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.

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.

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.

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.

Over the last 5 years, the Pediatric Consultation and Liaison Psychiatry Service at the C.S. Mott Children's Hospital has developed a 24/7 Social Work service that specializes in the spectrum of emergency department psychiatric services in the Children's Emergency Department. Prior to development of this service, patients had longer wait times and  multiple transitions in their care to receive a psychiatric assessment. Social work has partnered with advanced practice providers to support with psychiatric assessment, brief interventions, safety planning, coordinating psychiatric disposition, and completing post-discharge follow-up calls in the Children's Emergency Department setting. The 24/7 model was implemented in phases with close supervision, training, and partnership with medical and psychiatric providers. Additionally, emphasis was placed on utilizing a Zero Suicide approach to ensure evidence based best practices were implemented and promoted in the service. This talk will review strategies to develop a model that provides collaborative, safe, and innovative care that leverages the special skills of each profession. Development of the service also included focus on engaging non-psychiatric staff including building buy-in, care pathways, education, and utilizing a continuous learning healthcare model. Social work has a unique training and background in providing care to diverse populations and integrating culturally informed care into evaluation and intervention.

Learning Objectives:

Distinguish roles of specialty psychiatric providers in a medical emergency department.

Identify key training resources to develop staff with specialized skills to deliver psychiatric care in a medical setting.

Assess the impact of a psychiatric collaborative care model in a Children's Emergency Department.

Ketamine has a well-established efficacy and safety profile when used as an anesthetic agent in surgical procedures in both adults and minors. Ketamine use is being expanded to include other indications such as acute and chronic pain, complex alcohol withdrawal and alcohol use disorder, opioid use disorder, depression, and suicidality, with promising findings. Ketamine was also found to have rapid sedative effects when given to treat severe psychomotor agitation in pre-ER and ER settings, often via the intramuscular route. When it comes to severe agitation in a patient with borderline low blood pressure, heart rate, and respiration rate, almost all sedative agents, including antipsychotics, benzodiazepines, a1 antagonists, a2 agonists, and dexmedetomidine would further jeopardize the fragile vitals and may result in respiratory depression. In addition, most of these agents’ clinical effects peak after 20 to 30 minutes of administration via the intramuscular route, which can be a long time while attempting to maintain the safety of the patient, staff, and others. Ketamine, on the other hand, is found to be less likely to lead to further hemodynamic instability or respiratory depression. Additionally, the time needed to induce sedation is consistently found to be shorter when ketamine is used compared to other agents in several head-to-head clinical trials.

In this presentation, we will quickly review the mechanism of action of ketamine and discuss its indication in psychomotor agitation in pre-ER and ER settings. We will also review its efficacy and safety profile and best practices after administration.

Learning Objectives:

Understand ketamine role in treating psychomotor agitation in pre-ER and ER settings.

Explain the advantages of using ketamine in this context compared to other agents.

Appreciate best practices of medical care following ketamine use for agitation.

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.

Background:
Psychiatric patients presenting to the Behavioral Health Emergency Department can arrive in crisis with multiple co-occurring issues, including chronic or acute pain. Pain can cause or worsen anxiety and depression and is associated with increased disability and poorer quality of life in people with severe and persistent mental illness. Traditional pain management often relies on medication and poses risks and limitations in psychiatric care. Given the increased suicide risk associated with severe mental illness and pain, alternative non-pharmacologic approaches are imperative. Acupuncture and acupressure have been used for centuries to manage various disorders including pain.

The BH-ED supports patients during their most vulnerable time and often present in crisis. Patients come from diverse ethnic and socioeconomic backgrounds. Many patients have limited resources and utilize the ED as a place to receive treatment for their psychiatric and medical concerns.

Objective:
Assess the feasibility of nurses administering battlefield auricular acupressure (BAApress), patients' acceptance, and impact on pain and anxiety management.

Method:
Prior to initiating the study, nurses participated in the BAApress training done by BAApress Intervention initiated by AH WFBH Center for Nursing Research. Three Emergency Department nurses and study personnel received comprehensive BAApress training. The protocol consists of placing adhesive acupressure pads bilaterally on five specific auricular sites: 1) Cyngulate gyrus, 2) Thalamus, 3) Omega 2 4) Point Zero, and 5) Shen Men. These sites were selected based on the Veterans Administration Battlefield Auricular Acupressure Protocol for acute and chronic pain. This training process took approximately four hours. In this study, ten patients had five acupressure pads per ear placed at pre-selected acupoints as per battlefield auricular acupressure protocol shortly after admission and remained on patients during their stay. Patients were assessed daily for pain using Visual Analogue Scale Pain Scores and anxiety utilizing General Anxiety Disoder-7 on days 1 and 3.

Results:
Nurses were able to incorporate BAApress treatment without disruption to the nurse’s workflow. Results show 77% acceptance rate of acupressure treatment. Pain scores decreased each day (p=0.14). Anxiety scores significantly decreased (p=0.01). Nurses successfully initiated treatment in 77% of cases, with 100% patient satisfaction with pain management.

