NUBE 2024

Background: The Behavioral Health High Risk Quality Collaborative (HRQC) for Emergency Departments focused on the development and implementation of consensus best practices for screening, assessment, treatment, and discharge planning in the emergency department for high-risk behavioral health populations including individuals at high risk of Opioid Use Disorder and/or opioid overdose, suicide, violence, and high utilization. We examine the impact and lessons learned in this statewide collaborative, focusing on overdose risk.

Methods: 64 hospitals with 90 emergency department services participated in the HRQC. In Phase I, EDs participated in a Best Practices Workgroup to develop consensus best practices for four high behavioral health risk presentations (overdose, suicide, violence, high utilization), and implemented a regional mental health information sharing application (PSYCKES) in their ED. In Phase II, EDs implemented the consensus best practices and assessed their implementation status quarterly (each best practice rated on a 1-5 Likert scale from no to full implementation). In monthly learning collaborative calls, presentations by participating EDs or external experts highlighted resources, strategies, and challenges in implementing best practices. The HRQC technical assistance team offered monthly individual meetings with ED point persons to review existing ED workflows, identify gaps and opportunities, review external resources and strategies used by other EDs, and develop action items. Highly engaged EDs were defined as those with 6 or more individual consultation calls with the technical assistance team.

Results: In Phase I, EDs developed 36 consensus best practices (≥80% participants endorsed) for high behavioral health risk patients, with 10 of those for OUD/overdose risk. In addition, participating EDs had increases in the number of PSYCKES users and proportion of behavioral health presentations where the statewide clinical summary record was reviewed. In Phase II, EDs reported an increase on average in their level of implementation of best practices from Summer 2022 to Spring 2024. The largest increases in implementation were observed for highly engaged EDs (52% of participating EDs with 6+ TA consultation calls), with the greatest gains related to OUD specific best practices including buprenorphine inductions in the ED and providing naloxone kits with harm reduction education prior to being discharged. EDs that implemented OUD screening and OUD safety planning/relapse prevention planning also had higher levels of implementation of best practices overall. Qualitative notes from ED meetings identified barriers and strategies to address challenges.

Lessons Learned: EDs were able to develop and implement consensus best practices, with greatest gains observed for EDs that were more engaged or focused on OUD best practices. The HRQC identified challenges in implementing OUD best practices, including staff discomfort with treating patients with OUD and knowledge gaps among staff about which patients had elevated risk for an opioid overdose. Effective strategies to address these challenges included staff education and training on risk factors for opioid overdose, harm reduction, naloxone use and patient education; learning from clinicians that had expertise in buprenorphine induction in the ED; and developing a workflow to support best practices.

Learning Objectives:

Summarize ED consensus statements on OUD treatment and harm reduction related best practices for emergency departments.

Describe challenges and barriers to implementing OUD best practices in emergency services.

Describe strategies and lessons learned to support implementation of OUD best practices in emergency departments.