NUBE 2024

Introduction:
Navigating alcohol withdrawal is a complex facet of addiction medicine, marked by persistent debates and uncertainties. Despite ongoing efforts, achieving perfect management for patients withdrawing from alcohol remains elusive. Benzodiazepines persist as the mainstay of treatment, although alternative medications like clonidine continue to be subjects of exploration. This study delves into the prevalent practice of administering benzodiazepines within CIWA protocols, specifically for elevated blood pressure and/or heart rate, even when CIWA scores fall below the treatment threshold.

Background and Aim:
The ASAM guidelines advocate for a comprehensive approach to alcohol withdrawal, encompassing various medications for adjunctive treatment. However, observed clinical practices may not align with these recommendations. Clonidine, an alpha-2 adrenergic agonist, remains a source of contention in the context of alcohol withdrawal. Despite ASAM guidelines suggesting consideration of clonidine for autonomic symptoms in the absence of other withdrawal symptoms, its utilization is limited. This study aims to assess the frequency of benzodiazepine administration within CIWA protocols, notably for elevated blood pressure/heart rate, when the CIWA scoring is below the treatment threshold.

Methods:
Patients included in the study presented with alcohol withdrawal on a CIWA protocol. Exclusions comprised those with concurrent opioid withdrawal (COWS protocol) and those receiving continued clonidine as a home medication. Data, focusing on individual doses of medications, excluded continuous/scheduled doses and incomplete records. The study encompassed 167 patients over one year, revealing insights into the medication administration practices pertaining to alcohol withdrawal management.

Results:
Of the 167 patients studied, 59.28% (99) had a pre-existing hypertension diagnosis. A total of 614 medication doses were administered, either on an "as needed" or "one-time" basis for elevated CIWA scores or blood pressure/heart rate. Notably, 60.75% (373) of doses were for elevated CIWA scores, all of which were benzodiazepines. The remaining 39.25% (241) targeted autonomic instability. Strikingly, 97.5% (235) of these latter doses were benzodiazepines (223 lorazepam, 12 diazepam), and only 2.5% (6) of doses were clonidine that were given to a total of 5 patients, among whom all except 1 had a hypertension diagnosis. Of the benzodiazepine doses for autonomic instability, 75.32% (177) were administered to patients with a hypertension diagnosis.

Conclusion:
This study underscores a significant discrepancy between established ASAM guidelines and observed clinical practices, revealing a predominant reliance on benzodiazepines, even in cases of elevated blood pressure/heart rate where alternative medications could be considered. Notably, most patients with alcohol withdrawal also had underlying hypertension, emphasizing the potential role of adjunctive medications in optimizing patient care and potentially reducing benzodiazepine usage. Further exploration of alternative strategies is crucial to enhance the management of alcohol withdrawal, aligning with evidence-based guidelines and ultimately improving patient outcomes.

Learning Objectives:

Recognize guidelines for adjunctive treatment for AWS

Explore reducing benzo use via adjunctive treatment

Consider comorbidities/med adherence in Tx decisions

Background 
From 2019 to 2023 there were 478 adolescent patients put on legal 5150 holds for danger to self and taken to one of the three emergency departments of Alameda Health System of Alameda County California, which encompasses Oakland. Many of these adolescent patients had extended stays at the emergency department waiting for disposition to an inpatient bed. Some of the stays lasted up to three weeks. The average was 5 to 7 days which essentially was the duration of the hold, which meant that the inpatient treatment was done in the emergency department.

Method
Meetings were held by the departments of emergency medicine, psychiatry and social services to understand this serious problem and develop a solution. Community leaders of adolescent crisis stabilization facilities, inpatient hospitals and county crisis management were included as well. Out of these meetings, interventions were developed to address the problem. Rates of adolescent boarding were tracked over a 16-month period of time to assess the success of the interventions.

Results
A significant improvement was found following a concerted effort to understand and resolve the serious problem of adolescent boarding at the health system emergency departments. Through a collaboration of multiple health departments and county crisis and inpatient facilities, adolescent boarding was significantly reduced.

Conclusion
By identifying the precipitating factors related to the problem of adolescent boarding in Alameda County and improving communication and collaboration between emergency, crisis and inpatient facilities, a significant reduction in adolescent boarding Alameda Health System emergency departments was achieved.

