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This study evaluates a novel Psychiatric Model of Care integrating psychiatry-specialized nurse practitioners and support staff embedded within the emergency department (ED) 24/7. It demonstrates a significant reduction in median ED length of stay (LOS) for psychiatric emergency patients, particularly for those under involuntary psychiatric holds and those transferred to psychiatric facilities, suggesting improved patient throughput and crisis management efficiency.
Study Background
Patients presenting with psychiatric emergencies often experience disproportionately long ED stays—three times longer than those with nonpsychiatric conditions. Extended LOS in the ED can exacerbate overcrowding, strain resources, increase patient distress, and impede timely psychiatric evaluation and disposition. The challenges include limited specialized resources, delayed psychiatric assessment, and complex disposition planning, particularly for patients under involuntary psychiatric holds who require deeper evaluation and coordination with psychiatric facilities.
Addressing these gaps is critical to improving quality of emergency psychiatric care and efficiency in urban academic medical centers where demand is high and psychiatric resources are often limited.
Study Design
This quality improvement project utilized an interrupted time series design analyzing 5,222 deidentified ED encounters from January 1, 2023, to December 31, 2024, including preimplementation, rollout, and postimplementation periods at a tertiary urban academic center. Inclusion criteria were adults presenting with a psychiatric chief complaint, those requiring psychiatry consultations, or subjected to involuntary psychiatric holds.
The intervention, termed the Psychiatric Model of Care, embedded psychiatry-specialized nurse practitioners and supporting staff within the ED around the clock. Their roles included psychiatric assessment, crisis stabilization, and disposition planning. ED length of stay—defined as time from rooming to final disposition—was the primary outcome. Segmented quantile regression adjusted for timing and confounders was employed to analyze changes in median LOS.
Key Findings
Implementation of the Psychiatric Model of Care led to a significant overall reduction in median ED LOS for psychiatric patients from 8.35 hours (interquartile range [IQR] 3.76–18.35) to 5.61 hours (IQR 3.00–10.24), representing an adjusted median decrease of 1.64 hours (95% confidence interval [CI] -3.15 to -0.13 hours).
Notably, the most pronounced LOS reductions were observed in patients under involuntary psychiatric holds: a decrease of 9.66 hours (95% CI -12.92 to -6.40) for 72-hour holds and 18.80 hours (95% CI -52.76 to -10.67) for 14-day holds. Patients transferred to psychiatric facilities also benefited from a significant reduction of 4.80 hours (95% CI -10.46 to -1.88). However, LOS did not significantly change for patients without holds or those discharged or admitted to nonpsychiatric services.
This differential impact underscores the model’s strength in managing patients with complex psychiatric legal and clinical needs, facilitating expedited evaluation and disposition processes.
Expert Commentary
Embedding specialized psychiatric nurse practitioners in the ED represents an innovative approach addressing critical bottlenecks in psychiatric emergency care. The data align with prior literature emphasizing the positive impact of specialized psychiatric staffing on patient flow and safety in emergency settings.
While the study was a single-center quality improvement project, its robust interrupted time series design strengthens causal inference. Key limitations include the potential influence of unmeasured confounders such as changes in psychiatric inpatient bed capacity or external policy shifts, and the generalizability to nonacademic or resource-limited settings remains uncertain.
Future work should explore long-term outcomes, patient-centered measures such as satisfaction and symptom resolution, and cost-effectiveness analyses to further validate and optimize this care model.
Conclusion
The Psychiatric Model of Care significantly reduces ED length of stay for patients with psychiatric emergencies, particularly those requiring involuntary holds or transfers to psychiatric facilities. By integrating psychiatry-specialized practitioners directly within the ED team, the model streamlines assessment, crisis stabilization, and disposition, mitigating delays caused by subspecialty consultation waits and administrative hurdles.
These findings advocate for broader adoption and tailored refinement of embedded psychiatric care models to improve emergency psychiatric service delivery and alleviate ED crowding challenges.
Funding and Clinical Trial Registration
No specific funding disclosures were reported. This was a quality improvement project and not registered as a clinical trial.
References
Hewlett MM, Addo N, Kwan E, Manno R, Fahimi J, Becker DF, Raven MC. Effectiveness of a Novel Emergency Department Psychiatric Care Model in Reducing Length of Stay. Ann Emerg Med. 2026 Jul 8. PMID: 42421276.
Samartzis L, Dunger D, et al. Impact of psychiatric nurse practitioners on emergency department throughput for psychiatric patients: a systematic review. J Emerg Med. 2021;60(2):157-165.
Chang G, Decker C, Brown G. Emergency department length of stay for patients with psychiatric complaints. Acad Emerg Med. 2017;24(7):789-795.
