Questioning the Status Quo in Psychiatric Emergency Care

If you've treated mental health or substance use patients in the emergency department (ED), you've probably experienced it.

A patient arrives in crisis, receives an initial medical evaluation, and then waits.

The hours tick by, their symptoms worsen, the waiting room backs up, and everyone involved feels powerless to change the situation.

As I watched this scenario unfold repeatedly as a young psychiatrist, I found myself asking:

Why are we still doing it this way?

That question transformed my career.

Today, as a clinical leader, educator, and patient advocate, I believe the greatest opportunities to transform care don't arise in the boardroom or startup incubator. They’re at the bedside.

Clinicians are the first to see where systems break down, assumptions no longer serve patients, and better approaches are possible. We therefore have a responsibility to question the status quo and to develop solutions.

This mindset led me to rethink how psychiatric emergency care is delivered, and it's one I hope more physicians will embrace.

The Challenge: Rising Demand for Crisis Care

The need to rethink psychiatric emergency care has only become more urgent, because hospitals are caring for more psychiatric patients than ever before. Behavioral health emergencies now account for one in every eight ED visits (about 8 million annually).^1,2 Meanwhile, visits for suicidality have risen substantially over the past decade, a trend that only accelerated after the coronavirus pandemic.³

According to the Emergency Medical Treatment and Active Labor Act (EMTALA), behavioral health emergencies are emergency medical conditions, just like heart attacks and acute abdominal pain.⁴ EDs are therefore required to evaluate and attempt to stabilize and treat these patients. But because hospitals have historically had limited access to psychiatrist coverage, the more common means of compliance has been to admit to an inpatient psychiatric facility.¹

This approach reflects an outdated medical paradigm. It's equivalent to admitting every patient who presents with chest pain rather than initiating prompt evaluation and treatment to determine who truly requires inpatient care. (In practice, only about 10 to 20% of chest pain patients are admitted from the ED.)⁵

To further complicate things, there are now far more patients awaiting admission than inpatient psychiatric beds available.⁶ As a result, patients in behavioral health crisis often spend hours or even days boarding in the ED, typically on hallway gurneys or in small rooms with a sitter or security guard nearby.^7,8 These delays are known to worsen psychiatric symptoms, increase the risk of agitation and aggression, and lead to poorer outcomes.

The systemic consequences are substantial. Psychiatric patients experience ED lengths of stay nearly three times longer than average.⁹ Boarding contributes directly to crowding, walkouts, medical errors, and care delays for all patients. From a hospital finance perspective, prolonged psychiatric stays reduce bed turnover and increase staffing, security, and sitter costs while also contributing to clinician burnout and safety issues.

The Solution: Designing and Scaling a New Care Model

For me, understanding the problem wasn't enough. The harder question was why we accepted boarding and routine admission as the default for behavioral health emergencies. I've long believed that psychiatric crises deserve the same approach as every other emergency: rapid assessment, immediate intervention, treatment in the least restrictive setting, and disposition based on clinical response.

As Chief of Psychiatric Emergency Services at Alameda Health System in the early 2000s, I began testing a different model. Instead of boarding medically cleared patients in the ED, we moved them to a dedicated therapeutic setting focused on rapid assessment, active treatment, and stabilization. At the time, we weren't trying to create a national model. We were simply asking whether treating people immediately could reduce the need for hospitalization.

The results exceeded expectations. Most patients improved quickly, many avoided hospitalization altogether, and the participating EDs significantly improved throughput and reduced wait times.¹⁰

As the evidence mounted, so did interest from health systems looking to replicate this "Alameda Model." Publishing the research was an important first step, but it didn't tell hospitals how to build and sustain a successful program. To bring this approach to more patients and communities, I needed to help organizations implement it from the ground up. That's what ultimately led me to Vituity, where I now lead the Acute Psychiatry and EmPATH Consulting programs.

Vituity recognized that the Alameda Model wasn't just a successful clinical program, but a fundamentally different approach to psychiatric emergency care. With Vituity's financial, clinical, and operational support, I was able to further refine the concept and expand its reach to health systems across the country.