Conclusion:
Results showed substantial improvement in anxiety and modest improvement in pain, suggesting the potential for this treatment to be part of pain and anxiety management. Despite staffing challenges, nurses demonstrated ease in implementing this treatment effectively, suggesting its potential in various medical settings potentially benefiting a large group of patients. However, comprehensive large-scale studies are necessary to validate the effectiveness of battlefield auricular acupressure as an adjunct treatment in pain and anxiety management across diverse patient populations and settings.

Learning Objectives:

Determine feasibility of nurses administering BAA.

Assess effectiveness of battlefield auricular acupressure (BAA), as an adjunctive treatment for pain and anxiety.

Determine patients’ acceptance of this treatment modality.

Background: There have been significant increases in both pediatric visits for mental health to the emergency department, and the prevalence of autism spectrum disorder (ASD). However, there is a relative dearth of information about patients with autism spectrum disorder (ASD) or intellectual disability (ID) who seek emergency psychiatric care. There are unique challenges associated with this patient population in the emergency setting. Given this backdrop, this retrospective study explored clinical, demographic, and disposition-related information about this patient population over a 10-year period.

Methods: This study included individuals with ASD or ID (n =1461) and had presented to a psychiatric emergency department between 2012-2021. Data were extracted using a structured chart review methodology, and included demographic, clinical and visit information. Demographic data included: race/ethnicity, age, and primary insurance type. Clinical data included: Co-occurring disorders, reason for visit, prior treatment history, abuse history, and current medications. Visit data included: Medications given, restraints information, and disposition.

Results: Sample was predominantly White (77.21%), adolescent (mean age ± SD = 15.5 ± 4.3) and male (72.76%). There was an abuse history in a significant % of the sample, with physical abuse (16.97%) being the most prevalent. Psychiatric comorbidities were highly prevalent (84.47%). The most common reasons for presentation were aggression towards others (36.39%), suicidal ideation (22.56%), and self-injurious behaviors (11.16%). During the visit, 23.27% individuals received a new psychotropic medication, and physical restraint was utilized in 8.56% of visits. 28.27% of patients were psychiatrically hospitalized but 30% of those who needed hospitalization were discharged due to lack of inpatient bed availability. Presence of intellectual impairment (OR 1.97) and aggression (OR 3.57) were associated with a greater likelihood of discharge home due to inability to secure an inpatient bed.

Conclusion: This study adds to the limited literature about individuals with ASD or ID seeking emergency care. The results indicate a highly acute patient population with aggression, suicidal thoughts, and self-injurious behaviors who are frequently prescribed psychotropic medications and face barriers to accessing higher levels of care.

Learning Objectives:

Provide background information about the ASD/ID patient population in the emergency setting.

Explain the methods and results of this 10-year retrospective study.

Examine take home points about this study and what it says about optimal care for these patients and future research.

The increasing volume of children and adolescents presenting to emergency departments (ED) with mental health complaints presents a national crisis. A decade-long longitudinal study revealed that such presentations are trending upward, with an annual rise of 6-10% [1]. This trend will continue to have cumulative effects that challenge our current systems of care. In an effort to inform disposition in situations where aggression and violence are relevant, it is important that emergency medicine providers be informed regarding how to effectively assess the risk for violence in youth.  Youth demonstrating aggressive behavior can present a unique challenge to the ED setting, particularly if they are awaiting inpatient psychiatric treatment and/or possess psychosocial challenges that yield disposition planning difficulties. These situations are not unique to pediatric EDs or academic centers that may have integrated pediatric providers. Community hospitals that may have limited mental health resources might benefit from the implementation of evidence-based violence risk screening that can be applied by a variety of clinical staff to inform risk, treatment disposition, and safety planning.

While the ED presents a uniquely restrictive environment for all persons, some children are more likely to manage related distress through externalized behaviors when compared to adults [1]. Intervention by ED staff who have not received de-escalation training specific to children and youth may subsequently escalate young patients further, thus contributing to the risk of injury for both patients and staff.

There are several widely known youth-specific violence risk assessment tools, such as SAVRY [2], which has moderate validity for those aged 12-18 years old and is well known to the juvenile justice system. Similar well-validated violence risk assessment tools have useful applications, but can be time intensive and difficult to translate to the ED setting as they require specialized training programs. ED providers often have limited time to assess patients who present with psychosocially complex complaints.  Therefore, there is a practical necessity to validate a violence risk assessment tool that balances reliability and brevity.

The Fordham Risk Screening (FRST) has a growing body of data to support its utility in the ED [4] and civil inpatient settings [3]. Recently, the FRST has been integrated as a standard portion of the assessment of patients who present in behavioral or mental health crisis at Maine Medical Center’s (MMC) ED. All patients seen by MMC's Emergency Psychiatry team have been asked FRST screening questions and a subset of these patients are youth who present to the ED seeking crisis evaluation. Therefore, we aim to retrospectively evaluate the utility of the FRST as a clinical tool for evaluating and assessing the risk of violence in children and adolescents. Increasing objectivity of violence risk assessment will allow more thoughtful approaches to patient management in ED settings, and ideally reduce the length of stay and the necessity for pharmacologic interventions, while informing future risk of violence as predicted by an objective screening tool. This work will also inform whether it is possible to streamline risk assessment to a single tool for all ages.

