From Code Blue to Code Grey: Rethinking Behavioral Health Emergency Responses
“He was hearing voices telling him to kill himself. We told him to sit down and wait.”
A man in acute psychosis — in severe distress from auditory hallucinations telling him to end his life — walked into our ER searching for help. Instead, his emergency was met with delays, no treatment, and a system unequipped to respond with the urgency he deserved. For 10 hours, he sat untreated in a crowded hallway while we searched for an inpatient bed that didn’t exist. As his condition escalated, the staff, feeling they had no other option, held him down — one nurse, one tech, and two security guards — before chemically sedating him and placing him in physical restraints. Though sometimes necessary for safety, it is a traumatic intervention for both the patient and the staff. This incident was not due to a lack of compassion from the staff, but rather a failure of the system. The staff, though deeply empathetic, were left without the tools, resources, or structured response needed to support the patient appropriately.
He came to us asking for help. And we failed him.
His story is not unique. It reflects a systemic failure in how we respond to behavioral health crises — one that we cannot ignore any longer.
As a travel ER RN across six states and now as a clinical strategy consultant at Inflect, Vituity’s innovation hub, I’ve witnessed firsthand how bold, patient centered strategy can save lives and improve outcomes. I’ve stood beside patients during the most vulnerable moments of their lives. I’ve worked with over 40 hospitals and teams dedicated to disrupting the status quo in psychiatric emergency care — and I’ve seen real progress.
Over the years, I’ve responded to countless “Code Blues” — life-or-death moments when a medical emergency mobilizes a rapid, structured response. In those moments, there’s no hesitation. Teams unite with precision and urgency to save a life.
But when the emergency is psychiatric, the response looks different.
Behavioral health emergencies now make up 1 in every 8 ER visits8. While these patients may not always require the immediate physical interventions associated with traumas or code blues, they still warrant a structured and time-sensitive approach. Their emotional and psychological distress is urgent, and delaying care can exacerbate their condition. But rather than being met with coordinated care, they’re often boarded in chaotic hallways for 12 to 24 hours without treatment. Their symptoms worsen in overstimulating environments. They’re isolated, neglected, and sometimes retraumatized by the very systems meant to help them.
And yet — we know there’s a better way.
Three Approaches Changing Emergency Psychiatric Care
Through my work at Inflect, and working alongside the creator of the EmPATH model, Dr. Scott Zeller, I’ve seen how three interconnected approaches can dramatically improve outcomes:
- EmPATH Units: Transforming Psychiatric Emergency Care
EmPATH (Emergency Psychiatric Assessment, Treatment & Healing) units are revolutionizing psychiatric care by prioritizing healing environments over traditional, often stressful, ER settings.
Instead of the typical emergency department, EmPATH units have workflows built in to ensure immediate evaluation, treatment, and constant re-evaluation. The units also provide calming, therapeutic spaces with features like recliners, natural lighting, and open layouts — designed to promote recovery, and these units deliver powerful results.
The Impact of EmPATH Units:
- Faster Stabilization, Fewer Admissions: 75% of patients are stabilized and discharged within 24 hours, and psychiatric hospital admissions are reduced by 53%1.
- Shorter Stays: The average ED length of stay decreases from 16.2 hours to 4.9 hours, improving ED efficiency2
- Minimal Restraint Use: Less than 1% of patients require restraints or sedation3.
- Improved Follow-Up and Reduce Readmission Rates: 60% increase in a 30-day follow-up care established at the time of discharge4 and reduced 30-day psychiatric patient-returns to the ED by 25 percent.4
- Financial Impact: One hospital saw an $861,000 increase in revenue during its first year of operation by increasing their ED throughput — the efficiency of moving patients through the ED — and decreasing their inpatient insurance denials5
2. De-escalation Training: Tools That Empower Staff
During my time at a Level 1 trauma center in the South Side of Chicago, I witnessed how nurses skilled in de-escalation techniques were able to connect with patients in crisis, whereas others struggled. De-escalation training goes beyond traditional workplace violence training which focuses on learning how to escape patient holds or self-defense tactics. This training helps staff recognize the early signs of agitation, enabling them to intervene proactively, and advocate for offering the patient timely, appropriate oral medications before the situation escalates.
Research shows that de-escalation training improves staff confidence and self-efficacy in managing agitated patients. When structured de-escalation protocols were implemented, which includes early oral medication management, restraint use decreased by 70%6. The key is not limiting these skills to psychiatric specialists, but ensuring that every ED staff member is equipped to apply them effectively.
