Before 2020, if you entered Ericka Powell’s emergency department (ED) with a minor injury, you’d be seen in about two hours. If you had a more serious illness requiring admission, you’d stay four to six hours before transferring to a hospital bed. However, if you came in with a behavioral health emergency, you’d endure 13 or more stressful hours before you were routed from the ED toward proper treatment.
Powell (PEMBA, ’20), then the medical director for the ED at Lebanon, Pennsylvania’s WellSpan Good Samaritan Hospital, found that situation unacceptable. And for children, she knew it was even worse. They might wait 26 hours during an acute behavioral health emergency.
The delays also significantly contributed to burnout for physicians, nurses and techs, who – without proper training – often had to deal with volatile and potentially dangerous patients for hours on end. “Some of those patients are acutely ill, and their behaviors are hard to manage,” Powell says. “They’re tearing down doors while you’re trying to keep them and staff safe and care for other patients at the same time.”
Powell was in the Physician Executive MBA (PEMBA) program at the University of Tennessee, Knoxville’s Haslam College of Business, when the COVID-19 crisis erupted. The pandemic amplified the ED’s behavioral health care delays, but it also opened possible solutions that were previously unavailable. Powell immediately saw a one-of-a-kind opportunity to refocus her in-progress organizational action project (OAP) to address issues with behavioral health care in the ED. “I shifted the focus of my OAP to turbo-boost getting this problem solved,” she says.
Systemic Issues, Root Causes
With behavioral health patients in the ED twice as long as medical patients, Powell recognized that more than one root cause was at work. Some were isolated friction points that could be easily smoothed out, while others were longer processes riddled with waste and still more were mysteries that needed detective work to solve. “With my OAP,” she says, “I really wanted to use lean methodology and dig into what was broken everywhere.”
Powell knew a county-wide shortage of outpatient facilities forced behavioral patients to the ED when their doctors weren’t available. They remained in the ED until they could see a hospital psychiatrist to determine if they could be stabilized and discharged or needed to go to an inpatient psychiatric facility. If the latter, they had to wait until a bed became available in an external facility, and during that time, many became agitated and disruptive.
The facility shortage and the psychiatrist bottleneck would have been daunting obstacles to overcome before COVID, but the pandemic brought an unexpected breakthrough. The sudden need for social distancing prompted the government to quickly relax telehealth regulations, speeding up the intake process by making more psychiatrists available to their patients both at home and in the ED. This kept many patients from arriving in the ED and reduced time in the queue for those who did. “Telehealth is just a huge win for healthcare,” Powell says. “It fundamentally changes how we do things.”
With that blockage eased, Powell and her team began examining and redesigning the behavioral health admissions process to pinpoint additional delays.
Quick Wins and Surprising Insights
Patients’ antisocial behaviors were a key piece of the puzzle, so the team established a standardized rapid alert system that trained ED staff to recognize when patients were deteriorating, enabling them to intervene before situations became explosive. They also implemented several small, low-cost fixes for de-escalation, such as providing smokers with nicotine patches or gum to calm their nerves.
Getting patients into beds was trickier because external behavioral health facilities had to be matched to patients’ insurance. The team couldn’t change that, but they sped it up with innovations like a system-wide, daily bed scorecard showing psychiatric bed locations. That transparency helped the staff and eliminated waste in the process. With the hospital’s support, the ED has established connections with partner psychiatric facilities that shorten patients’ time to treatment.
Through her OAP, Powell also revealed an unrecognized, recurring problem. “I learned that 70 percent of the kids who come to my ED for behavioral health treatment are referrals from the school district,” she says. “That pointed to a major lack of resources in the schools. We’ve partnered with the school district to embed more first-line therapists on their end, which will decrease referrals.”
Powell, who is now the vice president of medical affairs for WellSpan, is still implementing her full OAP plan. Her to-do list includes establishing a dedicated behavioral health emergency suite and lobbying insurance companies to drop unnecessary testing that causes delays.
Then there’s COVID, which is still wreaking havoc on EDs everywhere, including Powell’s. The pandemic’s disruption of the healthcare system distorted Powell’s length-of-stay data, so she can’t compare results year over year, but the difference is obvious to her and her staff. “People are coming into my ED and they’re not escalating,” she says. “We’re able to provide them more direct point-of-care service. Many of them can transition home without an inpatient psychiatric stay. For the patients who need to stay, the hospital is supporting us with resources, access and touchpoints to serve them better.”
Powell plans to package the components of her project into a toolkit that other healthcare systems can use to transform their own processes. “What we’re doing is working, even though we don’t have hard numbers yet,” she says. “Our patients are getting better behavioral health care, and as a physician, that’s what matters most to me.”
Scott McNutt, business writer/publicist, firstname.lastname@example.org