NUBE 2024

Emergency departments have experienced a significant increase in visits from patients with behavioral health emergencies over the years. Unfortunately, this rise has not been accompanied by adequate national, regional, or state-level responses in acute care delivery, treatment development, care standards, or agreed-upon treatment goals and metrics. Consequently, millions of patients, both adults and children, spend extended periods in emergency departments each year without receiving proper treatment. This gap between the growing needs of these patients and the lack of a coordinated national response has prompted the development of numerous local solutions. These innovative approaches aim to transition from the traditional stabilization-boarding-disposition sequence to a treatment philosophy that views boarding time as an opportunity for active treatment and clinical improvement.

A key aspect of this new approach is the emphasis on understanding both patients' and healthcare workers' perspectives. Recognizing patients' experiences, wishes, and goals is essential for providing patient-centered care that is more holistic and therapeutic. Equally important is understanding the perceptions of healthcare workers who deliver care to boarding behavioral health patients. This dual perspective is novel and critical for developing effective and meaningful care strategies in emergency departments.

In this presentation, a panel consisting of a patient advocate and an expert in emergency medicine and behavioral health emergencies will describe the concordant and contrasting experiences of ED boarding, as well as the therapeutic goals envisioned and perceived by patients and healthcare workers. The presenters conducted semi-structured interviews with patients currently boarding for behavioral emergency care and with healthcare workers who provide care to these boarding patients in the same urban ED. Thematic analysis was performed to identify commonalities and disparities in the perspectives of the two groups. Based on these findings, the presenters developed a supportive, healing environment for ED behavioral health patients, focusing on interdisciplinary care with empathy and trauma-informed approaches to acute stabilization, treatment, and reassessment of both medical and psychiatric illnesses. The panelists will draw from their research, clinical experience, and programmatic expertise to discuss the design and implementation of interdisciplinary ED-based interventions informed by patient and healthcare worker perspectives and experiences, and share their learnings on what works and does not work in this novel clinical setting.

Learning Objectives:

Understand the Gap in Behavioral Health Emergency Care: Participants will be able to identify the critical gap between the rising number of behavioral health emergencies and the lack of adequate national, regional, or state-level responses in acute care delivery, treatment development, and care standards. This understanding will highlight the need for innovative local solutions.

Appreciate the Importance of Dual Perspectives in Care Delivery: Participants will take home concrete examples illustrating how a solid understanding of both patients' and healthcare workers' perspectives help provide effective and meaningful care. By recognizing patients' experiences, wishes, and goals, as well as the perceptions of healthcare workers, attendees will be better equipped to develop patient-centered, holistic, and therapeutic care strategies in emergency departments.

Implement Interdisciplinary Interventions in the ED: Participants will learn how to design and implement interdisciplinary ED-based interventions informed by patient and healthcare worker perspectives. Drawing from the research, clinical experience, and programmatic expertise presented, attendees will learn how to create supportive, healing environments for ED behavioral health patients, focusing on trauma-informed approaches to acute stabilization, treatment, and reassessment of both medical and psychiatric illnesses.

As the promise of 988 and other elements of a full crisis continuum have advanced, the realization of an ideal system of immediate access to care for anyone, anytime, anywhere has advanced. This emerging crisis continuum of services favors utilizing front-line crisis workers through crisis call centers, mobile behavioral health teams, and behavioral health crisis stabilization units (CSU's) rather than law enforcement and hospital emergency department (ED) use.

This presentation will explore this evolution of systems and the tension present in crisis care at all levels, involving balancing safety with minimizing trauma by using the least restrictive supports for an individual’s needs. It will explore innovations and best practices helping advance this shift in roles and partnerships of caring for higher acuities related to imminent risk of harm to self and others, substance use, and physical health challenges that often automatically connect those in crisis to law enforcement and Emergency Departments as the front-line care option. The session will examine (1) 911/988 coordination and management of risks other than harm to self with crisis call centers, (2) the coordination of law enforcement and emergency medical services with mobile behavioral health teams and mobile dispatch, (3) Emergency behavioral health CSU's infrastructure of medical tools, staff and training in triaging and managing medical, psychiatric, and substance use needs safely and effectively (4) and the balance of the opportunity for a near zero sequential intercept, inclusive coordinated system for all in crisis with care that feels like care in the face of challenges in overcoming barriers to this change.

