Bill Klaproth (Host): This is Today in Nursing Leadership, a podcast from the American Organization for Nursing Leadership. I'm Bill Klaproth. And with me is Erin Morris, Director of Behavioral Health Services at UK Healthcare and Marc Woods, Chief Nursing Officer at UK Healthcare Eastern State Hospital, as we discussed the nurse-led redesign of psychiatric emergency care through a treatment-first EmPATH model, which aims to improve access to timely care, reduce ED boarding, eliminate the use of sitters, decrease violence, and enhance overall system performance. Erin and Marc, welcome.

Erin Morris, MSN, RN, CEN: Thanks for having us, Bill.

Marc Woods, DNP, RN, NEA-BC: Yeah. Glad to be here. Appreciate it.

Host: Thank you. I'm interested to learn about this. So, thank you for your time today, Marc. Let me start with you. So, what is EmPATH? How did this idea come about? How long did it take, and can you talk about the importance of collaboration and the teamwork it took to bring this about?

Marc Woods, DNP, RN, NEA-BC: Yeah. So, EmPATH stands for Emergency Psychiatric Assessment for Treatment and Healing. It's kind of a newer crisis stabilization area or unit for behavioral health. Some of the differences between traditional crisis stabilizations and EmPATH is that, with ordinary crisis stabilizations, oftentimes, you could be too sick. You can be not sick enough. You could be the wrong kind of sick. You know, maybe they don't do adults, maybe they don't do substance use or whatever. And with an EmPATH center, we sort of say, "This is where we want you to start your behavioral health crisis." So, instead of going to an ED, we are asking them to come to this behavioral health sort of unit where they're greeted by behavioral health experts. They're seen within 30 minutes. Treatment is started very quickly, and access to this treatment is very open. People can drive themselves up to it. EMS can take you to it. And so, it's kind of a newer model throughout the country. I think we were the 30th EmPATH unit when we opened up back in July.

And I think since that time there's about 60 across the country. So, people are really starting to get the benefits of this EmPATH model, and implementing it as well. So, some of the most important parts of of This is collaborating early with leadership. There is a socialization of the idea, because these concepts are very different. Very different than what we've ever done before in healthcare. And so, instead of encouraging behavioral health crisis to go to the ED, we're saying, "No, no, no, don't go there. We want you to come to the EmPATH unit first."

And so, we're treating you first and we're not making decisions on whether or not you should be inpatient. In fact, it's a 23-hour observation bed kind of situation where we're treating you first. And about 76% of the patients that we see and treat this way, they don't have to be inpatient. In fact, they can go on with their lives. It's not disruptive at all. It's very encouraging to hear some of the stories coming back, of people saying, "Not only did you save my life, but you also helped me keep my job, keep my house, because I didn't have to be admitted to an inpatient service." So, we've had great success with this and we're just happy to be able to share it with other organizations as well.

Host: Yeah, this just seems to make sense. When I hear you talk, I'm like, "Why haven't we done this all along?" This is kind of crazy. So, let me stay on that point, Erin. So, what was happening in your emergency department before this design? Give us a look into the before.

Erin Morris, MSN, RN, CEN: Yeah. So in the before actually, as a little bit of background, I actually was an emergency department nurse and manager for 11 years before I moved into the behavioral health role. So, this is, you know, from firsthand knowledge, like the way we were treating these patients was not in a trauma-informed care manner. In the ED, you have a lot of priorities and people coming in in mental health crisis, they can be kind of shifted to the bottom when you think in terms of strokes and motor vehicle accidents and gunshot wounds and all of those things that are immediately life-threatening.

But those of us that work in the behavioral health world know that suicidality is just as lethal as a heart attack. And so, getting people to the right place to get the right care. So when someone will arrive to the emergency department, the emergency department is about throughput and safety, right? So, how do we keep these patients safe while they're with us and while they're waiting for a consult? So, they come in, they get asked to take off all of their clothes, get into a gown, which feels very exposed, when you're already in a mental health crisis. You get told to stay in this room or on this stretcher if you're unfortunately in a hallway bed, which most eds have these days. You can't move around. You have to ask for everything. And then, you also get a one-to-one observer to keep you not only within the ED, so that you can't leave without that critical assessment piece, but also to make sure that you are not going to harm yourself or others while you know someone doesn't have direct eyes on you. So again, someone sitting right there that you don't know, observing your every movement, it just feels kind of icky to people.

