NUBE 2024

Welcome to NUBE 2024 - Junji Takeshita, MD, FACLP, AAEP President. Conference Opening Remarks - Priyanka Amin, MD, and Jennifer Peltzer-Jones, PsyD, RN, NUBE Program Chairs.

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.

This panel presentation aims to spark dialogue among attendees about the future of emergency psychiatry training and provide a roadmap for curriculum enhancement.

Emergency psychiatric care has significantly evolved since the American Association for Emergency Psychiatry (AAEP) published its model curriculum in 2004. This presentation examines the existing curriculum and proposes essential updates to align with current practices and emerging challenges.

The original AAEP curriculum, developed by consensus in the late 1990s, provided a comprehensive framework for training residents in core competencies like rapid assessment, crisis intervention, and risk management. These foundational skills remain crucial. However, the evolving nature of healthcare delivery, technological advancements, and shifting patient demographics necessitate a curriculum revision.

We will begin by reviewing the AAEP consensus process and the key components of the 2004 curriculum that remain relevant. These include prioritization skills, patient assessment and management, crisis intervention techniques, and professional communication. We will then introduce new areas for integration into the curriculum to address contemporary challenges.

Proposed additions include:

1. Telepsychiatry Competencies: Training residents to conduct remote emergency assessments and interventions effectively.
2. Substance Use Emergencies: Enhanced training to manage the ongoing opioid and stimulant crisis and evolving drug use patterns.
3. Cultural Competence and Health Equity: Skills to provide culturally informed care and address disparities in emergency psychiatric services.
4. Interdisciplinary Collaboration: Emphasizing effective teamwork with diverse healthcare professionals, as per ACGME “teaming”.
5. Community-Based Crisis Intervention: Working with the site-specific variety of emergency psychiatry service delivery modalities, such as mobile crisis teams and community-based emergency services.
6. Updated Psychopharmacology: Focus on newer medications and rapid-acting interventions for acute agitation, suicidality, and withdrawal management.
7. Legal and Ethical Considerations: Addressing challenges in involuntary treatment, capacity assessment, patient rights, boarding issues, and duty to protect.
8. Suicide/Violence Risk Assessment: Understanding evidence-based tools, improved EHR screening protocols, and technology integration. Personalized, collaborative safety planning and follow-up care.

We will also identify elements of the original curriculum to be de-emphasized or removed due to changes in practice patterns.

Finally, we will discuss strategies for residency programs to incorporate these updates effectively, including integrating new content into existing rotations, technology for education, and developing partnerships with community organizations.
By modernizing the emergency psychiatry curriculum, we can ensure that the next generation of psychiatrists is well-prepared to meet the complex needs of patients in crisis.

Learning Objectives:

Identify core components of the 2004 AAEP emergency psychiatry curriculum that remain essential and those requiring updating or removal.

Describe at least five new content areas to be incorporated into emergency psychiatry residency training to address contemporary challenges.

Discuss strategies for implementing curriculum updates in residency programs, including integrating new content and leveraging technology for education.

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.

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.

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.

We will walk through the case of a 10 year old child with a psychiatric history of complex PTSD, ADHD and DMDD presenting to the emergency department for “aggression”. The patient spent 20+ days boarding until a residential placement was found. In those days, there were more than 30 workplace violence injuries, 50 violent restraint episodes, and countless brainstorming sessions. When the “going got tough” and the facilities' process, resiliency, and resources were challenged, “the tough got going”. A multi-disciplinary team came together to optimize pharmacotherapy, behavior modification, therapies, and other modalities to remain true to our mission and “do what is right for kids”.

Learning Objectives:

Identify pharmacologic options for agitation.

Self report increase knowledge related to care of complex pediatric patients.

Self report increase in knowledge of non-pharmacologic agents of behavioral change.

Psychiatric assessment relies heavily on history; it is important for accurate assessment to have reliable information about a patient's past. Many times patients are unable or unwilling to provide such information themselves. Even when they do supply information, it may be incomplete or of questionable authenticity. This happens often enough to consider obtaining collateral information to get what is necessary to develop a diagnosis and treatment plan. Without such information errors may be made, with possible serious consequences. In emergency room assessments, often a decision must be made about potential dangerousness to self or others and the need for hospitalization. 

Current electronic medical records have embedded many tools to assist clinicians in providing care. Records of encounters within the institution can be easily searched. Some systems, such as Epic, have a function (in Epic's case, CareEverywhere) which can display records from other institutions. Other online sources exist, such as Prescription Drug Monitoring Programs, criminal justice docket sheets, general search engines and social media sites. Patients' insurers are also helpful sources of data, as are calls to pharmacies (often mandated by medication reconciliation requirements.) Phone calls to emergency contacts and others in a patient's life can yield vital historical and current data—whether patients must consent to such calls is debatable, and often waived if evaluation is truly emergent and care is taken not to release any information save that the patient is being evaluated.

Many laws and practices have weighed in to protect the privacy necessary for appropriate medical care, especially psychiatric and substance abuse services. In the US this is done notably by the Health Information Portability and Accountability Act (HIPAA) and Consolidated Federal Regulations Title 42 (42CFRPart 2) as well as applicable state laws. There is some confusion, as well as reasonable differences of opinion, concerning the balance between privacy and clinical imperatives.

We will present our experiences and informed opinions on the utility, bordering on necessity, of obtaining collateral information on nearly every patient assessed in an emergency setting. Legal and ethical concerns will be highlighted. Methods for doing such searches will be reviewed, as well as management of phone calls to other contacts. We will seek participation from our attendees on their use of collateral information in decision-making and work toward development of best practices for assessment.

Learning Objectives:

Describe the value added to assessment by including collateral information.

List applicable legal and ethical considerations in contacting collateral sources.

Demonstrate familiarity with searches within electronic health records and online.

Ethical issues, particularly those involving respect for patient autonomy, arise in emergency psychiatry practice all the time. Most clinicians working in this setting recognize that there is an ethical component when a patient is committed or determined to lack capacity to make their own medical decisions. In these cases we determine there is a good reason to override the person’s autonomy. Yet, the ethical issues are woven into the clinical care so tightly when the illness is directly impacting the patient’s ability to make decisions for themselves, that we often simply do not think about them. We think of ethics as the discussion of the complicated cases that cause disagreement among staff or catch media attention and we do not examine the ethics of the small decisions we make all of the time. If we did recognize and take a few minutes to explore these small decisions in everyday practice, we might discover that some are driven by systemic issues of bias toward our patients that have been written into our processes and procedures. Recognizing this may be the first step we can take in working toward change.