The presentation will reflect on real-life examples of challenges, successes, and opportunities encountered in managing high acuity situations, derived from ten years of experience in diverse crisis service levels and leadership positions. It will highlight the significance of effective high acuity management in fostering inclusive environments that welcome all, thereby reducing implicit bias in healthcare access and restricting law enforcement's role in crises to instances of immediate risk to public safety.

Learning Objectives:
The audience will understand how managing higher acuity at each crisis level is important to creating access to all that feels like care and minimizing Emergency Department boarding and legal involvement.

The audience will learn about current tensions in safety vs. creating access to care at each of the three major crisis levels with real-live examples and discussion with the audience.

The audience will learn about tools, training, and systems that support managing high acuity levels safely in this model.

Crisis services definitions can vary widely depending on one’s location; the concept of a CSU (Crisis Stabilization Unit) can even mean completely different things depending on what part of the country one is in. Understandably, this variation has led to confusion as well as difficulty in establishing federal guidelines, regulations, and reimbursements; an attempt for nationwide standardization has been long overdue. To address this, in 2024 national experts from the worlds of emergency psychiatry and crisis care were assembled by the federal Substance Abuse and Mental Health Services Administration (SAMHSA) division of the U.S. Department of Health and Human Services (HHS) in Washington, DC, to serve on the Crisis Services Standards and Definitions Workgroup. This Workgroup was given the marching orders to: build upon partner research, environmental scans, claims review, and experiential data, with a focus on addressing the widespread variability in crisis service definitions. This variability is particularly notable for mobile crisis and crisis stabilization services. This Workgroup was to propose draft model standards that can be used by State, Territory, Tribal, and local partners; providers; as well as public and private payers. SAMHSA and HHS stated a belief that this clarification of crisis services standards and definitions will promote widespread alignment, further payor adoption of crisis service coverage, and increased access to quality, equitable care.

Two AAEP leaders who were included in this project, along with one of the top Crisis Services and Suicide Prevention authorities from SAMHSA, will report to the NUBE audience, with a view from a participant’s lens on the deliberations and outcomes of the national consensus -- and offer insights on how the new federal standards will affect all aspects of individuals and organizations in the crisis and emergency psychiatry spectrum for the foreseeable future.

Learning Objectives:

Describe the problems created by the lack of standardization and consistent definitions of crisis care spectrum programs across the USA.

Identify the varied levels of emergency psychiatry programs and crisis care programs.

Differentiate between Behavioral Emergency and Crisis Stabilization levels of care.

Recognizing that providing excellent care for behavioral health patients in the Emergency Department (ED) is essential to ED staff, management, and the organization's mission and values, an "ED Behavioral Health Core team" is formed. The core team, primarily composed of ED nurses and techs, focuses on the coaching and mentoring of other ED nurses, improving the care of the behavioral patient. The team focuses on patient and staff safety, creating champions for this patient population. They aim to prepare nursing staff better to take care of this population with education, daily shift reports, and monthly in-person meetings to discuss barriers and consider ideas for improvement. Presentations include education on special populations like geriatric psych, severe mental illness (SMI), and pediatrics. Because the team has been so successful and inspiring, it has evolved into a multidisciplinary team with participation from physicians, pharmacists, social workers, and security personnel.  As a community ED, the Chandler Regional ED comprises 60 beds within a Level 1 trauma center. With 70,000 annual ED volumes and 429 inpatient licensed beds, we see over 2,000 patients with a behavioral health concern yearly. This ED has no dedicated space for psychiatric/behavioral patients, has no psychiatric inpatient unit, and boards psychiatric patients in the ED on average twelve hours before transferring them to a psychiatric facility. ED management will also measure team success using data. They will collect data on 1. Restraint use/time in restraints, 2. Completion of safety room checks with security personnel, and 3. Care conference form Usage. Even though there are not many resources for behavioral patients within our hospital, we have successfully recruited ED personnel to champion this patient population's care and have seen objective and subjective improvements very early on.