Host: Yeah, right.

Marc Woods, DNP, RN, NEA-BC: And a long length of time too, right?

Erin Morris, MSN, RN, CEN: Yeah.

Marc Woods, DNP, RN, NEA-BC: Long stays, long hours.

Erin Morris, MSN, RN, CEN: Yeah. So, you're waiting for assessment from some kind of consult service that could happen in a couple of hours. It could happen in 12 to 14 hours. There's no real guide for that.

Host: Yeah, it doesn't feel llike there's a real human factor there. It's like, "I'm a number." It screams, "Get me out of here. I am sitting in a gown or I'm with a person I don't know."

Erin Morris, MSN, RN, CEN: Yes.

Host: "I'm uncomfortable. I'm awkward. Who are these people? And I'm not feeling totally respected. Get me out of here," right?

Erin Morris, MSN, RN, CEN: And then, if you add in intoxication, whether that be alcohol or illicit substances, most site consults services won't see you until you are clinically sober. So, that further progresses that waiting time for evaluation and treatment.

Marc Woods, DNP, RN, NEA-BC: Yeah. Yeah. We had long length of stays as well. But nothing like nationally, what a lot of people are seeing. We hear horror stories of patients that have gone to the ED for a behavioral health need. And they're in their ED for days and sometimes even weeks. And so, we weren't experiencing that. We did have long lengths of stay, you know, 16, 18 hours in an ED. But again, that's why we are encouraging them to come to this area, for us, where they're going to be greeted within 30 minutes by a behavioral health specialist, peer support specialists, people that have lived experience to be able to say, "I've been where you are. There's hope. I'm going to instill hope and come on in. Are you hungry?" And we start the care planning process immediately.

Host: Right? So, that's the psychiatric boarding process. Why is that a system design issue then?

Marc Woods, DNP, RN, NEA-BC: Yeah. So to think of it this way, when you go to an ED for most hospital systems, it's a decision of whether or not you're admitted to an inpatient service or you're not admitted and you go home and we give you services, a follow-up in two to three weeks, or we give you a list of numbers of people to call on your own or whatever. And it felt like there was just a gap. There's a gap in the system of care. There's many people that are experiencing behavioral health crisis that, you know, their crisis may actually feel a little bit better within 24 hours. You'd be surprised at just how much a night's sleep, or eight hours spending with a behavioral health professional. We'll change their outlook or change the whole process in general.

The other reason I say it's a systems issue, is because if this were a cardiovascular event, they wouldn't stay in the ED for several days. We wouldn't tolerate that. We wouldn't say that's the best care that we can get. We would look at that very differently. And that's why I say this is a systems based problem that we need to look at and say we have a population of individuals coming to an area that's really not suited for them.

Host: Right. So Erin, as Marc was just saying, people can improve overnight. Is that because of access to timely behavioral healthcare? Is that what makes the big difference?

Erin Morris, MSN, RN, CEN: It is. So at our EmPATH, when someone arrives, they're met with the triage nurse as well as our provider. So, they tell their story one time the provider hears it and immediately starts placing orders for treatment. That the nurse then implements to give that patient the quickest response time possible.

And the nice thing about EmPATH is because we are all mental health professionals, once that treatment is kind of administered and we're going with it, then they spend the next however many hours they're with us, interacting with people, trained on how to react and how to help people get out of crisis. It's not just give them medicine and wait and see what happens. It give them some medicine, give them some treatment, and then engage with them to reach goals and set goals for themselve and their treatment plan.

Host: Yeah. So, it kind of happens immediately then. And then, Marc, it sounds like this impact eliminating sitters then at this point. And can you tell us what impact that has had on, uh, staffing and safety, reducing restraints, violence and injuries?

Marc Woods, DNP, RN, NEA-BC: Yeah. So, when we opened up, July 30th, 2024, I think, Erin, we've seen about 8,300 people since that time. Two-thirds of which have had suicidal ideations, suicidal thoughts. And so, you think about that. That's a lot. That's a lot of people.

Host: And those people would've just been in the ED regularly intermixed with stroke and heart attack, and I broke my leg and everything.