As an emergency psychiatrist who has recently completed a degree in bioethics, I now notice the small things we do every day that have ethical ramifications and deserve our attention. And I see how some of the dilemmas we face are created by how we do our work. Can we change? Maybe, but first we must see the problems. We are all busy doing our day-to-day work and stepping back to examine underlying ethical concerns is difficult. Thinking of ethics in the context of everyday work rather than as something separate and associated with only the complicated cases may help us provide better and more ethical care.

In this brief “rapid fire” presentation, I want to encourage audience members to recognize and begin to examine the small things, the “microethics” of our everyday practice. I will start by reviewing the concept of what is referred to as micro or everyday ethics in medical practice and will then use a case or two to further illustrate my points. This will be followed by a few minutes for audience members to share their own stories of every day ethical decisions. My hope is that this presentation and brief discussion will simply be a first step in beginning to think about ethics in our everyday interactions, while considering how this information can help us address procedural issues.

Learning Objectives:

Define microethics, the ethics of everyday clinical practice.

Identify an ethical issue in your everyday practice and explain why it is an ethical issue.

Explain how recognizing a microethics issue can help you identify underlying processes and procedures that may need critical reexamination.

Working in the emergency department, often means psychiatrist will hear about trauma. In the child psychiatry world, this trauma is often abuse. As a mandated reporter, a psychiatrist is obligated to report abuse. This task can often feel daunting. It can feel daunting due to lack of understanding about the child welfare system. In addition, there is often guilt about what the child protective services (CPS) will do to the child. Hence often psychiatrists will skirt around having these difficult conversations with the child and family.
 
This session will highlighting several child protective cases. During the case presentations, it will to utilize three separate areas interviewing skills, review of common roadblocks with using child protective services, and how to use multidisciplinary teams when working with a traumatized child and to overcome the challenges when working with CPS.
 
Although each case will have elements of all three practical skill. Case one is about a child whom is not talking but there is a high suspicion of abuse. Case two involves a case where CPS is already involved but you still have concerns about their welfare and are concerned about the child going back to abuser and you are unable to contact their case worker. Case 3 involves a child that is abandoned in the emergency department. All three of these cases involve a wide variety of problem solving to help child and the emergency department/hospital needs.
 
Pooja Amin will provide a brief overview of the child welfare system. Pooja Amin and Dr Meghan Schott, will provide an overview of the cases. Finally, Dr Schott, a child and adolescent psychiatrist will share her experiences of serving on DC’s citizen review panel, a federally required entity for each state to review child protective services.

Learning Objectives:

Equip participants with effective interviewing techniques and communication strategies to help children feel safe and comfortable discussing their experiences with ongoing abuse.

Enable participants to identify common roadblocks in working with Child Protective Services (CPS) and develop strategies to effectively navigate these challenges.

Explore the roles of various professionals (e.g., social workers, psychologists, legal representatives) in managing and supporting child abuse cases within the emergency psychiatry setting.

Objective: This scoping review aims to summarize the current state of research literature on the management of agitation and aggression in the care of youth with Autism Spectrum Disorder (ASD) in the emergency department (ED). Clinical guidance for the management of agitation in this patient population will be outlined.

Method: This study used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) extension for scoping reviews searching PubMed and PsycINFO databases (May 1, 2013 through July 24, 2024) for studies that reported management of agitation or aggression in the care of youth with ASD in the ED.

Results: Management of agitation and aggression in the care of youth with ASD in the emergency department has been documented. Approaches include beginning with a rapid assessment and functional behavioral assessment. There exists a typical differential diagnosis followed by non-pharmacologic and pharmacologic treatment strategies. Restraint and inpatient psychiatric hospitalization are discussed.

Conclusion: There exists a growing literature on the management of agitation and aggression in the care of youth with ASD in the ED. Recommendations for the management of this patient population in the ED are outlined.

Learning Objectives:

Attendees will understand the current evidence base for the management of agitation of pediatric patients with ASD in the ED.

Attendees will understand clinical recommendations for the management of agitation in pediatric patients with ASD.

Attendees will learn how to integrate both non-pharmacologic and pharmacologic strategies for managing agitation in pediatric patients with ASD in the ED.

Despite increasing psychiatric and behavioral health presentations to emergency departments, Emergency Medicine (EM) residents and physicians have limited training in caring for these patients. The training that is received is not standardized across residency programs and is primarily focused on didactic lectures. During this session, we will discuss our own approach to bridging this gap and the development of a fellowship designed for EM-trained physicians. Our fellowship is housed at a large, urban, tertiary-care medical center and includes rotations with the Department of Psychiatry’s inpatient units, inpatient consult-liaison service, emergency consult service, and addiction medicine service as well as an outpatient continuity clinic.  Finally, we will discuss the observed and anticipated effects of escalating training for EM-trained physicians.

Learning Objectives:

Summarize the current state of psychiatric and behavioral health training for Emergency Medicine physicians.

Describe the development of a psychiatry and behavioral health fellowship at an urban, tertiary-care medical center.

Discuss the anticipated effects of increased psychiatric training for Emergency Medicine physicians.

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!

The AAEP Rising Scholars Program recognizes and supports the development of junior faculty and trainees who have the potential to make substantial contributions to the practice of emergency psychiatry. This one-year Fellowship offers a year-long, mentored experience. The program seeks to help emerging scholars deepen their connection to AAEP and develop a professional network that can accelerate innovation and collaboration.

Join us as we present the Rising Scholars Awards to the 2024 awards recipients:

Christine DeCaire, MD
Katherine Dowdell, MD  
Christina Jones, DNP, PMHNP  

Background: Emergency Department (ED) visits for psychiatric concerns are increasingly common, comprising >10% of more than 130 million ED visits annually (Theriault, 2020). Despite the growth of ED-based psychiatric care, there are limited data available regarding staffing and service models, productivity, resource utilization, and clinical quality of emergency psychiatric care (Bruffaerts, 2008; Lofchy, 2015). This study aims to address this gap by characterizing existing service models, quality-/value-based metrics, and best practices across a spectrum of Emergency Psychiatry practice settings nationwide.