Learning Objectives:

Conference attendees will be able to identify steps in developing a specialty ER team.

Conference attendees will be able to discuss the benefits of having a behavioral health specialty team in a community ER.

Conference attendees will be able to formulate best practices in recruiting Emergency Department staff to a specialty team.

As one of two healthcare systems within a Midwest city, Summa Health struggled to maintain continuity of care across encounters. The same individual seeking care for the same chief complaint might receive vastly different treatment based upon the clinicians caring for them from encounter to encounter. Furthermore, each encounter was treated by clinicians as a stand-alone interaction. Clinicians might “chart review” what had been done at a prior encounter, but there was no mechanism to share a comprehensive understanding an individual’s goals, needs, and challenges. Additionally, no structured way to incorporate community-based interventions into hospital-based care existed – patients effectively were “discharged” to find their way. As a result, the same patients with the same challenges were treated over and over with little forward progress made.

Among front-line clinicians of all varieties, this status quo was a source of frustration. Collaborating on care plans was time-consuming and ad hoc. Thus, Summa Health Department of Psychiatry developed a Complex Patient Treatment Planning Committee, involving clinicians from multiple disciplines and specialties to collaborate in the development of Complex Treatment Plans for a subset of individual patients who were not being well-served with an ad hoc process. A registry of patients was developed, multidisciplinary treatment plans were developed and vetted by experts across a variety of settings, and these plans were shared across the system and the community to support a unified approach to help individuals meet their goals.

As a result of this Committee, individual clinicians were supported in their care of these complex patients with a robust treatment plan that crossed between encounters and organizational boundaries, improving patient care and reducing clinician frustration.

Learning Objectives:

To describe the challenges of caring for complex patients within a fragmented healthcare system.

To provide an example of one approach to complex treatment planning within a healthcare system and community.

To examine the factors that may contribute to success for a multidisciplinary team approach to increasing continuity of care for behavioral health patients.

Purpose of Presentation:
This presentation aims to comprehensively explore the evolution of Crisis Stabilization Nursing (CSN) within the context of mental health care. The primary purpose is to elucidate the historical development, contemporary practices, and emerging trends that have shaped CSN, while emphasizing its pivotal role in the broader field of Psychiatric-Mental Health (PMH) Nursing. By delving into the purposeful evolution of CSN, the presentation seeks to offer insights that can inform and inspire current and future nursing professionals.

Summary of Evidence:
The presentation synthesizes a diverse range of evidence, including historical literature, empirical studies, and anecdotal experiences, to chronicle the evolution of Crisis Stabilization Nursing. It highlights the shifting paradigms in mental health care that necessitated the development of specialized crisis intervention strategies. The evidence underscores the importance of adapting nursing practices to the dynamic needs of individuals experiencing mental health crises, emphasizing the journey from traditional psychiatric care models to the more person-centered and recovery-oriented approaches seen in contemporary CSN.

Description of Practice or Protocol:
The core of the presentation focuses on the nuanced practices and protocols that define Crisis Stabilization Nursing. This includes a detailed examination of crisis assessment techniques, de-escalation strategies, and the incorporation of trauma-informed care principles. By illustrating how CSN has evolved beyond mere crisis intervention to encompass a holistic and individualized approach, the presentation aims to provide a roadmap for nursing professionals seeking to enhance their skills in crisis stabilization.

Method of Evaluation:
The effectiveness of Crisis Stabilization Nursing practices will be assessed through a multifaceted evaluation methodology. Quantitative measures, such as the reduction in hospitalization rates and readmission rates. The presentation will delve into the challenges of evaluating crisis intervention, emphasizing the importance of quantitative metrics and the nuanced understanding derived from qualitative insights.

Relevance to PMH Nursing / Results:
This presentation underscores the profound relevance of Crisis Stabilization Nursing within the broader landscape of PMH Nursing. Results will showcase the positive impact of specialized crisis interventions on patient outcomes, including improved symptom management, increased patient satisfaction, and a decrease in the overall burden on emergency mental health services. It emphasizes the symbiotic relationship between crisis stabilization and the core tenets of PMH nursing, such as patient advocacy and empowerment.