Learning Objectives:

Understand the problem of adolescent boarding at Alameda Health System in the context of a national problem of adolescent boarding at emergency departments.

Understand the process of developing successful interventions to mitigate the problem of adolescent boarding.

Understand how the efforts to reduce adolescent boarding were achieved.

Background:
Approximately 21% of unhoused individuals listed mental health care as an unmet need. As a result, this population heavily relies on the emergency department (ED) or psychiatric hospitalization for mental health services. Street Psychiatry programs work to holistically diagnose and treat mental illness on the street by addressing the tri-morbidity complex of homelessness (mental health, substance use, and physical disability) while improving access to care. Community interventions like these have historically been successful, as seen in a 2005 study revealing greater use of mobile outpatient services than traditional services for psychiatric and substance use support. The purpose of this study is to understand the mental health needs of our local unhoused population, determine their utilization of available resources, and identify key areas for meaningful intervention.

Methods:
All adult homeless or housing insecure patients were recruited in partnership with The Night Ministry at an outreach site at the Forest Park Chicago Transit Authority (CTA) Blue line station or Howard CTA Red line station. Participants were eligible if they were older than eighteen years and deemed to have capacity, as assessed by screening questions. Once identified, participants completed a survey consisting of demographics, homeless history, substance use, psychiatric diagnoses, barriers to care, and community interventions. At the core of the survey were three standardized questionnaires: the PHQ-9, GAD-7, and a Trauma Screening Questionnaire (TSQ). All participants provided informed consent prior to completing the survey.

Results: 
A total of 37 patients completed the survey over a time period of two months. Additional survey collection and final data analysis are still in progress. Our preliminary findings show that the majority of participants (70.3%) were both chronically homeless (>1 year) and reported having a mental health diagnosis. Additionally, analysis revealed that those who had been homeless over one year had a higher likelihood of screening positive for depression on the PHQ-9 (p=0.029). Participants presented with higher than national average rates of mental illness including depression (40.5%), bipolar disorder (37.8%), and psychotic disorders (21.6%). Approximately 62.2% of participants screened positive for anxiety, while only 16.2% had a prior diagnosis. 51.3% of participants stated that mental health negatively impacts their life on a daily basis. Up to 40.5% of respondents were interested in treatment for substance use. 62.2% of respondents reported no use of mental health services within the previous year, while approximately half said they desire mental health services. Finally, the number one reported barrier in access to care was distance or transportation (43.2%).

Conclusion: 
Our preliminary findings reveal high rates of mental illness and significant barriers to care within the unhoused population. In addition, the low rate of utilization but increased desire for services points towards a lack of accessible care for this population. The findings emphasize the importance of community interventions, like Street Psychiatry programs that integrate psychiatry, case management, and substance use services, to effectively address medical and social factors impacting an individual’s mental health. Additionally, homelessness itself is highlighted as a significant contributor to poor mental health.

Learning Objectives:

Identify the ongoing mental health concerns for the unhoused and housing insecure community

Assess utilization of resources amongst people experiencing homelessness

Determine the interest in engaging with mental health resources and barriers in access to care

Background: About ~50% of hospitals/emergency departments (ED) do not provide psychiatric services¹ despite mental health related ED visits being common. Patients who present to the ED for psychiatric concerns often end up “boarding” in the ED, meaning that evaluation is complete, but the patient has not been transferred to the appropriate level of care. It is well established that psychiatric boarding can negatively affect patients, staff, and health systems. One possible root cause for limited access to ED psychiatric services could be reimbursement. Differential reimbursement between outpatient psychiatric and medical/surgical services is also well-articulated; however, less is known about this topic in the ED, and there has been little published regarding ED-based psychiatric patient billing patterns. Notably, in a small 2019 survey of ED physicians, there was significant billing variability for psychiatric boarders; 35% billed for observation, 31% did not bill for observation, and 35% were unsure if they billed for observation.² This may indicate that facilities are under-billing for observation services.

Objective: The purpose of this study was to describe billing, and by proxy practice patterns, in non-boarders and boarders accessing emergent psychiatric services.