Learning Objectives:

Consider the need and potential clinical utility of violence risk assessment in children and youth specific to emergency departments.

Appreciate the uniqueness of caring for youth in the Emergency Department setting, particularly when there are violence risk factors.

Understand factors that contribute to pediatric violence risk when compared to adults.

Interdisciplinary collaboration can be a complex process that requires time, patience, and understanding of the different points of view and training of each discipline. People working within healthcare often share core values but are often trained in isolation from the other disciplines. Professional silos can occur as each discipline focuses on what they can offer in terms of patient care and staff supports but a strong adherence to “staying in our lane” can also hinder opportunities for shared teaching, case conceptualization, interdisciplinary team responses in crisis. Solid interdisciplinary teamwork is even more challenging when members of the team change frequently, such as who responds to a crisis, staff covering the shift, or rotating attending physicians.

A panel of Directors in safety and security, nursing, and psychiatry and nurse management will describe their collaborative leadership process when navigating serious and complex issues relating to patient and staff safety for inpatient psychiatry and emergency medicine. As a tertiary level hospital in a primarily rural state, complexity of patient needs, recruiting trained staff in a time of extensive staff shortages, and identification of resources are consistent challenges. The team will describe a crisis stabilization unit (CSU) that was developed as a way to meet the needs for patients diagnosed with psychiatric illnesses who experience long waits in the emergency, require increased resources and support, and historically not receiving mental health treatment while they wait for a bed. The presentation will describe the development of two unique staff positions within nursing and safety and security and the successful integration of these staff members on inpatient psychiatry and emergency medicine. Research on interdisciplinary teams in healthcare and use of simulation-based training (e.g., Engum & Jefferies, 2012; Saragih, et al., 2024) provided guidance for development and expansion of training for frontline staff in safety and security and nursing who are responsible for crisis responses and prevention of dangerous behavioral episodes. Discussion will review of challenges, barriers, and the concept of transdisciplinary teams to meet complex patient needs and staff safety.

Learning Objectives:

Participants will understand strategies to support interdisciplinary leadership collaboration for cross training emergency response teams.

Participants will learn about the development of unique staff positions to address staffing shortages and complex patient needs.

Participants will understand the difference between an interdisciplinary and a transdisciplinary process as it relates to developing skilled core response teams.

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.

Frequently, patients present with psychiatric symptoms and turn out to have a medical etiology. Many of these medical mimics are commonly known such as hypoglycemia and myxedema coma but some are less common which makes them more difficult to diagnosis and manage.  This course will focus on some of the less common etiologies of such psychiatric presentations including catatonia and NMDA receptor antagonist. Evaluation and treatment in the emergency department using case presentations.

Learning Objectives:

To list non-traditional causes for patient presenting with psychotic features or depression symptoms.

To describe the lorazepam challenge for patients with catatonia and expected outcome.

To define procedures needed to determine a definitive etiology for rare medical mimics.

From the discovery of NMDA encephalitis by Josep Dalmau in 2007, autoimmune encephalitis has become an ever expanding group of diseases that is durably changing the landscape of modern neurosciences. These syndromes can initially present with acute or subacute behavior changes sometimes overshadowing subtle neurologic symptoms such as movement disorders or seizures. There is a variety of scenario in which patients with autoimmune encephalitis can, at least initially, be mistaken for patients with primary psychiatric diagnosis. While novel therapeutic approaches have greatly improved outcomes of patients with autoimmune encephalitis, delay in diagnosis remains a major obstacle. As the knowledge around autoimmune encephalitis continues to progress, first line clinicians should be more and more familiar with the specificities of this group of disease in order to close the gap between onset of symptoms and adequate treatment.

This presentation will feature:

1. Basic neuroscientific concepts and outline of the latest discoveries in autoimmune encephalitis such as mechanism of autoantibodies (intracellular vs extracellular; effector vs biological marker), pathogenesis (infectious triggers, paraneoplastic syndromes).
2. Main syndromes and their clinical presentation with emphasis on behavioral symptoms through clinic vignettes.
3. Simplified diagnostic algorithm and decision tree, adapted from the 2016 consensus clinical criteria of autoimmune encephalitis. 
4. Symptomatic management of psychiatric symptoms presented by patients with autoimmune encephalitis and the difference with classic management. 
5. Outline of the neurologic workup: who needs an MRI, an EEG, CSF analysis, malignancy workup. 
6. Outline of the management of autoimmune encephalitis.
7. Recovery and residual psychiatric symptoms and their management. 
8. Future considerations: will an autoimmune panel be sent for every patient in the psychiatric emergency room

Learning Objectives:

Recognize atypical presentations of behavioral emergencies that could suggest an autoimmune encephalitis.

Be familiar with the main autoimmune encephalitis syndromes and their mechanisms.

Know the outline of the workup, treatment, and psychiatric symptomatic management of autoimmune encephalitis.