Future Implications:
In looking ahead, the presentation explores the potential future implications of the continued evolution of Crisis Stabilization Nursing. It envisions a landscape where CSN plays an increasingly vital role in preventive mental health care, potentially influencing policy changes and shaping the trajectory of mental health services. By embracing a proactive and adaptive stance, the presentation aims to inspire ongoing innovation and excellence in Crisis Stabilization Nursing, ultimately contributing to the advancement of mental health care as a whole.

Learning Objectives:

Influencing policy changes and shaping the trajectory of mental health services.

Evaluate effectiveness of Crisis Stabilization Nursing practices.

Evaluate the evolution of Crisis Nursing.

The Huntsman Mental Health Institute (HMHI) of the University of Utah, through active involvement and integrated efforts with our community, have developed an alternative to Emergency Departments for the evaluation, stabilization and treatment of people experiencing acute mental health exacerbations. In this presentation, we will discuss the HMHI Receiving Center, which provides emergency care for individuals experiencing a mental health crisis. It is also serving as a pilot program for the Kem and Carolyn Gardner Mental Health Crisis Care Center (MHCCC), affiliated with HMHI, which will open in March 2025. This presentation serves to introduce the HMHI Receiving Center purpose and to discuss initial findings of this pilot program to serve our community.

The HMHI Receiving Center provides walk-in treatment as well as EMS/Police/Fire drop off for patients to get services and treatment 24 hours a day, seven days a week. Services include short, highly intensive interventions focused on resolving crises in the least restrictive manner possible. Services include crisis evaluation, psychiatric assessment, medication prescribing, peer support, case management, and connection to on=going resources and support, and crisis observation, if needed for up to 23-hours. The HMHI Receiving Center also provides detox initiation for community rehabilitation programs, inpatient medical detox, and HMHI Bridge outpatient medication-assisted treatment program.
Through a collaboration with Salt Lake County and multiple community partners the MHCCC will be a centralized emergency psychiatric center for the county of Salt Lake City, Utah. Taking data and experience from the HMHI Receiving Center we have been able to further develop and trial how to best facilitate the needs of our patients and community partners.

Learning Objectives:

The HMHI Receiving Center is an alternative to psychiatric emergency rooms for the people of Salt Lake County.

Utilizing community partnerships allows for a centralized psychiatric emergency center.

Discussing of initial data from our pilot program to show how this model can alleviate some burden on emergency departments.

Confronted by diminishing outpatient resources, patients with psychiatric emergencies are forced to seek other avenues for treatment, including the healthcare system’s last remaining safety net—the emergency department (ED). As inpatient beds are scarce across the state and nationally, many patients spend several days or weeks in the ED without any acute behavioral therapy while they wait for an inpatient bed to become available. The current state of emergency psychiatric care calls for patient-oriented solutions focused on converting boarding time from wasted time to treatment time—initiating the healing process for our patients in distress presenting to the ED as a last resort.

Integration of psychiatric occupational therapy (OT) services to provide active treatment to ED boarding patients is a promising intervention. OTs are an integral part of psychiatric care in both inpatient and outpatient mental health settings. Their training and expertise uniquely position them to offer individualized treatment and assessment for patients with complex behavioral needs in the ED setting. Their treatment strategies include group and individual interventions to build coping skills, the integration of sensory modulation strategies into daily activities, and the promotion of engagement in healthy routines and behaviors. The use of occupational therapists in the emergency room setting for behavioral health patients has not been widely studied.

This presentation will be conducted by a multidisciplinary panel consisting of experts in rehabilitation services, social work, and emergency medicine. The panelists will reflect on their local experience of establishing a psychiatric OT consultation program in the ED. Drawing from their own research and programmatic expertise, the expert panelists will lead a case-based discussion to review: (1) how to financially and programmatically establish and support a psychiatric OT program in the ED, (2) how to integrate OT interventions into the delivery of care in the ED, and (3) what individualized treatment can be provided by OT during ED boarding. The panelists will also review local data on patient-reported outcomes.

Learning Objectives:

Understand different facets of psychiatric OT services that can be integrated into emergency psychiatric care in the ED.

Operationalize and support ED psychiatric OT consultation program.