Methods: This retrospective cohort study analyzed commercially insured administrative claims data with the most recent 2 years of data (2021, 2022) from the Merative™ Marketscan® Commercial Database.³ The study cohort included adults with a minimum of one ED-associated claim, a primary mental health/substance use disorder diagnosis (F-code), and a non-null procedure code. The primary outcome was frequency of pre-defined CPT/HCPCs code frequency (67 codes). Patients could have more than one ED encounter. Approved under Stanford University IRB PHS 40974.

Results: There were 112,985 unique enrollees with 359,504 associated claims. Fifty-five pre-selected CPT/HCPCs codes were present in the sample. Most claims had a service encounter of < 1 day (n = 344,901; non-boarder) as compared to encounters >= 1 day (n = 14,603; boarder). For non-boarders, top codes were 99284 (32%; n = 112,025), 99285 (25% n = 85,832), and 99283 (22%; n = 77,173). For boarders, top codes were 99285 (34%; n = 5,017), 99284 (21%; n = 3,011), and G0378 (17%; n = 2,472). ED-related medical evaluation codes were the most common for non-boarders (86%, n = 294,933) and boarders (68%, n = 9,919). Psychiatry-related codes occurred in 8% of non-boarder claims (n = 28,733) and in 15% of boarder claims (n = 2,145). Observation codes were in 6% of non-boarder claims (n = 18,989) and 17% of boarder claims (n = 2,493). Finally, crisis-related billing codes were infrequent <1% for non-boarders (n = 2,246) and boarders (n = 46), respectively.

Conclusion: Observation billing codes were associated with 17% of ED boarder claims, potentially indicating underused codes, and thus, that these ED visits are being under-reimbursed. Additionally, the lack of psychiatric-related claims, and infrequent use of crisis-codes, across the sample suggests that access to psychiatric and crisis-related services in the ED setting may be worse than prior estimates. Moreover, the use of boarding codes in non-boarder claims may signify that these patients could be considered boarders in future analyses.

Learning Objectives:

Describe some of the potential contributing factors related to billing heterogeneity in high-acuity settings for patients with psychiatric and substance use disorders.

Articulate that observation billing codes are likely underused and may result in under-reimbursement for this patient population.

Understand that the infrequent billing of psychiatric services may indicate substantively lower rates of access to psychiatric services in the ED than previously described.

Introduction: Social determinants of health are defined by DHHS as the “conditions in the environments… that affect a wide range of health, functioning and quality-of-life outcomes and risks” (ODPHP, 2024). Evidence supports the bidirectional connection between social determinants of health and mental health outcomes (WHO, 2022). In 2022, the Ohio Department of Mental Health and Addiction Services initiated the Access to Wellness (ATW) program with the goal of providing recovery support for long-term wellness in multi-system adults with Serious Persistent Mental Illness (SPMI), including people with homelessness. The funds, which are used to address social determinants of health, provide assistance with housing, emergency, basic needs, and transportation. Though this program has been successful in obtaining recovery support for homeless individuals who are linked with community providers, its success has been limited in patients presenting to the emergency department (ED); in the first year, only 2% of patients referred from the Riverside ED successfully received the funding. The majority of these ATW referrals were lost to follow up largely due to barriers such as lack of transportation and means by which to communicate with ATW staff. The objectives of this study were to 1) increase the number of ED patients referred to the ATW program who successfully receive recovery support funding 2) prove the value of a bridge case manager in optimizing outcomes for patients who present to the ED with mental health crises and housing instability.

Methods: Beginning in year two of the ATW program, a full-time bridge case manager was placed in the Riverside ED who met with patients on arrival to the ED and followed them post-discharge, providing assistance with transportation and other daily needs while maintaining communication with the patient through the care coordination meeting required for funding dispersal. For patients with established case managers, the bridge case manager served as a patient advocate and liaison, while providing full case management services for patients who were not previously linked in the community.

Results: Following implementation of a bridge case manager, over the following year, 15 of 69 referred patients successfully received funding, representing a nearly 20% increase in access to funding. An additional 17 patients attended the initial care coordination meeting, remain linked with the program, and are in the process of receiving funding.

