounds specifically aligned to evaluate throughput and outcomes, and to further understand the impact to the entire patient flow—from entry to discharge. 

More often than not, availability of beds and services outside of the ED prohibits the effective treatment of behavioral health patients. Therefore, understanding the entire patient journey, along with operations, clinical needs, and design solutions that support the very detailed requirements of behavioral health environments and emergency departments is key. What’s more, it’s incumbent upon the designer to provide evidence-based solutions for each clinical operation. Coming up with solutions to the “right” problem begins with a critical risk assessment of the patient journey in order to align the severity of needs with the treatment planning for the at-risk patient population. 

Although behavioral health within the ED is appropriately focused on safety and security, therapeutic treatment must be included if outcomes are to shift from extensive lengths of stay to immediate intervention that cultivates a positive outcome for the patient, a reduction in boarded patients, and improved operations at lower costs to the patient and the health system alike. 

Ultimately, it is crucial that design supports operations, and not the opposite, where forced workarounds are required to mitigate the challenges and inefficiencies of the built environment.

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