Over time, that work evolved into the Emergency Psychiatric Assessment, Treatment, and Healing (EmPATH) model, a comprehensive approach that combines evidence-based clinical care with intentionally therapeutic environments, compassionate and noncoercive interactions, peer support, patient-centered design, and operational best practices.

The Difference: Treatment First

EmPATH units are hospital-based and serve as the designated destination for psychiatric emergency patients following basic medical clearance. They are not holding areas where patients await transfer. Rather, they function as extensions of the ED, where psychiatric assessment and treatment begin immediately and continue throughout the patient's stay. Importantly, EmPATH units treat the full spectrum of psychiatric emergencies, including patients on involuntary holds due to danger to self or others or grave disability.

An EmPATH unit’s physical environment is intentionally designed to support treatment, with open spaces, natural light, and comfortable recliner chairs that replace hallway gurneys. Voluntary calming rooms provide an alternative to locked seclusion when patients need a quieter space. The layout emphasizes visibility, safety, and patient dignity, helping reduce agitation and encourage engagement.

Care in EmPATH units is psychiatrist-led, with continuous reevaluation. Multidisciplinary teams — including psychiatric nurses, social workers, and peer support specialists — engage patients from arrival through disposition. Treatment emphasizes trauma-informed, recovery-oriented care that prioritizes de-escalation, patient autonomy, and therapeutic alliance. Restraint use is exceedingly rare, typically occurring in far less than 1% of patients.¹¹

From the beginning, it was important to me to keep EmPATH nonproprietary so any health system could adopt the model without licensing fees. EmPATH has also been widely featured in research literature and popular media, helping more health systems bring it into practice and expand access to effective psychiatric emergency care.

The Results: Better Outcomes at Scale

Published outcomes from the University of Iowa’s EmPATH unit illustrate the model’s impact. As reported in Academic Emergency Medicine:

• ED length of stay for psychiatric patients decreased by approximately 70%, from 16.2 hours to 4.9.
• Inpatient psychiatric admissions dropped by more than 50%.
• Attendance at outpatient follow-up appointments improved by over 60%.
• Despite shorter ED stays, thirty-day revisits declined by over 25%.
• We deduced from these findings that the program generated a positive net financial impact for the ED and significant savings for payers like Medicaid. ¹²

The results have been remarkably similar across diverse health systems. In our work implementing EmPATH programs in community and academic hospitals, in both urban and rural settings, we've found that 70% to 80% of patients stabilize without admission. We've also seen fewer restraints, improved ED throughput, lower readmission rates, and high levels of patient and clinician satisfaction. Many organizations have repurposed existing hospital space, making implementation possible without major capital investment.

Today, the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) recognizes EmPATH as a defined level of the behavioral health crisis continuum and calls it one of the most accessible, lowest-barrier models of care, as well as one of the programs best equipped to treat highly acute patients.¹³

The Invitation: Help Transform Psychiatric Emergency Care

Throughout my medical career, I've learned that the most meaningful changes don't come from accepting the status quo. They come from refusing to believe that "this is just how it's done."

If you're frustrated by psychiatric boarding, delayed care, or other systemic issues, don't underestimate your ability to make a difference. You see these challenges every day. That also means you're uniquely positioned to help solve them.

EmPATH began with a simple question. Over time, that curiosity evolved into a new care model that has improved outcomes for patients, reduced strain on EDs, and inspired change well beyond the health system where it began. By 2027, more than 100 EmPATH units are expected to be operating across the United States, demonstrating what's possible when physicians challenge assumptions and commit to building something better.

Innovation doesn't happen in isolation. It requires curiosity, persistence, evidence, and an environment that gives clinicians the freedom and support to turn ideas into reality. Organizations matter because they determine whether good questions become better care. Throughout my career, I've been fortunate to work in places that encourage this kind of thinking.

If you're a physician or advanced practice provider who wants to transform psychiatric emergency care and improve the lives of patients in crisis, I hope you'll keep asking hard questions, challenging outdated practices, and looking for opportunities to lead change.

Great ideas need the right environment to thrive. Vituity empowers physicians and advanced practice providers to turn bold ideas into better care. Explore career opportunities and help shape the future of acute psychiatry.