3. Emergency Psychiatric Intervention (EPI): Transforming Behavioral Health Care in Traditional ERs
Through firsthand experience, it’s clear that delays in psychiatric care are often due to outdated, inefficient processes — not a lack of compassion. The Emergency Psychiatric Intervention (EPI) program addresses this challenge by offering a solution that enhances behavioral health care without the need to build a separate EmPATH unit. EPI improves care in traditional emergency departments using three key strategies:
- Eliminating Over-Processing
Streamlines workflows by removing redundant steps, allowing for faster assessments and care that is tailored to individual patient needs. - Risk Stratification and Split Flow
Enables low-risk patients to bypass time-consuming protocols, improving throughput and preserving resources for higher-acuity cases. - Early, Appropriate Medication Use
Encourages timely administration of second-generation antipsychotics — preferably in oral form — to minimize sedation, reduce restraint use, and shorten length of stay.
In a multi-site EPI implementation involving nine EDs, the results were compelling:
- Door-to-Medication Time: Reduced from 158 minutes to 44.5 minutes. The percentage of patients receiving medication within one hour nearly doubled.
- First-Generation Antipsychotic Use: Decreased by 79%.
- ED Length of Stay: Shortened by 46 minutes, even with steady patient volumes.
- Provider Confidence and Restraint Use: 34% of ED staff reported increased confidence in managing BH patients; 82% observed a decrease in restraint use.
EPI is a powerful, evidence-based approach that any emergency department can adopt to significantly enhance behavioral health care — no new construction required.
From Observation to Action
As healthcare professionals, we have an obligation to bring the same structure, commitment, and compassion to behavioral health emergencies as we do to medical crises. The tools exist. The evidence supports them. Now we need the will to implement them.
Models like EmPATH are proving that we can respond differently — humanely, effectively, and immediately. We’re seeing fewer restraints, shorter lengths of stay, and better outcomes for patients and the teams who care for them.
If you’re a nurse, tech, security team member, clinician, or hospital leader who’s felt the strain of a broken system — or imagined a better way — let’s talk.
I’d love to hear your thoughts in the comments.
Eliza Stein, MSN, CNL, RN is a Clinical Strategy Consultant at Inflect, Vituity’s Innovation Hub, and a travel emergency room nurse.
Sources:
1. Beckjord, E. (2023, April 7). First Emergency Psychiatric Assessment, Treatment and Healing (EmPATH) Unit opens in Lexington, Kentucky. Psychiatric Times. Retrieved May 7, 2025, from https://www.psychiatrictimes.com/view/first-emergency-psychiatric-assessment-treatment-and-healing-unit-opens-in-lexington-kentucky
2. Zeller, S., Calma, N., & Stone, A. (2014). Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments. Western Journal of Emergency Medicine, 15(1), 1–6. https://doi.org/10.5811/westjem.2013.6.17848
3. Inflect Health Advisory. (2024). EmPATH outcomes dashboard: 12-month summary report.
4. Kim, A. K., Vakkalanka, J. P., Van Heukelom, P., Tate, J., & Lee, S. (2022). Emergency psychiatric assessment, treatment, and healing (EmPATH) unit decreases hospital admission for patients presenting with suicidal ideation in rural America. Academic Emergency Medicine, 29(2), 142–149. https://doi.org/10.1111/acem.14374
5. Stamy, C., Shane, D. M., Kennedy, L., et al. (2021). Economic evaluation of the emergency department after implementation of an emergency psychiatric assessment, treatment, and healing unit. Academic Emergency Medicine, 28(1), 82–91.
6. Annals of Emergency Medicine. (2018). Decreased restraint use after initiation of emergency department agitation protocol. https://www.annemergmed.com/article/S0196-0644%2818%2930833-3/fulltext
7. Vituity. (n.d.). Emergency psychiatric intervention & reducing ER wait times. https://www.vituity.com/healthcare-insights/emergency-psychiatric-intervention/
8. Peters, Z. J., Santo, L., Davis, D., & DeFrances, C. J. (2023). Emergency department visits related to mental health disorders among adults, by race and Hispanic ethnicity: United States, 2018–2020 (NCHS Data Brief №464). National Center for Health Statistics. https://www.cdc.gov/nchs/products/databriefs/db464.htm