Methods: Invitations to complete a voluntary, anonymous, 30-question Qualtrics survey were disseminated to the email listservs of two national Emergency Psychiatry organizations between 12/5/2023-2/23/2024. Potential participants entered their primary practice institution into a Google-based worksheet, and survey links were sent to the first respondents from an identified institution to mitigate duplicative responses. 30 complete survey responses were received. The survey and project proposal were reviewed by the IRB, and a determination was reached that the project did not meet criteria for human subject research on 11/21/2023.

Results: 30 respondents representing all geographic regions of the United States reported on coverage hours by psychiatrists (averaging 24-35 hours per week), accessibility and delivery of services across different shifts (with in-person services predominant, particularly during business hours), and annual ED patient volumes (ranging from <10,000 to >100,000 annual visits). Over 70% of respondents reported having access to inpatient psychiatric units. Frequent ED boarding of psychiatric patients was observed in approximately 60% of settings, with identified causes including community inpatient psychiatric bed shortages and transportation issues. Most respondents expressed uncertainty or dissatisfaction with the adequacy of training for emergency medicine (EM) physicians and trainees in managing acute psychiatric presentations; some institutions offered psychiatry-specific EM training. Quality metrics were commonly utilized to measure service performance and value, with metrics including service response time, restraint use, ED readmissions, and length of stay. Clinical best practices included initiation of medication-assisted treatment for substance use disorders, completion of suicide safety plans, provision of bridge psychotropic medication prescriptions, and naloxone dispensing.

Lessons Learned: While Emergency Psychiatry is practiced using diverse models of service delivery and staffing, there are common practices and challenges across settings and geographic regions. These data can be utilized to drive practice benchmarks and best practice guidelines for a growing subspecialty while supporting efforts to enhance the quality and effectiveness of services in this critical area of healthcare.

Learning Objectives:

Characterize Service Models and Staffing in Emergency Psychiatry.

Evaluate Resource Utilization and Clinical Quality Metrics in Emergency Psychiatry.

Identify Common Challenges and Best Practices in Emergency Psychiatry.

Background: Homelessness is a risk factor for Emergency Department (ED) utilization.(1) Additionally, people who are unhoused are more likely to have a mental health diagnosis compared to the general population. Among persons with mental illness, homelessness increases ED utilization.(2) In most healthcare systems, frequent ED users are more likely to have a mental health diagnosis.(3)

In context of the above discussion, it is reasonable to suggest that access to shelter impacts ED utilization. During cold weather months, the incentive to avoid cold exposure may increase ED use, especially if there is scarcity of shelters or other housing resources outside of the hospital setting. However, there is limited research — particularly in the United States — describing this phenomenon. In October 2023, the City of Detroit made a significant change to its shelter access policy: intakes were limited to Monday through Friday 8AM-6PM, and walk-ins were no longer allowed. We hypothesized that the reduction in shelter access would lead to an increase in ED visits due to homelessness.

Methods: A preliminary analysis of ED visits at an urban Level I Trauma Center in the Midwest (90,000+ visits per year) after the change in shelter access revealed an increase in total visits related to homelessness in 10/2023-12/2023 as compared to the previous year. To quantify the overall impact of this change, we conducted a retrospective chart review of ED visits during cold weather months by unhoused individuals before and after change in shelter access occurred (10/2022-3/2023 and 10/2023-3/2024). Unhoused individuals were identified through multiple avenues using homelessness-related ICD-10 codes and ED chief complaints. Additional variables collected included: total ED visits and ED length of stay, and presence/absence of psychotic disorders, bipolar disorders, alcohol use disorders and substance use disorders (also using ICD-10 codes).

Results: Initial analysis in this review demonstrated a 10% increase in the total number of ED visits by unhoused individuals between the two time periods. There was also a 4% increase in the number of different patients who made ED visits between the two time periods. Not all data has been abstracted or analyzed (expected complete date: 9/30/2024) though the next steps include: calculating ED LOS (average and total) for these groups, ED disposition, frequency of psychosis/bipolar disorders/substance use disorders and alcohol use disorders in each population. We hypothesize that the reduction in shelter access led to a disproportionate increase in ED visits by those with severe mental illness and/or substance use disorder diagnoses who are unhoused.

Conclusions: The ED perceived an increase in presentations and boarders after shelter access changed. This study will quantify if there was an actual change and, if so, what risks factors/vulnerable populations were affected. This study contributes to the understanding of how social determinants of health, such as housing, interface with the healthcare system. Our findings draw attention to and reflect a potential need to revisit shelter accessibility in urban areas, as a vulnerable population is being affected in a manner that is increasing the strain on the healthcare system.

Learning Objectives:

Audience members will be able to describe one example of how social determinants of health (e.g. shelter availability) affect emergency department utilization.

Audience members will be able to describe how unhoused individuals with severe mental illness and/or substance use disorders are affected by shelter availability.

Audience members will be able to describe how access to shelter affects length of stay (LOS) and frequency of emergency department encounters.

Background: The United States continues to be in the midst of an opioid epidemic with the number of deaths due to overdose compounding each year. Although various measures have been employed to fight this epidemic, improving medication access is paramount. Buprenorphine is a very effective medication for OUD (opioid use disorder) that can significantly reduce the risk of overdose and improve recovery outcomes. The emergency department (ED) is primed to serve as an effective access point for initiating OUD (opioid use disorder) treatment, offering utility and ease of access to buprenorphine for patients in need.

Our poster presents a literature review of buprenorphine induction in the ED.

Methods: A systematic literature review was carried out based on the PRISMA model on PubMed. Search terms included (buprenorphine OR suboxone) AND (opioid use disorder OR Opiate misuse OR opioid abuse) AND (management OR treatment) AND (psychiatric emergency room OR CPEP). Papers published between 2012-2024 were included in this literature review. The literature review led to an initial discovery of 69 hits on Pubmed. After abstracts were reviewed for relevance, 28 comprised randomized clinical trials, observational studies, and implementation protocols.

Results: ED-initiated buprenorphine significantly improved patient engagement in addiction treatment at 30 days (78%) in comparison with a brief intervention (45%). It also led to higher retention rates (62-65%) and follow-ups indicating the potential for long-term sustained recovery. The effect of high-dose induction (up to 32mg) was studied which showed its effectiveness in rapidly stabilizing patients. From a financial standpoint, ED-initiated buprenorphine proved to be cost-effective ($54,000 per quality-adjusted life year) compared to standard care. However, there exist barriers to effective implementation such as additional clinician training and infrastructure that may not be available in EDs nationwide. For the maintenance of sustained treatment, ongoing support and resources are pivotal, requiring an integrated care model with ED physicians, primary care doctors, and psychiatrists.

