NUBE 2024

Background: Emergency Department encounters for behavioral health emergencies (BHEs) often originate from 9-1-1 first responders, specifically emergency medical services (EMS) clinicians and law enforcement (LE) officers. It is critical for EMS clinicians to have management strategies for BHEs, yet relatively little information exists on best practices or innovative strategies. Over the past 8 years, the Los Angeles County EMS Agency’s Commission has engaged in a comprehensive evaluation of the 9-1-1 response for BHEs and developed a performance improvement plan to advance the quality of care and safety for patients and first responders. This panel will describe the objectives, methods, and interventions of LA County’s Behavioral Health Initiative Committee (BHIC), with potential application to all providers of psychiatric/behavioral emergency services, identifying opportunities to improve the continuum of care and, in particular, 9-1-1 pre-hospital behavioral health services.

Methods: The BHIC was assembled with broad representation from EMS, LE health agencies, and the public. BHIC objectives included: 1) produce a process map of the BHE response from the time of a 9-1-1 call to patient arrival at transport destination, 2) identify and describe the different agencies that respond, 3) describe the critical decision points in the EMS and LE field responses, 4) acquire data that quantitatively and/or qualitatively describe the services available, and 5) recommend interventions for system performance improvement.

Results: The BHIC generated comprehensive process maps for the prehospital response to BHEs, articulated principles for evaluation, and described key observations of the current system including: 9-1-1 dispatch criteria are variable and often defaults to a LE response, the LE response inadvertently criminalizes BHEs, EMS field treatment protocols for BHEs (and especially agitated patients) are limited, substance use disorder treatment lacks integration, destination options differ by transporting agency, and receiving facilities’ capabilities to address BHEs are variable. Recommendations for performance improvement interventions and initial implementation steps included: standardize dispatch protocols, shift away from a LE primary response, augment EMS treatment protocols for BHEs and the management of agitation, and develop alternate destination for EMS transport.

This general session will describe a comprehensive performance improvement initiative in LAC-EMS Agency’s 9-1-1 response to BHEs. The initiative included a thorough current state analysis, followed by future state mapping and the implementation of interventions to reduce LE as the primary responder when an EMS response is often warranted, and to improve EMS protocols and access to resources for BHEs. These strategies may be adapted across other EMS systems and requires leadership or support from behavioral emergency specialists.

Learning Objectives:

Understand and apply 4 principles that guide the evaluation and improvement of 9-1-1 services for BHE’s.

Describe key strategies to enhance the EMS quality of care and safety for patients with BHE’s.

Identify opportunities and barriers to shift away from a law enforcement response to a medical response for BHE’s.

Background: PSYCKES (Psychiatric Services and Clinical Knowledge Enhancement System) is a web-based, HIPAA-compliant platform developed and managed by the NYS Office of Mental Health that integrates statewide information on the patient’s mental health and general medical history including ER and inpatient services, medications, outpatient providers and service utilization, and high-risk alerts related to suicidality/self-harm and opioid overdoses. In 2018, the NYS Department of Health (DOH) and the Office of Mental Health (OMH) recommended emergency departments (EDs) use PSYCKES, and launched the Behavioral Health High Risk Quality Collaborative (HRQC) in 2019 which supported implementation of PSYCKES in as a tool to help identify and evaluate individuals with high behavioral health risks, including history of suicide attempts, overdose risk, and high utilization of emergency and inpatient mental health services. We examine the impact of HRQC learning collaborative participation on PSYCKES access and usage by ED staff, as well as lessons learned from implementing this health information tool in emergency departments.

Methods: The PSYCKES application was made available to all EDs in NYS in July 2018, and EDs were invited to enroll in the HRQC to support implementation. The HRQC was launched in January 2019, and participating EDs submitted action plans and participated in individual technical assistance calls to assess progress and troubleshoot implementation challenges. Notes taken during the calls identified implementation barriers and action steps to be taken by the ED project teams to address those barriers. We compared HRQC participating and non-participating EDs on PSYCKES use at baseline (year prior to launch) and monthly over the five years after the launch. Measures included the number of PSYCKES users per month by hospital/participation status (data source: PSYCKES usage logs), and the proportion of Medicaid patients receiving a behavioral health related ED service that had their PSYCKES clinical summary viewed (data source: Medicaid claims and encounter data, and PSYCKES usage logs). Additional information on PSYCKES use in the ED was obtained through a post-project survey administered in Spring 2024.

Results: The number of PSYCKES users, and the proportion of behavioral health presentation who had their clinical summary viewed in PSYCKES increased over time. We share the characteristics of hospitals with increased PSYCKES use including participation status, and ED type. Over half (52%) of HRQC-participating EDs reported implementing PSYCKES for all psychiatric presentations, and a third (32%) reported using for a subset of based on patient factors, with some EDs reporting variation in use by staff preference and ED shift. The PSYCKES clinical summary information EDs reported using most frequently was level of ER/inpatient utilization, identifying care coordination and outpatient providers, medication reconciliation, and risk information.