Marc Woods, DNP, RN, NEA-BC: Absolutely. In the ED with a sitter. So if there are healthcare professionals listening right now, one of the appeals to you is that you can reduce the amount of your cost on sitters by implementing this sort of model. We've used zero sitters since we've opened up. And we've been surveyed by the Joint Commission who has absolutely raved about this model.

Even for patients that come to us that are high-risk for suicide, they're not on a sitter, they're not on a close, they're not on one-to-one, if you will. Part of it is the design of the unit that we have. There's windows everywhere. There is glass, lots of places from the nurses station. You can see all parts of the unit. And so as a result of that, almost every patient that walks in the door is on a constant close, right?

But if there's anything that I can say, for those looking to save on cost, it's the sitter piece. We've eliminated the amount of sitters. And you might say, "Well, what do you mean by that?" Well, when patients were coming into the ED, lots of organizations, their first go-to is to put, assign someone, assign them a nurse, assign them a tech, to sit with them and watch them. And that robs the patient of so much dignity, robs the patient of so much privacy in the process. It's really dehumanizing as well.

Oftentimes, those patients have to change out into gowns. At EmPATH, we don't ask tjem to do that. We make sure that they're safe and secure. And they go through a metal detector and that sort of thing. But we're able to accomplish the same thing in this new setting, new model. Zero sitters. And so, we've essentially given nurses back their time. Because what happens is a lot of organizations don't have the number of techs it takes to sit with these patients, so sometimes they'll have nurses sitting with these individuals. And so, we've given their time back.

Host: Again, this just seems to make sense, but I know you probably encountered a few roadblocks or hurdles along the way. So, what are some of the challenges that you faced as a nurse leader trying to gain consensus and bring this model to the organization?

Erin Morris, MSN, RN, CEN: I think one of the biggest things and we started it early, was our community outreach and how do we get the stakeholders that are involved. Not just within our own organization, but within organizations that will bring patients to us or we will send patients to how do we get them with the buy-in. So, we started meeting with our local EMS and police groups early studying how, where they were taking patients, when they were taking patients, and then looking at who those patients were and could they come to the EmPATH. And so, we continue that work. Every week, we meet with our EMS and police, getting them to, review patients say, why did you take that patient to the ED versus coming directly to EmPATH. And it's really made a difference. And it's helped a lot of the buy-in then from our own organization, because they're seeing that reduction in arrivals to the ED. There was a lot of pushback too, myself included.

We didn't think this model could work, right? Like, the ED,we would say you don't understand. These patients are coming to the ED in crisis. And they are violent, you know, unredirectable. You can't manage them without restraints and medications. And there was a lot of, like, fear about how that would affect the nursing staff and the violence that is involved with some of that. So, we just had to keep chipping away and giving tours and having people come over and see it and see that it actually does work.

Host: Yeah. It sounds like the results have been. Oh, it's very, very much worth it.

Marc Woods, DNP, RN, NEA-BC: Very promising. A few things I'd add to Erin's comment, it was just, you know, early on. Erin's right, a lot of socialization that had to take place. This was a concept. And an idea that, Dr. Zeller is sort of the godfather of these EmPATH models, right? He's an emergency psychiatric physician. So, he's developed this model. And we took his lead. But, you know, I'm really proud to say that this was in the very beginning. This was an idea and a concept that was brought to our organization by a nurse, a nurse leader. And it was encouraged by a nurse leader. And so, in the early stages, I was blessed and fortunate to be able to do just that, bring this to the organization. And this was in 2019, we opened this thing up in 2024. So, there were many years of socialization of the idea, lots of trying to persuade other people that this would work. Erin's a perfect example of that. Now, she's the one out here proselytizing to everybody that this will work. "This can work, I promise you."

And keep in mind, the ED, it just makes sense. These patients would come in into an ill-fitted sort of setting for them. And oftentimes they would be restrained, sedated. And people are surprised to hear us say that our restraints, we've seen 8,000 people, I don't know, Erin, maybe 30, 20?

Erin Morris, MSN, RN, CEN: Thirty?

Marc Woods, DNP, RN, NEA-BC: Twenty or 30 episodes of that.

Erin Morris, MSN, RN, CEN: Yeah.

Host: Wow.

Marc Woods, DNP, RN, NEA-BC: Over time. And so, in the very beginning, lots of socialization of the idea. And as a nurse leader, oftentimes we don't get the opportunity to bring really great ideas to the table and lead some of that conversation. And so, this one example of us being able to do that. Super proud of that.