Discussion/Conclusion: This literature review emphasizes the importance of buprenorphine induction in the ED as an effective and economic intervention for OUD. Evidence in the literature indicates improved patient engagement and better long-term outcomes. Future research should focus on understanding barriers to initiation to ensure equitable access, optimizing its implementation by training providers, having standardized treatment protocols, and providing appropriate referral channels.

Learning Objectives:

Understand the impact of ED-initiated buprenorphine on OUD treatment.

Identify barriers and challenges in implementing buprenorphine induction in the ED.

Discuss the role of integrated care models in supporting ED-initiated buprenorphine treatment.

Day 2 Opening Remarks - Leslie Zun, MD, Conference Director, Priyanka Amin, MD, and Jennifer Peltzer-Jones, PsyD, RN, NUBE Program Chairs.

When most physicians hear the term “negotiation”, they immediately imagine an adversarial process…..typically tied to contracts, employment agreements, or payer partnerships.  This brief session is meant to note an alternative view of this term that is actually VERY much in line with the ethos and mission of those administering emergency psychiatric interviews.

This conversation will note how there are innate components of the negotiation process that not only are already in use by AAEP members but also strategies that (once consciously noted) can be maximized to the benefit of both the professional and the patient.

Inherent in this will be discussion of how this approach embraces a principle approach that is non-judgmental, non-adversarial, and rooted in compromise and partnership. Additionally, we will proffer the five types of active listening…with the goal of moving our daily work from levels 1-2 to level 5!

By examining all of the above, the attendees will be able to have a “rapid fire” approach on what they are doing well in their interview processes….and what can be improved/enhanced. Inherent in this will be a better understanding of utilizing and maximizing the tenets of actual negotiation!

Learning Objectives:

Examine what "negotiation" actually represents while removing any adversarial nature attributed to this term.

Provide clear examples of how negotiation principles can benefit engagement and outcomes when interviewing individuals in crisis.

Manifest how negotiation philosophy can relate directly to the field of emergency psychiatry, as it emphasizes interventions that are non-judgmental, non-dichotomous, and welcome to compromise/amendment.

Behavioral emergencies often occur in high-stress environments, where immediate and effective intervention is crucial. Traditional emergency response methods may inadvertently retraumatize individuals who have experienced trauma. Trauma-informed care (TIC) prioritizes the safety, trust, and empowerment of patients, ensuring interventions are sensitive to the effects of trauma.

This presentation explores the core principles and practical implementation of trauma-informed care in emergency settings. Key principles such as safety, trustworthiness, peer support, collaboration, and empowerment will be highlighted. We will discuss strategies for training emergency responders, assessing trauma, and implementing immediate interventions.

Through a case study, we will demonstrate the real-world application and effectiveness of trauma-informed approaches, showcasing their positive impact on patient outcomes. This session aims to equip mental health counselors and emergency responders with the knowledge and tools necessary to enhance the overall response to behavioral emergencies.

Learning Objectives:

Participants will be able to define trauma-informed care and identify its key principles, including safety, trustworthiness, peer support, collaboration, empowerment, and cultural sensitivity, and understand how these principles can be applied in emergency response situations to enhance patient outcomes..

Participants will learn specific techniques and interventions for assessing and managing trauma in emergency settings, including immediate stabilization methods, effective communication strategies, and tools for screening and assessing trauma. They will also gain insights into training and educating emergency responders to integrate trauma-informed care into their practice.

Participants will analyze real-world case studies that demonstrate the application and effectiveness of trauma-informed care in emergency situations. They will be able to identify successful interventions, understand the challenges faced, and apply these lessons to their own practice to improve patient outcomes and reduce the risk of retraumatization.

As an ER nurse for twenty years and now a psychiatric nurse practitioner, I have never had a case impact my practice as much as Amanda's. I took care of Amanda as an ED nurse in May 2024. I want to share this fascinating and impactful case with conference attendees. It is a case full of assumptions.

A homeless 40-year-old female, Amanda, comes to the ED via ambulance after people living in a home became worried about "a woman lying in their backyard on a mattress, incontinent to urine and without pants for three days". The patient is severely sunburned (Phoenix in May), has a temperature of 103 degrees, but is alert and oriented. Pt denies mental health and substance abuse. No medical history and takes no medications. No old records are found. Basic labs and UA ordered, fluids hung, and ice packs applied to the neck and groin. Through conversation, it is discovered that Amanda has her master's degree in accounting and lost her job one year ago. She has two children she sees occasionally, and when asked what she does during the day, she replies, "I am a ho on the streets." As the patient's RN, I could not reconcile her situation with her presentation. I left my shift that night with a strong feeling toward this patient. I felt so strongly at one point that I even half-heartedly considered taking her home! I came back to work four days later and learned that Amanda had been admitted to the hospital with Hyponatremia and discharged the day before. She was discharged with a ride home but instead fell asleep on hospital grounds in a bush. I raised concern about her condition to multiple parties, and upon a more extensive review of her medical record, it was discovered that she had been diagnosed with a brain tumor on her front lobe in 2021 and even admitted to our facility in the Neuro ICU in 2021. After being sent to her mother's apartment and trespassed by police there, A "BOLO" is issued for Amanda to all charge nurses in the ED, and amazingly, she appears that same night again via EMS for nausea and vomiting. A head CT is done on her second trip to the ED, and doctors discover that her tumor is now the size of a softball on her frontal lobe, and it is impacting her decision-making. She is taken to the ICU and has a craniotomy four days later. A day after surgery, she is alert, oriented, and trying to rebuild a life with family members who had given up on her. This story has many twists and turns that make it even more compelling. All types of medical professionals (doctors, nurses, social workers) who participated in Amanda's story made assumptions about her in some way. It tells a story of how we can mistakenly view patients in the ED judgmentally and perhaps how changing our mindset can and will save a life just like Amanda's.

Learning Objectives:

Listen to a fantastic and heart warming story from an ED nurse who took care of a homeless patient (5/24) and changed both of their lives forever. This story is extremely relevant to all conference attendees.

Describe educational initiatives related to this case.

Discover how this case was presented to the “ER Behavioral Core team” to inspire participation and ignite a passion for improving the care of behavioral health patients in our ED.

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.

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.

Junji Takeshita, MD, FACLP, AAEP President.

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.

