Scotland has the highest number of drug deaths in Europe and is ranked as having the worst health inequalities in central and Western Europe (Public Health Scotland, 2024). We see this at the human level on a daily basis in our emergency departments (EDs), where presentations of crisis are rising and the true numbers may be underestimated. To improve the care for patients, new models of care need to be considered but we also need to develop the research evidence.

Capturing presentations of crisis

Capturing patient experiences through discharge coding is difficult and we likely fail to address the nuances of presentations (Baratt et al., 2016). Take, for example, a young man presenting with a leg abscess to the ED. He may get antibiotics and discharged with the coded diagnosis: ‘Abscess’. However, the reality of his presentation may be that the abscess is the result of injecting drugs. He may have underlying mental ill health and past trauma due to a combination of social inequalities and chaotic life. His drug use is essentially his way of self-medicating. Most ED clinicians will recognise this type of presentation, and the accompanying feeling of helplessness that the ED is not the right place to address these patients’ complicated needs. So, how can these patients’ needs be better met?

Rethinking emergency responses to mental health and substance use crises

For those presenting in crisis, the ED is an ill-suited environment. ED staff are time-poor and often lack mental health training. The environment is busy, noisy and bright. We know that mental health patients report poor experience and can feel stigmatised.

We therefore need a better model for emergency psychiatric care and it exists. The research arm of our ED in Fife (Fife Research in the Emergency Department; FiRED) is researching the adoption of the EmPATH model. EmPATH is a concept pioneered by a leading US Emergency Psychiatrist, Dr Scott Zeller, for providing better emergency psychiatric care. EmPATH stands for Emergency Psychiatry Assessment Treatment and Healing and these units are dedicated psychiatric emergency rooms. They are co-located with traditional EDs, but staffed with mental health professionals and those skilled in de-escalation and crisis interventions.

EmPATH models were introduced around a decade ago and there are now dozens of units across the US, Australia, Canada, and Singapore. They provide a therapeutic ‘lounge-like’ environment that, in contrast to the busy ED, has adjustable lighting, recliner chairs, nature murals, and access to refreshments and activities. Some have gardens or exercise areas. They are designed specifically to minimise risk to patients vulnerable to self-harm, with ligature-safe fittings and furniture.

Learning from the EmPATH model

We recently hosted Dr Zeller on a visit to Scotland to talk about EmPATH. At a series of events he met with hospital leaders, Scottish Government representatives, psychiatrists, mental health nurses, researchers, and ED staff to talk about the merits of such a space where the environment itself can be healing. Dr Zeller spoke of the compelling evidence that these units demonstrate reductions in hospital admissions, return rates, and better outpatient follow up (Kim et al., 2022). Crucially for Scotland, EmPATH units can manage substance use disorder alongside other mental health crises in a non-dualistic way.

Ways forward in Scotland – developing the evidence

The Royal College of Emergency Medicine (RCEM) and the James Lind Alliance partnership have identified optimising care for mental health patients as a top priority for emergency medicine research. Knowing that alternative models such as EmPATH exist gives us something to work towards, but we need to understand our own UK situation in this regard.

Thanks to an RCEM research grant, NHS Fife and FiRED are undertaking a pilot observational study to try to understand who is presenting in crisis and what is happening to them in the ED. The UPDATE-ED study (Understanding Psychological Distress and Therapeutic Environment in the ED) will prospectively gather data on all patients presenting with mental ill health, substance use disorder or psychological distress (or any combination of these, which we know often co-exist). Together with five other sites in NHS Lothian, Oxford, and Reading, we will have a better estimate of those attending in crisis, and what their ED journeys look like.

We hope that our pilot study may lead to more national work and a research network looking into whether EmPATH can work in the UK. We would welcome anyone with a shared interest to reach out and see if we can collaborate to improve emergency psychiatric care.

References

Public Health Scotland (2024). Scotland’s public health challenges. Available at: https://www.publichealthscotland.scot/about-us/what-we-do-and-how-we-work/scotland-s-public-health-challenges/

Barratt H, Rojas-García A, Clarke K, Moore A, Whittington C, Stockton S, et al. Epidemiology of mental health attendances at emergency departments: systematic review and meta-analysis. PLoS One. 2016;11(4):e0152988. https://pubmed.ncbi.nlm.nih.gov/27120350/

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;29(2):142-149. doi:10.1111/acem.14374. https://pubmed.ncbi.nlm.nih.gov/34403550/