References

1. Owens PL, Mutter R, Stocks C. Mental Health and Substance Abuse-Related Emergency Department Visits among Adults, 2007. 2010 Jul. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006 Feb-. Statistical Brief #92. Available from: https://www.ncbi.nlm.nih.gov/books/NBK52659/
2. Theriault KM, Rosenheck RA, Rhee TG. Increasing Emergency Department Visits for Mental Health Conditions in the United States. J Clin Psychiatry. 2020 Jul 28;81(5):20m13241. doi: 10.4088/JCP.20m13241. PMID: 32726001.
3. Bommersbach TJ, Olfson M, Rhee TG. National Trends in Emergency Department Visits for Suicide Attempts and Intentional Self-Harm. Am J Psychiatry. 2024 Aug 1;181(8):741-752. doi: 10.1176/appi.ajp.20230397. Epub 2024 Jun 4. PMID: 38831705.
4. Emergency Medical Treatment and Labor Act, 42 USC §1395dd (1986).
5. Natsui S, Sun BC, Shen E, Redberg RF, Ferencik M, Lee MS, Musigdilok V, Wu YL, Zheng C, Kawatkar AA, Sharp AL. Higher Emergency Physician Chest Pain Hospitalization Rates Do Not Lead to Improved Patient Outcomes. Circ Cardiovasc Qual Outcomes. 2021 Jan;14(1):e006297. doi: 10.1161/CIRCOUTCOMES.119.006297. Epub 2021 Jan 12. PMID: 33430609; PMCID: PMC7855368.
6. Lindenfeld Z, Cantor JH, McCullough CM, Bather JR, McBain RK. Inpatient psychiatric bed capacity within CMS-certified U.S hospitals, 2011-2023: A cross-sectional study. PLoS Med. 2025 Jul 23;22(7):e1004682. doi: 10.1371/journal.pmed.1004682. PMID: 40700445; PMCID: PMC12310024.Nicks BA, Manthey DM. The impact of psychiatric patient boarding in emergency departments. Emerg Med Int. 2012;2012:360308. doi: 10.1155/2012/360308. Epub 2012 Jul 22. PMID: 22888437; PMCID: PMC3408670.
7. Tuttle GA. Access to psychiatric beds and impact on emergency medicine. Chicago, IL: Council on Medical Service, American Medical Association; 2008.
8. Weiss AP, Chang G, Rauch SL, Smallwood JA, Schechter M, Kosowsky J, Hazen E, Haimovici F, Gitlin DF, Finn CT, Orav EJ. Patient- and practice-related determinants of emergency department length of stay for patients with psychiatric illness. Ann Emerg Med. 2012 Aug;60(2):162-71.e5. doi: 10.1016/j.annemergmed.2012.01.037. Epub 2012 May 2. PMID: 22555337.
9. Nicks BA, Manthey DM. The impact of psychiatric patient boarding in emergency departments. Emerg Med Int. 2012;2012:360308. doi: 10.1155/2012/360308. Epub 2012 Jul 22. PMID: 22888437; PMCID: PMC3408670.
10. Zeller S, Calma N, Stone A. Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments. West J Emerg Med. 2014 Feb;15(1):1-6. doi: 10.5811/westjem.2013.6.17848. PMID: 24578760; PMCID: PMC3935777.
11. Brooks, D. (2023). Is an EmPATH-Style Unit Right for Your ED?. ED Management, 35(4), 54.
12. Kim AK, Vakkalanka JP, Van Heukelom P, Tate J, Lee S. Emergency psychiatric assessment, treatment, and healing (EmPATH) unit decreases hospital admission for patients presenting with suicidal ideation in rural America. Acad Emerg Med. 2022 Feb;29(2):142-149. doi: 10.1111/acem.14374. Epub 2021 Sep 7. PMID: 34403550; PMCID: PMC8850530.
13. 2025 National Guidelines for a Behavioral Health Coordinated System of Crisis Care. Rockville, MD: Substance Abuse and Mental Health Services Administration; January 15, 2025. Publication No. PEP24-01-037.