Lessons Learned: ED implementation experiences highlight the need for multi-department buy-in on the value of integrating behavioral health information into general ED processes, the challenge of incorporating external technology into ED workflows, and approaches for identifying and training staff during a time of significant bandwidth constraints and turnover. Despite challenges, the majority of EDs were able to successfully implement PSYCKES to support screening, assessment and discharge planning.

Learning Objectives:

Summarize the benefits of using a statewide mental health information sharing program in the emergency room.

Describe the strategies and challenges in implementing behavioral health information technology in general emergency services.

Explain the impact of the NYS High Risk Quality Collaborative on uptake of the PSYCKES application, a statewide mental health information sharing platform.

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.

Background:  Psychiatric emergency department visits are often associated with long wait times. This leads to agitation and dissatisfaction among patients, delay in care, patients leaving without receiving care, staff frustration, and increased costs. Prior publications indicate that triage guidelines correlate with wait times and patient satisfaction. Atrium Behavioral Health Charlotte is a dedicated psychiatric emergency department in the southeast region that treats all ages, populations, and psychiatric diagnoses. The ED patient volume has risen yearly from 2020 to 2023 leading to overcrowding and long wait times.

Method: The triage process was modified and implemented with Plan-Do-Study-Act (PDSA) cycles that involved provider and triage nurses. Pre and post surveys were administered to clinicians to evaluate perceptions of the triage process before and after the implementation. The triage process was redesigned to improve workflow and reduce redundancy of treatment. A sorting/lead registered nurse role was created to navigate the triage process with a patient and establish the level of acuity. Focused assessments were instituted as it was determined a full assessment was not needed to determine disposition for all patients. Patients could be quickly triaged by a nurse to assess patient safety and determine the need for immediate intervention or treatment. Provider (Advanced Practice Provider or physician) assessment now occurred in triage. We evaluated 5,249 ED visits between 9/22 and 4/23 before implementing the modified triage process and we assessed 4,202 ED visits between 7/23 and 2/24 after the implementation. The Wilcoxon test for unpaired samples was used to assess differences ED times. Time differences include Arrival to Triage, Triage end to Provider, Roomed to Provider, Provider to Disposition, Disposition to Depart, and Total length of stay.

Results: Prior to the triage change, 747 patients left the ED after check-in without being seen and the median time for patients’ length of stay from door to discharge was 287 minutes. The median total length of stay was reduced by 110 minutes leading to a 38% reduction (p<0.001). The median time from being roomed to seeing a provider has been reduced from 98 to 43 minutes (56% reduction; p<0.001). The median time from arrival to the ED until seen by a provider has been cut in half to 76 minutes (52% reduction; p<0.001). The percent of patients who left the ED before starting treatment has been reduced from 10.5% to 6.3% (40% reduction; p<0.001).

Conclusion: Implementation of the modified triage process reduced redundancy in assessments, which helped to have patients assessed by a provider quicker with decreased wait times at various touchpoints in the ED encounter. The data show that this new process led to significant decreases in left without being seen (LWBS) rates. Decrease in LWBS rates helped this psychiatric ED recapture lost revenue from patients that normally would have left without being seen due to long ED wait times. This process also helped eliminate redundancy of psychiatric assessments which freed up a social worker for disposition planning. This process also improved interdisciplinary communication.

Learning Objectives:

Explain the components of an optimized behavioral health triage protocol.

Show psychiatric emergency department wait times before and after the implementation of a modified triage protocol.

Describe the dissemination methods and uptake of a triage protocol in psychiatric emergency care settings.

Background: Emergency Medical Services (EMS) play a critical role in the initial 9-1-1 response to individuals exhibiting suicidal ideation and behaviors, often leading to emergency department encounters. However, there is a significant lack of standardized training and guidelines for EMS personnel in this area, resulting in varied outcomes for those in crisis. In early 2024, Los Angeles (LA) County’s EMS Agency, the largest in the country, launched a quality and performance improvement initiative to evaluate the current evidence for EMS assessment and management of individuals with suicidal ideation and behaviors. This initiative has led to key recommendations for LA County to develop new standardized policies, practices, and training. This general session will review the current findings and status of LA County’s efforts to enhance the 9-1-1 EMS response to patients with suicidal ideation and strategies that can be deployed in local jurisdictions.

Methods: A multi-stakeholder, community-partnered, performance improvement committee consisting of representatives from EMS, law enforcement, emergency department physicians, psychiatrists, nurses, and the Department of Mental Health was formed to conduct a comprehensive evaluation of existing protocols, identify gaps, and develop recommendations for policy enhancement and training improvement. The committee conducted a comprehensive literature review, including policy review from 34 county EMS agencies across California and national guidelines, and identified strengths and deficits in the current EMS response through case studies of base hospital radio calls and robust interdisciplinary discussions. The committee also designed and deployed a cross-sectional survey to capture LA County EMS personnel’s experiences with current protocols, identifying common challenges they face in assessing and managing suicidal patients. These processes collectively led to identifying key areas to enhance EMS policy, education, and training.