Lessons Learned: Numerous barriers are faced by homeless individuals with SPMI who present to the ED with mental health crises, and to successfully improve social determinants of health for this patient population, these barriers must be addressed. Utilization of a bridge case manager was imperative to the the success of a state-funded recovery support program for emergency department patients with SPMI and housing instability.

Learning Objectives:

Educate on possible intervention to improve patient's access to resources in the community

Provide education on impact on social determinants of mental health

Provide education on interdisciplinary care with social work and other mental health agencies

Aggression and violence in healthcare setting is on the increase. With the post-pandemic mental health crisis across all ages, an increased volume of emergency room patients visits, lack of inpatient beds, prolonged time between the triage  and actual psychiatric evaluation,  additional time between decision and disposition and  overwhelming  increase in boarding of the patients in the emergency departments,  there was an  increased risk of aggressive, violent behaviors in that setting. Program OAASIS,  is a  part of QIP that focuses on creating safe environment  by  using simple techniques by ED staff to reduce the risk of aggression and violence. Presenters will teach the audience step by step what OAASIS is and how to implement this interventions and create safer place for patients and themselves. This is very simple, wholistic, easy to use program with foundation in Trauma Informed Care that can potentially lead to the culture change within the organization.

Learning Objectives:

Aggression and violence in the emergency rooms.

Introduction to OAASIS program.

Step by step introduction to OAASIS interventions.

• Emergency Physician – Why you should treat your Mental Health Crisis like a Code Stroke
  • Group Welcome (Team Assessment) – Meet your patient within 10 minutes of arrival to the department. Your team will have the opportunity to hear the presentation from EMS and the patient together. You will establish a rapport, explain the process, and prepare your patient for what is to come.
    • Initial Assessment determines the Targets for active crisis intervention
    • Suicidal Crisis as an example of active treatment in the ED
    • Disposition based on outcome of active intervention including Crisis Stability Planning and Lethal Means Reduction

Learning Objectives:

Calling a Code for Mental Health Crisis is safe, efficient, and improves care.
Embedding Suicide Risk and Agitation Protocol into your Code improves department safety.
Initiating Treatment in the Emergency Department for Mental Health Crises decreases admission rate and improves patient care.

Introduction
High ED utilization is a known strain on the healthcare system as ED visits are being used as a substitute for limited outpatient services which usually address chronic conditions and their comorbidities. Prior studies have found homelessness,¹ degree of financial insecurity,² and severity of mental health diagnosis³ to be associated with frequent emergency department visits. A subset of those with severe mental illness are individuals with SSD (schizophrenia spectrum disorders). Schizophrenia is often correlated with other medical and psychiatric comorbidities; a combination that significantly affects health and wellbeing.
This study investigates sociodemographic factors associated with high ED utilization (defined as five or more ED visits per year) by individuals with schizophrenia at Boston Medical Center: an urban safety net hospital in the Northeast.
Methods
We extracted data from the electronic health record of all encounters (i.e. billed visits or hospitalizations) made by adults with a SSD at Boston Medical Center (BMC) in Boston, Massachusetts and defined SSD as a chart history of at least one International Classification Of Disease Code 10^th edition (ICD-10) primary diagnosis code of F20,F25,F28, F29 which resulted in a sample of 7,960 individuals.
Patients with a history of neurocognitive disorder without an F20 or F25 diagnosis (n=263) were eliminated from the sample. The final cohort was restricted to patients with ED visits between January 1st 2016 and June 30th 2016, resulting in a final sample of 5,502 individuals.
Results
The mean age of the study population is 50.30 (sd=16.53). The study population was composed of 39% females, 60% males, 49.35% non-Hispanic black, 26.53 % non-Hispanic white, 16.49% Hispanic, 2.38% Asian and 0.4% Native Americans. 85.64% were English-speaking and the second most spoken language was Spanish. Almost all individuals (96.39%) had public insurance. Of those individuals who were at risk of housing instability, 72.9% had a history of being in a shelter or currently living in a shelter. 11.54% of individuals had 5 or more ED visits within a year. Around 8% of patients had an intellectual disability, 4% were pregnant, 39% had a co-occuring substance use disorder, and around 94% had a comorbid medical disorder.
Females had 0.83 times the odds of having 5 or more ED visits within a year compared to males. English speaking patients had around 1.84 times the odds of having 5 or more ED visits within a year as compared to non-English speaking patients. There was a significant relationship between race and number of ED visits with Χ2 =33.80, p <0.001. We will explore these associations further using a zero inflated poisson regression controlling for substance use and serious physical comorbidity.
Conclusion
In conclusion, research regarding the factors influencing likelihood of high ED use for individuals with SSD is highly necessary to provide better quality of care and alleviate the burden in Emergency Departments. Upcoming research should aim to explore inequalities related to specific demographic factors, in addition to medical and psychiatric conditions.