Emergency Departments (EDs) are seeing a rising number of visits related to behavioral emergencies. Evidence indicates that ED healthcare staff face increasing safety threats from workplace violence (WPV) while treating episodes of acute agitation. Historically, experts have often viewed Agitation and Workplace Violence (WPV) as two separate issues, with separate management and prevention strategies. A handful of researchers have begun to question this approach citing potential conflict between patient and staff safety goals within the recommended guidelines for management and prevention of acute agitation and workplace violence. In this context, Wong et al have proposed that agitation and workplace violence are not two separate issues, but rather, two sides of the same coin. ¹

In this presentation, a multi-institutional panel consisting of behavioral emergency and patient safety experts in emergency medicine, will present (i) findings from recent literature review, using a novel conceptual framework on the overlap (and conflict) between patient and staff safety goals within current best practice recommended guidelines for management and prevention of agitation and workplace violence (ii) in-depth discussion on the challenges posed by the above conflict, including duality of “patient care paradox”, related under-reporting of WPV events, staff frustration and burnout, implicit bias contributing to disparity in outcomes including higher use of restraints among vulnerable population, etc. (iii) and finally, we will propose that instead of the traditional approach of competing staff and patient safety goals, we need to adopt a more unified, trauma-informed, systems-based approach that focuses on improving overall (Patient & Staff) safety during management and prevention of agitation and WPV events.

This presentation will be conducted by our expert panel. During the presentation our panelists will draw from their own research, programmatic expertise, and clinical experience to provide a rigorous discussion of latest evidence and new research on management of Agitation and workplace violence, present evidence on conflicting goals for patient and staff safety and propose a novel, trauma-informed, systems-based conceptual model that will help guide future research and serve as a roadmap to help provide focus and prioritization for future research in principles of management of agitation, workplace violence, and disparity mitigation in order to create a safe setting for patients and clinicians alike.

Learning Objectives:

Analyze the factors (e.g. structural, organizational, interpersonal) that influence agitation management practices and exposure to workplace violence.

Compare and contrast the evidence of overlap (and conflict) in patient and staff safety goals within current best practice guidelines for management of agitation and workplace violence and evaluate a novel perspective about agitation and workplace violence management (they are not two separate topics, but “two sides of the same coin”).

Implement a trauma-informed, systems-based approach to local institutional guidelines that will prioritize overlapping principles of management of agitation and workplace violence to mitigate bias, disparity and improve safety for patients and clinicians alike.

Political ideology and beliefs are rarely illegal and seldom relevant in psychiatric emergency care. Nonetheless, security and intelligence professionals are increasingly recognizing that ideologically motivated violence is a leading threat. From skirmishes at public protests, to threats against public health leaders and poll workers, to insurrection, incidents both isolated and expansive are increasingly coming under public scrutiny. And as law enforcement agencies do a better job of embracing multidisciplinary strategies like behavioral threat assessment and management, This presentation will provide a basic overview of what is known about ideologically motivated violence in the United States and provide practical guidance for PES clinicians in evaluating and understanding people at the intersection of violence risk and extreme ideological beliefs.

First, clinicians must be able to carefully navigate potentially fraught discussions about political ideology in clinical settings. There has long been an opprobrium about discussing politics in the workplace. Delving deeply into political beliefs in behavioral health settings is complex and perilous, with notable risk of transference and countertransference leading to disruptions in the therapeutic alliance. Practical guidance on navigating these turbulent waters will be offered.
Second, clinicians need to understand that the overlap between political extremism and violence risk is small and nuanced. Extremist ideology may be incidentally noted during an evaluation or the ideology may be expressly linked to violent threats or behavior as the primary cause for evaluation. While the adage to use individualized assessment and individualized treatment plans holds true for people with extremist beliefs there are specific considerations which will be discussed pertinent to evaluation of people which apply in the evaluation and management of violence risk.

Third, considerations related to clinical and administrative decision-making will be explored. Just as law enforcement is increasingly partnering with behavioral health and social services for threat management cases, so too do we need to reach out in the management of our high-risk cases. Identifying psychiatric illnesses and social stressors amenable to clinical interventions is critical. Peer supports for hate-based ideologies and for parents of people with extremist ideologies may be available in some regions. In some cases, people who are ambivalent about continued engagement with extremist organizations may respond well to CBT and RET even in the absence of other psychopathologies.
Case examples, critical terminology, and guidance for building both ad hoc and lasting productive partnerships between clinical services and law enforcement partners will be woven throughout the presentation.

Learning Objectives:

Assess risk factors for violence relevant for people with strong political and ideological beliefs.

Formulate strategies for consultation and documentation in high risk clinical cases.

Develop personal strategies to recognize and mitigate personal and organizational countertransference.

In Malaysia, Dutch botanist Pieter Korthals in 1831 first discovered Kratom or Mitragyna speciosia. Kratom is derived from the Nitragyna speciose korth, a tropical forest tree found in Malaysia, Thailand and Myanmar. The trees’ leaves contain psychoactive opioid compounds, that have been consumed for thousands of years. Kratom contains alkaloids that bind to opioid receptors, with an opioid drug structure.

Kratom can be ingested in various routes, traditionally chewed but also smoked or strained in teas. The leaves have a very bitter taste that can be masked by adding sugar or honey in juices or teas. As an alternative, lemon juice can be added to facilitate the extraction of the plant alkaloids.

Kratom induces euphoria, and in lower doses acts as a stimulant, increasing energy, alertness, while in higher doses it induces sedation. Kratom is purportedly used for anxiety, depression, inflammation, libido. Importantly, given opioid activity, it suppresses opioid withdrawal. With regular use, Kratom is associated with dependence and addiction.
Kratom’s pharmacological properties are similar to those of opioids but unlike opioids it is not a federally regulated substance. There are increasing number of case reports with Kratom intoxications and withdrawals that are challenging for the physicians. Kratom is not a very commonly known substance and is also difficult to detect as it does not cause positive findings in urine drug screens. The assessment relies on the history from the patient or specific immune-assay tests. The treatment can consist of symptomatic treatment with Clonidine but also with Suboxone. There are several cases reported of Kratom withdrawal.

Kratom is gaining increasingly popularity and about 40 million Americans are current using Kratom recreationally. However, there are currently very limited clinical studies available that demonstrate safety and efficacy in humans. The FDA has not approved Kratom for any medical use, and publishes warnings regarding its toxicity. Available information is mostly based on reports from users or animal models. Case reports involving the use of Kratom are concerning and alarming. The use of Kratom is associated with increasing numbers of ER visits, calls to poison control centers and even deaths related to multiple causes.