The other piece I would say though, is one of the more difficult things in the collaboration, it can't stay there. You could be a nurse executive. And you could have the best idea on the planet, but you cannot get it across the finish line without engaging other individuals, collaborating with other leaders, convincing them of the value of doing this. And so, that's when this really picked up speed.

And we'd be remiss if we didn't mention Dr. Lindsay Jasinski, who is my partner, CAO. And when she came on board for this idea, things really took off. She started meeting with MCOs. She started meeting with, you know, other legal individuals and doing the accounting and the performance and whatnot. And that's when this really, really took off.

Host: So, let's talk about leadership a little bit. What leadership decisions then were most critical for success?

Marc Woods, DNP, RN, NEA-BC: Yeah. So, just a handful. You know, you have to treat this truly, as you said, we have to treat this as a system redesign, not just a unit. You're not just adding a unit. And there's a couple of different ways to do it. Some people will attach it to their ED. We just so happen to not be attached to an ED. We're a couple of miles away from our systems ED. So, that's the first piece. It's a system redesign.

I will also add that you have to commit to treatment-first philosophy. When you go to an ED, one of the first things they're trying to do is determine where you need to go. Can they treat you right then and get you going, or do you need to go pretty early on in the process? That's not the case here. We've got 23 hours to decide where you need to go, and we're hopeful to get you back home. Seventy-six percent of the time we can do that. That's why we treat in the very beginning: medications, engagement, therapy. And then, we make a decision about hour 15, 16 as to do you need to go to inpatient? Or you're going to be able to go home with an appointment tomorrow or the next day.

Host: Okay.

Marc Woods, DNP, RN, NEA-BC: Yeah.

Host: Yeah. Erin, any final thoughts before we wrap from your perspective on this?

Erin Morris, MSN, RN, CEN: I just think that that how EmPATH has shaped our system, I mean, we've seen people that drive in from other states because they've heard about us. We are seeing patients that before had no interaction with the mental health world or had just been struggling on their own. And because of the EmPATH model and because of what they hear and the stigmatization that's reduced, they are now seeking help.

And I think one of the key pieces that Marc talked about is that 24 to 48 hour follow-up, working closely with our community partners to be able to provide that to patients. If you call yourself, you may wait six weeks, six months for an appointment that doesn't keep people out of crisis and it doesn't keep people in a healthy frame of mind. But if you can get somebody in within 24 to 48 hours, it just makes all the difference in the world to them.

Marc Woods, DNP, RN, NEA-BC: Yeah. I would just add, you know, we have a philosophy on our EmPATH unit where, instead of finding ways to say no, we find a way to say yes. And so, that means taking patients sometimes that we weren't sure really met the standards or the needs of a crisis or whatever.

I'll finish with sharing a really short story that illustrates the impact this can make on your community. It wasn't just about taking patients from the ED and bringing them over here, redirecting them, that, you know, reduced the compression on the ED. This was about like serving people in the community that we knew weren't getting treated. And so, we told this story to a group of law enforcement officers who work at a local jail in Lexington, Kentucky. And I'll never forget it, gave me chills, probably will give me chills today when I talk about it, but we were giving them a tour. We were also talking about the program itself. We uttered that we had treated over 8,000 people and two-thirds of those people came to us with suicidal thoughts. And this one gentleman was brave enough in uniform, stood up and said, "Thank you. You saved my life and you helped me keep my job, and you guys treated me here," and how awesome is that to be able to see that connection immediately?

Host: Well, that's why you all do the work you do to make a difference and serve and improve people's lives, and save people's lives that you just said. So, thank you for sharing that story, Marc. I really appreciate it.

Marc Woods, DNP, RN, NEA-BC: Absolutely.

Host: Well, thank you both for your time today and sharing with us about the EmPATH model. This is great, great work, And we hope more healthcare organizations will think about adopting this model. So, thank you for bringing it to our attention today. We appreciate it.

Marc Woods, DNP, RN, NEA-BC: Yeah, thank you, Bill.

Erin Morris, MSN, RN, CEN: Thank you for letting us share it.

Host: Yeah, thanks for having us. And once again, That is Erin Morris and Marc Woods. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you at aonl.org/nursing-leadership-podcast. This is Today in Nursing Leadership. Thanks for listening.