Design individualized OT interventions, focusing on safety, treatment, reassessment, and patient empowerment.

AAEP has been intensely involved in the idea of emergency psychiatric training for decades. Our mission notes that we want to advance this knowledge base for the good of all involved.  As such, the idea of specialty certification and/or fellowship is paramount.

The purpose of this conversation is to update attendees on steps/process/progress made on this topic from the AAEP perspective. This will include examining past attempts, the current state of affairs, and the details on this endeavor going back approximately 3-5 years.

We will look at the differences in categories (fellowship vs. certification vs. focused practice designation) as well as how this affects the abilities for this work to affect psychiatrists, emergency medicine physicians, or both!
Part and parcel to the past years' work will be a explanation of our partnerships with multiple important stakeholders. This includes but is not limited to ABEM, ACEP, ABPN, and the APA. Additionally, we will note how conversations were had with many other important components (AADPRT, CORD, NAMI, ACLP, etc…).

Further examination will be given to the need to examine the core population of who would be utilizing this (emergency medicine, psychiatry, or others) as well as what this process would look like. We will also examine the synergy that exists when combining two professional medical groups as opposed to solo efforts within one specialty silo.
Lastly, we will provide data on where any pertinent processes stand, including public commentary, support, and criticisms. As such, this talk will serve not only to educate on this SPECIFIC topic but also to show a more GENERAL example of how to advocate on important emergency psychiatry topics over an extended period of time.

Learning Objectives:

Discuss the need/rationale of a formal emergency psychiatric certification/recognition.

Process the varying degrees of certification and fellowship that exist, as well as the benefit/risk towards exploring each category.

Inform and update attendees on AAEP progress and related partnerships with ABEM, ABPN, ACEP, APA , and others as a means to the operationalization of this goal!

A patient dying by suicide is one of the most difficult aspects of providing mental health care. Many providers struggle with coping in the aftermath of a patient death by suicide. Despite providers’ difficulty in accurately predicting who will go on to attempt or die by suicide, there is increasing pressure from regulatory bodies for healthcare organizations and providers to prevent suicide, with much scrutiny when a patient dies by suicide as well as emphasis on zero suicide. The Joint Commission (TJC) changed their definition of a sentinel event pertaining to suicide to one that occurred within seven days after last contact with levels of care, including the emergency room. As the timeframe of patient death by suicide has been expanded from three to seven days post-discharge, with broadening of the levels of care included in TJC’s revised sentinel event policy, it is anticipated that there will be increased reporting to TJC and investigations within healthcare organizations to evaluate contributory factors and root causes associated with these patient deaths. Providers who are struggling with coping in the aftermath of a patient death or other adverse outcome may have difficulty effectively contributing to a patient safety investigation such as a root cause analysis (RCA) following the death of a patient. There are existing data showing that when providers impacted by an adverse outcome are appropriately supported, they can meaningfully contribute to improving the culture of safety in an organization.

This presentation will review the intended goals of patient safety investigations such as RCAs and the unintended impact these investigations can have on providers who worked directly with patients. Participants will learn about expected acute stress reactions and strategies for coping. The session will also review ways to support providers impacted by these events, both individually and through support programs.

Learning Objectives:

Describe the intended purpose of a root cause analysis (RCA).

List three acute stress reactions and three strategies for coping after an adverse event.

Identify resources for providers impacted by adverse events.

With rising incidents related to workplace violence, Emergency Department leaders at UCHealth in Fort Collins, CO found ourselves at a loss for how to best to support our staff in continuing to provide excellent care while facing increasing concerns of violent and disruptive behaviors within the workplace. After taking steps to address workflows within the department, we knew that we needed to get creative and look outside of the walls of the hospital to address the gap seen within our community. Partnering with local law enforcement and our cities municipal court system, we have developed the Healthcare Accountability Restorative Program (HARP) which aims to address common violations within the healthcare setting to hold individuals accountable while providing opportunities for treatment. By using a restorative justice model, HARP focuses on showing the impact the incident of violence has on the victim, community and the individual with opportunities to give back to each subsect with a variety of healthcare related tasks.