This presentation is based on a systematic review of literature of the current available data on Kratom and will be providing physician and clinician education about Kratom as a substance.

Utilized sources were Pubmed, Ovid, Medline, PsychInfo, EMBASE.

Learning objectives:

Kratom use- Clinical presentations, toxicity, risks.

Pharmacology of Kratom.

Kratom use- Diagnosis and Treatment

Precipitated opioid withdrawal is an abrupt onset of severe withdrawal symptoms after administration of full or partial mu antagonists.  This clinical case series and skill building workshop will elucidate options for management of precipitated opioid withdrawal in the emergency department.  Precipitated withdrawal can lead to symptoms from piloerection, nausea, vomiting and diarrhea to delirium and critical illness.  This series will look at 3 different patient scenarios to help guide clinicians in providing critical care for patients in acute precipitated withdrawal.  The fear of this complication and challenges managing precipitated withdrawal can be a barrier for some providers in starting buprenorphine.  Education around how to manage precipitated withdrawal can assist clinicians in increasing their comfort with buprenorphine initiation.

The patient scenarios involve precipitated opioid withdrawal with naloxone and buprenorphine administration in the ED and in the community. Clinicians will have increasing comfort in assessing patients Clinical Opioid Withdrawal Score (COWS) as well as immediate management of withdrawal symptoms.

Patient #1 has initiated buprenorphine through a home start and is presenting to the ED with worsening symptoms of withdrawal.

Patient #2 received naloxone by EMS in the field after unintentional opioid overdose and presents to ED with signs of precipitated withdrawal.

Patient #3 was started on buprenorphine in the ED and has rising COWS despite maximizing buprenorphine dosing.

This presentation will discuss using multimodal agents including buprenorphine (IV, SL and patches), benzodiazepines, ketamine, anti-dopaminergic agents and full agonist opioids for management of opioid withdrawal symptoms. The clinical scenarios, patient characteristics, risk factors for precipitated withdrawal and patient outcomes as well as follow up care will be discussed. Clinicians can utilize these skills to improve care for patients and gain confidence in starting medication assisted treatment in the emergency department.

Learning Objectives:

Recognizing precipitated opioid withdrawal.

Treating precipitated opioid withdrawal with multimodal agents.

Increasing confidence to initiate buprenorphine treatment for opioid withdrawal safely in the ED.

Cannabis and cannabis derivates are enjoying wide popularity in the U.S. While many developments came to a hold during the Covid-19 pandemic, the legalization of cannabis further progressed along with an expanding market for Delta-THC.

Cannabis is federally a schedule 1 substance but hemp derivates are exempt from this law through the 2018 Farm Bill. The substances classified as hemp derivates include the Delta-THC and CBD. Due to this legal loophole, they are easily accessible and sold at local convenience stores, gas stations or online. The sales of Delta-THC in the last 2 years have exceeded over 2 billion dollars.

The most used Delta-THC are Delta-8-, 9- and 10-THC. Delta-THC’s effects are similar to marijuana as they induce euphoria, feeling stoned and can cause anxiety and psychosis. The effects on cognitive alertness differ as Delta-8 -and 9-THC are sedating while Delta-10-THC is rather activating. Altered sense of time as well as short-term memory deficits and poor concentration are associated with any of the Delta-THC. In addition, cardiovascular effects including tachycardia and hypertension have been reported.

Legally, the THC content of these substances is supposed to be less than 0.3% THC. The majority of Delta-THC do not undergo any laboratory testing prior to marketing. Conducted tests of products have shown discrepancies with worrisome results with deviations from the claimed content on the label by up to 150%.

There is no standardized method established to synthesize Delta-THC. Chemically, the Delta-THC are molecularly close relatives. First, manufacturers must extract CBD from hemp and then convert it to psychoactive cannabinoids. For this chemical synthesis process, unsafe household chemicals are frequently used. Those potentially leave residual substances in the Delta-THC, so that the substance can contain toxic solvents, for example acetone, heavy metals, or lead. These toxic byproducts can lead to harm in the user and potentially cause lung damage if smoked or vaped.
Along with the increasing popularity of Delta-THC, there are also increasing cases of toxicity being reported. During the time between January 2021 and February 2022, the DFA (U.S. Food and Drug Administration) reported over 2,300 calls to national poison control centers. Every third person who called poison control required a medical evaluation in a hospital setting, while one person required an inpatient admission. Due to these safety concerns, seventeen states have banned the sales of Delta-8-THC while seven others have restrictions in place.

This presentation is a systematic review of literature discussing the available data on Delta-THC for psychiatric and medical use. Utilized sources were Pubmed, Ovid, Medline, PsychInfo, EMBASE.

Learning Objectives:

Policy of Delta-THC, Legal aspects.

Effects of Delta THC use.

Toxicity of Delta THC.

Michael Gerardi, MD, FACEP, Incoming AAEP President. Priyanka Amin, MD and Jennifer Peltzer-Jones, PsyD, RN

It is important to recognize the difference between schizophrenia and bipolar disorders both in diagnostic evaluation and treatment.  There are occasionally organic causes of manic episodes and it is important to recognize these causes as soon as possible.  Bipolar disorders have intermittent symptoms and treated more like a seizure disorder and with seizure medications.  These patients can be very creative and very high functioning, and similarly have very high rates of suicide.

This presentation will look at the causes of manic episodes, the recommended evaluation, the clinical considerations, the current treatment options, the prognosis, the importance of continuity of care of these patients, and what to communicate to the family to expect.

Learning Objectives:

Consider the causes that might mimic manic episodes and their management.

Recognize that manic episodes are similar to seizures both in evaluation and treatment.

Understand the high suicide risk of patients with bipolar disorder.

Acetaminophen overdose is a potentially fatal clinical syndrome, warranting prompt and accurate assessment and clinical care. Acetaminophen toxicity can occur from acute ingestion, or chronic use over time. Though this talk focuses on acute hepatic consequences of overdose, inadvertent exposure over time often has a worse prognosis due to later recognition and treatment. The acute toxidrome has 4 stages, whereby stage 2 is what appears to be a resolving syndrome. However, if unrecognized, this may progress to severe hepatotoxicity and death. An Acetaminophen level 4 hours after the overdose that is greater than 150 mcg/mL warrants urgent initiation of the antidote N-Acetylcysteine and inpatient hospitalization.