Results: 0 out of the 34 California counties evaluated had dedicated policies for the evaluation and management of patients at risk for suicide nor were any substantive practices identified in national guidelines. References to “suicide” or “danger to self” were often embedded within broader contexts such as “restraints,” “refusal to transfer,” or “behavioral crisis,” with limited, non-specific guidance. Survey results quantified the current state of providers’ education and confidence in evaluating and managing patients at risk for suicide. These results, along with committee case reviews, identified domains for quality improvement including written protocols that define terminology and provide guidance on: use of an evidenced-based screening tool, determining disposition, safety planning, and protocols for interacting with law enforcement.

Conclusion: This general session will describe the critical gap in standardized EMS protocols for evaluation and management of patients at risk for suicide, including results of an LA County EMS provider survey and a robust committee process following a quality improvement framework. A thorough analysis of the current state identified opportunities for system-wide improvements and innovation in EMS quality of care for 9-1-1 patients at risk for suicide. Leaders in emergency psychiatry will understand strategies to collaborate with key stakeholders to develop appropriate policy, education, and training.

Learning Objectives:

Examine a performance improvement committee’s approach to evaluate the current state of EMS field evaluation and disposition of individuals at risk for suicide, including a review of best practices and an analysis of current field protocols across California.

Review the results of a cross-sectional survey designed to understand EMS providers’ perspectives regarding opportunities and barriers to improve care for patients at risk for suicide.

Explore strategies for improvement or innovation in EMS policy, practices, and training to enhance quality of care for 9-1-1 patients at risk for suicide.

Background: Currently, youth seeking emergent mental healthcare are often required to complete routine laboratory assessment, regardless of presentation, to ensure “medical clearance” prior to consideration of inpatient psychiatric care. These laboratory tests are often low yield and have the potential to cause significant trauma and avoidable restraint, particularly with youth. Furthermore, this introduces excess cost, spurious lab findings and delays in care for a system that is already constrained by long lengths of stay, inefficiencies, and excess cost. Several states have adopted evidence-based tools, or SMART clearance, and workflows to eliminate the use of routine laboratory findings for medical clearance and based this clearance on clinical presentation and judgment of medical and psychiatric staff.

Methods: We describe the project design and implementation of the MI-SMART tool (adapted from the Sierra Sacramento Valley Medical Society SMART project), via an initiative by the Michigan Department of Health and Human Services, at a large, academic, tertiary care children's hospital in the State of Michigan. This includes initial stakeholder development, including mental health professionals in consultation-liaison psychiatry, inpatient psychiatry and emergency psychiatry, pediatric hospitalists and intensivists, pediatric emergency department (ED) professionals, administrative and information technology staff, as well as partners at Community Mental Health and the Department of Health and Human Services. This stakeholder group met iteratively from January 2024-June 2024 to design workflows in the pediatric ED and psychiatric ED setting, as well as parallel workflows with the inpatient pediatric floors and pediatric critical care setting. The result was the piloting of a electronic medical record navigator with a standardized MI-SMART checklist and template for documentation, page alerts and best practice advisory alerts, workflows, tip sheets, and standardized education to operationalize the implementation of the MI-SMART resources. A data dashboard with key performance indicators was created to track process and outcome measures over time. The first three months of pilot data will also be presented as it relates to the relevant care of the pediatric population in the children's hospital.

Results: We will present stakeholder working group development, collaborative design of the MI-SMART resources, as well as pre-implementation data from the first three months of launching MI-SMART across the children's hospital. This will include review of process measures including number of MI-SMART forms utilized, acceptability of by providers and staff in the ED and hospital setting, number of youth successfully transferred to an inpatient psychiatric facility using the MI-SMART build and resources, time to triage in the ED to completion of the MI-SMART form, time to completion of the MI-SMART form and psychiatric consultation. Additional outcome measures that will be shared include routine labs and diagnostic studies gathered, cost, restraint use, as well as patient and family satisfaction.

Lessons Learned: Use of an evidence-based set of resources to mitigate the use of potentially unnecessary and traumatizing routine labs for medical clearance of youth requiring psychiatric admission may be a feasible, acceptable, and cost-efficient alternative to current medical clearance practice, while improving safety practices and patient, family and staff experience.

Learning Objectives:

Understand current evidence related to best practice for medical clearance of individuals, particularly youth, who require psychiatric admission from emergency settings.

Describe the process of designing an evidence-based tool to employ clinical judgment and best practice in supporting medical clearance of youth in the ED setting, rather than routine labs.

Review process measures and clinical outcomes resulting from initial data gathering on the implementation of the MI-SMART form and resources at a single, academic children's hospital.