In this presentation we address what workplace violence is within healthcare, impacts these disruptions have on healthcare systems nation-wide, our experience with why violent and destructive acts are not being reported, and what we have created to address these gaps within our own community. We will discuss the development process of HARP along with the implementation of the program in April 2024. We will review our initial findings including barriers, opportunities for future growth, and the successes we have discovered along the way.

Learning Objectives:

Define workplace violence in the healthcare setting.

Identify common violations within the healthcare setting that would qualify for municipal court restorative justice programming.

Learn about the Healthcare Accountability Restorative Program (HARP) implemented in Fort Collins, Colorado and understand barriers and results from the first 8 months of programming post go-live in April 2024.

This presentation walks participants through an understanding of the biggest contributors to their areas of stress in a healthcare workplace environment in the context of critical incident and disaster response and recovery, and what can be done to effectively and reasonably reduce symptoms and increase active coping. We will cover examples of cognitive, behavioral, and emotional challenges while discussing practical and accessible strategies for recognizing and managing through burnout, compassion fatigue and moral injury experiences in healthcare. Participants will also come away with a better understanding of the most effective and efficient ways to helpfully engage patients and colleagues who may be experiencing crisis, or who are just in need of support while also developing insight into their own resilience and coping tactics and styles.  

Learning Objectives:

Recognize common experiences and behavioral indicators of burnout, compassion fatigue and moral injury.

Develop and understanding of elements needed for an effective coping plan.

Assess personal, active coping strategies and effective crisis deescalation strategies.

Our work is rewarding, yet stressful and not without risk.  Despite our best efforts at providing optimal care and managing risk, adverse events, although infrequent, can have profound impacts on individuals who care for patients, on institutions, patients and families.  Unanticipated deaths or injuries and other adverse events occurring within our facilities or following discharge from emergency departments, or who are cared for by mental health clinicians can represent personal and professional crises for practitioners. Existing literature on adverse outcomes in health care tends to focus on medical errors such as missed diagnoses or procedural errors.  Physicians caring for such patients can be considered “second victims” due to the emotional impacts following such events and some health systems have peer support programs in place to assist such providers.   There is less data on adverse outcomes in behavioral health not involving medical errors, such as patient suicides shortly or immediately after discharge, overdose deaths or harms inflicted on others by a patient; and on the impacts on clinicians who care for such patients.  

Emergency behavioral health providers are faced with the task of conducting risk assessments and determining level of care such as hospitalization vs. discharge. As such they may be subject to perceived accountability of patient behaviors following discharge from emergency departments. At the same time, community resources and options for containing risk, including inpatient bed availability may be limited, necessitating outpatient disposition. Suicide deaths involving patients currently in treatment or shortly after discharge can be particularly emotionally impactful on clinicians due to the nature of the therapeutic relationship as well as institutional responses which may view all suicide deaths as “adverse events”. Indeed, many institutions have “zero suicide” initiatives with the admirable, but unachievable goal of eliminating suicide deaths among behavioral health patients. If an organizational assumption is that all suicide deaths are preventable, caregivers who learn of the death of a patient by suicide may experience feelings of failure, fear of reprisal or even post-traumatic symptoms.

Hospital Adverse Event or Sentinel Event review committees are often tasked with the important work of conducting root cause analyses, morbidity and mortality reviews, institutional risk management or minimizing liability. Such committees may or may not have a goal of providing support to members of the care team. Within behavioral health, given the importance of supporting clinicians who have cared for patients involved in adverse events, while lessons learned for system improvement, specific behavioral health Adverse Event Committees can be uniquely suited to accomplish both tasks simultaneously. Providing immediate emotional support and reassurance to providers, allowing sufficient time between psychological first aid efforts and detailed case reviews; and prioritizing suggestions for systems improvements over individual responsibility are important functions of such committees.

This presentation will provide an overview of the topic of adverse events in behavioral health, and impacts on clinicians. We will then provide case examples to illustrate how a behavioral health Adverse Event Committee can help support providers and identify areas of potential system improvements.

Learning Objectives:

To provide an overview of behavioral health adverse events and impacts on clinicians.

To learn how to better support clinicians following behavioral health adverse events such as patient suicides.

To highlight the unique roles of a behavioral health Adverse Event Review Committee.