Acetaminophen pharmacology is critical to treatment. Toxicity occurs when the body's innate metabolic pathways are saturated, causing build-up of a toxic metabolite which binds to hepatocytes, leading to liver injury and fatality. N-Acetylcysteine treatment enhances the clearance of the toxic metabolite, and should be promptly started. There are specific protocols for oral and for IV management. Astute and correct treatment has high success rates, though serious complications may result. In cases where Acute Liver Failure occurs, there is a high mortality rate, and 1/3 of patients will require a liver transplant. Fortunately, if N-Acetylcysteine is given within 8-10 hours after the overdose, serious hepatotoxicity is uncommon and death is extremely rare, regardless of the initial serum concentration.

Learning Objectives:

An appreciation of the emergent nature of Acetaminophen overdose.

Using the serum Acetaminophen level to decide when to treat.

Proper use of the antidote N-Acetylcysteine.

In 2018 , the FDA has granted psilocybin a “ breakthrough therapy designation “ status for treatment- resistant depression. One year later , another “ breakthrough therapy designation” was granted to Psilocybin for treatment of MDD. This designation reflects the drug potential to treat resistant psychiatric disorder. Recent studies reveals that psilocybin assisted therapy offer a wide range of possible therapeutic benefits ( for example in alcohol use disorder , tobacco use disorder and end-of-life anxiety and depression). In this presentation, I will explain what is psilocybin-assisted therapy and what disorders it  help with based on recent studies.

Learning Objectives:

Obtain knowledge on history of psychedelic therapy from the past to the present time.

Discuss psilocybin pharmacology and phases of psilocybin therapy.

Discuss therapeutic benefits of psilocybin based on recent studies.

Daniel Kahneman’s Nobel prize winning research, on behavioral economics, established how humans often make snap decision that often defy logic. Physicians are no different. Emergency physicians are, in fact, more likely to use “fast thinking” compared to other physicians. This is in part due to needing to make quick decisions based off a triage model on a large volume of patients. However, this can create a bias in how we diagnosis and treat patients.

Bias can occur through implicit bias or subconscious perceptions. These often include unconscious feelings about something one cannot control like race, gender, and weight. Microaggressions are often subconscious buy can also be conscious and often reflect biases in the form of words and gestures. Emergency psychiatry has its own form of microaggressions by using words like “boarder,” “borderline,” and “frequent flyer.” Although these terms might help the physician segment medicine’s harsh realities, it paints the patient in a negative light, leading to poorer quality of care. This presentation will look at things like implicit bias and microaggressions that can occur during an interview by utilizing research from both the diversity, equity, and inclusion (DEI) and psychiatry fields.

However bias is not always subconscious. Chart checking is an invaluable tool that can inform decision making based on past events. When one relies to much on past history rather than current presentation, this can lead to bad outcomes for our patients. Unfortunately, one may never know when a potential negative event occurs in the emergency department since it will occur out of sight and hence a confirmation bias occurs.

The psychiatric interview is a unique skill that goes beyond the traditional subjective, objective, assessment, plan (SOAP) note. During training we teach students, residents, and fellows the art of the psychiatric interview but often do not reassess our own interviewing skills. However, since the interview is highly subjective itself, it leads to more bias compared to other components of medicine. How does one retrain oneself to the level of naivety of first year medical students, while still retaining the knowledge of a season attending?

This presentation will begin by providing a brief overview of the history of bias in medicine with more of a focus on psychiatry and basic DEI principles. Next the speakers will share real life examples of when medicine have failed in emergency psychiatry due to an overreliance on chart checking. The speakers will also discuss their own personal mental health journeys where bias has come into play in their treatment. Finally, it will conclude with how one can look at the art of interviewing and try to remove bias as much as possible by providing real world clinical skills.

Learning Objectives:

Define implicit bias and microaggression.

Understand how mircoagressions and other forms of bias are used in everyday settings including mental health.

Utilize interviewing skills to help eliminate common points of bias during clinical interviews.

The goal of this presentation is to propose a framework for conceptualizing adolescent social media use behavior that relies on a functions-based approach. We will describe an algorithm for eliciting a social media use history that focuses on evaluating function-specific behaviors and interactions and assess for related risk and resilience factors.

Background: 
Social media (SM) use among adolescents soared over the past decade, raising questions and concerns about its impact on youth mental health. While research points to a correlation between this rise and negative mental health outcomes, there is a paucity of literature discussing approaches to screen for SM use and assess for associated risk and resilience factors. The problem with available screening assessments is that they rely on specific knowledge of the applications. The issue with this is that SM applications cycle rapidly, making it difficult to keep up. Previous practices focused on “screen time” as a measure for SM use. However, recently, some researchers have advocated for a more nuanced, multi-dimensional approach that highlights “how” and “why” adolescents use SM. In this poster, we propose a framework for identifying “use types” that satisfies this nuanced model, focusing primarily on the function of SM use, and evaluating risk and resilience factors associated with each use type.

Methods: 
A literature survey was conducted to identify variables of SM use such as type of engagement and type of online interactions, paying particular attention to risk and resilience factors associated with each category of use. We describe a function-based algorithm that attempts to provide direct clinical guidance on how to conduct the SM use segment of the psychiatric interview without requiring extensive knowledge of the applications used by adolescents. To do that, we focused our framework on 5 main SM functions: social networking, image sharing, video sharing, direct messaging, and streaming.

Results: 
When examining the literature, we identified two major parameters describing adolescents' engagement with SM. First, is the type of use, categorized into consumption and contribution. Second, is the type of interactions, divided into public and private. Recognizing these parameters, we created an algorithm that focuses on eliciting SM use history by asking three major questions: “What function are they using? How are they using SM? And Who are adolescents engaging with on SM?”. By combining type of use with type of interactions, we were able to identify four general use types: private consumption, private contribution, public consumption, and public contribution. We then identified risk and resilience factors associated with each use type found in the literature.

Conclusions: SM use has become a fixture in the life of adolescents. Due to the significant role it plays and the implications of its use during this phase of development, it is imperative that child psychiatrists are able to accurately evaluate use and assess for risk and resilience factors associated with it. Using our framework, clinicians can assess the adolescent’s SM use and understand both their risk and resilience factors without relying on prior application knowledge.

Learning Objectives:

Learn how social media consumption and contribution behavior can be elicited and formulated during a psychiatric interview.

Learn how public vs private interactions impact adolescent mental health and how to ask about these interactions in a psychiatric interview.

Develop an assessment of the adolescent’s social media use type and explore possible protective and risk factors.

Has this happened to you? You are on busy shift and have just admitted an 88-year-old patient to the hospital because the family says that caring for patient at home “has become too much.”  As you walk into the next room, you see that your new patient is also in her 80’s and has dementia.  The patient looks amazing, but the daughter who cares for her looks exhausted and depressed.  How long will it be before this caregiver is also overwhelmed?  You realize that the best thing you could do to help the patient is to help the caregiver.  But what can you do?

In this dynamic, case-based lecture, we will explore the issues related to Caregiver Stress and Burnout among those who care for older adults. We will offer practical tips aimed at healthcare providers who encounter the impacts of caregiver stress in the clinical setting but who may not feel equipped to help. As faculty from Geriatrics and Emergency Medicine, we will share insights drawn from the literature as well as from experiences in our ACEP Level 1 Accredited Geriatric Emergency Department.

Learning Objectives:

By the end of this lecture, the audience will understand:

• What caregiver stress and burnout are and how they impact both sides of the patient-caregiver dyad.
• How to identify caregiver stress and burnout, including how to use clinical screening tools to find cases that might go unrecognized.
• How to make effective recommendations and interventions to help caregivers who are experiencing stress and burnout as they try to meet the increasing needs of loved ones at home.

Richard deShazo (2018) writes about  "…the unfortunate role and responsibility of organized American medicine in past and present health disparities in our country." A long history of slavery, racism and mass incarceration in the US continue to rear their pernicious heads in how we provide health care to minoritized and marginalized communities in particular.  Racial and ethnic bias have a habit of showing up stronger and often unconsciously in situations of stress, ambiguity, and time pressure.  As such, health and mental healthcare practitioners who work under these conditions in urgent and emergency care settings are susceptible to misperceptions that can lead to unequal treatment and medical error.  In fact, the National Standards for Culturally and Linguistically Appropriate Services (CLAS STANDARDS) were developed in 2001 and revised in 2013 by the Office of Minority Health specifically to provide guidance for health care administrators and practitioners to rectify these inequalities.  This is the imperative of health justice and equity in medicine and behavioral health.

This interactive and participatory session will draw from humanities and poetry to highlight the pernicious nature of bias and to illuminate the psychological, interpersonal and organizational challenges at hand. The session aims to help participants understand the perils of stereotyping in clinical settings, and will provide tangible tools and strategies for enhancing awareness. understanding, and communication skill development towards greater health equity, and practitioner and patient satisfaction with care. Moreover we will explore the power and importance of assertive and empowering communication approaches towards equity in patient advocacy. The presentation will focus on both practitioner awareness and skill development, as well as taking an organizational and healthcare team perspective on transforming how care is delivered toward the elimination of health inequities and the enhancement of health justice.

Learning Objectives:

By the conclusion of this presentation, participants will deepen their understanding of the role of bias and stereotyping in health inequities.

By the conclusion of this presentation, participants will deepen their self-reflection on biased communication with patients and family members in acute behavioral and emergency settings.

By the conclusion of this presentation, participants will grow their capacity for assertive communication in helping colleagues and team members remain accountable to the CLAS Standards of culturally and linguistically appropriate services in clinical settings.

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.

The imposter phenomenon (IP) is a negative state of self-doubt experienced by various professions, genders, and races, with a prevalence rate reported from 9-82%. If you were to do a quick internet search, there are numerous TED Talks, social media sites, and business professional literature dedicated to exploring and explaining IP. In emergency psychiatry, IP can surface in a variety of forms: as a contributor to/direct source of distress in patients, burnout in trainees, or stunted professional growth with experienced staff. IP has been psychiatrically linked with depression and anxiety, and those who experience it may struggle with personal relationships and/or marital distress. In the workplace, leaders and administrators need to recognize and address IP as it is linked to turnover, procrastination, and inability for managers and supervisors to appropriately delegate. In academic settings, IP causes more subjective distress in non-white groups than stress that comes from racial discrimination. Despite these many negative outcomes, IP does not easily fit into a diagnostic category, and so it is not always discussed or taught in an academic setting (outside of perhaps a lecture in medical school). However, because of the risk that IP can pose to anyone, at any point in one's career, and because of its prominence in popular culture, it is imperative that we are able to identify and address IP in our patients, our peers, our colleagues, and ourselves. This talk will provide an academic overview of this concept, risks for developing it, signs to identify it, ways to combat it, and how to psychiatrically treat it in therapy. Based off of a 2020 ACGME small group discussion outline, an experiential component ("think-pair-share") will be utilized to engage the audience in active learning. Popular media clips will be incorporated to capture the audience's attention, and when possible, the audience will be encouraged to share their own experiences in dealing with IP or caring for patients who are suffering from IP. Supervisors will also be given information on how to address IP with trainees using the ACGME recommendations.

Learning Objectives:

At the end of the presentation, the audience will be able to define imposter phenomena, prevalence, and negative outcomes from it.

At the end of the presentation, the audience will be able to list 2 risk factors for experiencing imposter phenomena.

At the end of the presentation, the audience will be able to list 3 interventions to combat imposter phenomena.

When errors are made in the practice of medicine the results can be devastating. Unfortunately, errors are all to common. It is estimated that hundreds of thousands of patients die each year as a result of medical error, and medical error might be the third leading cause of death in the US, behind only heart disease and cancer.  Commonly cited risks for making errors are high workload, time pressure, multitasking, and multiple handoffs- all things that are extremely common in emergency psychiatry!   Caring for patients with mental illness in crisis can certainly leave one prone to mistakes. Behavioral health patients in emergency departments have a longer length of stay, often causing their care to run over several shift, increasing the risk of handoff errors.  When mistakes are made in the care of patient in emergency psychiatry the results could not only cause immediate harm to the patients, or to the community, but can also have a long-lasting effect eroding the trust in a medical system that could provide them with help.  We will review the type of errors that are common in the field of emergency psychiatry through several case reviews, and spend the final half of the presentation discussing the recovery process.  We will review the literature and common practice around the responses to errors. We will look at the individual responses, with patients, with staff and with families, as well as systemic approaches to responding to errors. We will discuss some error prevention techniques that can easily be implemented in emergency departments.

Learning Objectives:

Attendees will be able to identify common causes for errors in the medical setting.

Attendees will learn skills for navigating responses to medical errors.

Attendees will learn techniques for error prevention in the emergency psychiatry setting.

Priyanka Amin, MD, Jennifer Peltzer-Jones, PsyD, RN, NUBE Program Chairs