Learning Objectives:

highlight the burden of high ED use in individuals with schizophrenia spectrum disorders (SSD)

assess demographics of individuals with SSD and high ED visits to explore factors correlated with frequent ED use

assess prevalence of substance use disorders and medical disorders that may be correlated with high ED use in individuals with SSD

Introduction:
Borderline crisis is a common behavioral health presentation in the emergency department (ED)¹. At times, hospitalization is counterproductive for patients with borderline personality disorder (BPD) presenting to the ED². Psychiatrists in the ED must explore alternative safe dispositions by allying with outpatient support and community resources.
Case Description:
We present a case series of three patients with BPD presenting with borderline crisis in which the emergency psychiatry team coordinated with their outpatient support for a safe and timely disposition. Patient one is a 27-year-old non-binary adult who presented to the ED after a suicide attempt via cutting following an argument with their partner. In the ED, they demonstrated emotional volatility, behavioral dyscontrol and agitation. Despite initial behavioral dyscontrol and volatility, resolution of symptoms was seen upon connecting patient with their significant other. A safety plan was developed by contacting the outpatient provider and arranging close follow-up. Patient two is a 42-year-old female who presented after the crisis line called EMS due to suicidal ideation with plan of cutting and earlier non-suicidal self-injury via cutting. Destabilization occurred in the context of disappointment regarding scheduling mental health appointments. Although initially presenting in crisis, she was able to safety plan with her roommate. They agreed to connect with her social worker and psychiatrist for follow-up care. Patient three is a 25-year-old female living at a chemical dependence treatment center, who presented with passive suicidal ideation increased from chronic baseline suicidal ideation over frustration towards the treatment center’s restrictions. Her initial crisis resolved while she was in the ED, and she desired to return to treatment. Psychiatry was able to work with staff at her treatment facility who were actively involved in safety planning. Since psychiatry was able to partner with her treatment facility in facilitating a safe plan home, she was able to continue her chemical dependency treatment.
Discussion:
This case series highlights the need for emergency psychiatry to form an alliance with a patient’s community mental health support. In each case, the patient’s crisis began with mood dysregulation then progressed rapidly due to maladaptive coping. Hospitalization was not indicated in these cases. Inappropriate use of hospitalization for borderline crisis is not only inferior to other treatment options but can also reinforce maladaptive behavior³. In the ED, we halted the cycle of borderline crisis. Without involving outpatient support, patients would have inappropriately lengthened the disruptive cycle and stayed in the ED for longer periods of time. There are many iatrogenic consequences of having a patient with BPD in the ED including reinforcing inadequate solutions for short-term crisis, overreliance on medications as a fleeting solution, and exposure to countertransference¹. In each case, we engaged the patient’s outpatient team to expedite a safe discharge from the ED and avoid further exposure to the iatrogenic harm that patients with BPD can face in the ED. Community mental health care is essential for allowing patients with BPD return to the community after borderline crisis.

Learning Objectives

Find ways to ally with community mental health resources from the ED.

Understand disposition options other than psychiatric hospitalization or ED boarding for patients presenting in borderline crisis.

Learn practical advice for partnering with community mental health supports as an emergency psychiatrist.

Background
Workplace violence is a persistent threat in emergency departments, impacting both staff safety and patient care quality. A rise in patient acuity has been observed within Atrium Health Behavioral Health Charlotte where patients often exhibit symptoms and behaviors of aggression, agitation, and psychosis. This facility has an emergency department (ED), ED observation (BH observation), and inpatient units. Staff injuries have also risen in part where patients required restraints. Multiple interventions can be found in the literature; however, their effectiveness varies in this specialized setting.
Objective
Implement purposeful nursing rounds and employ Dynamic Appraisal of Situational Aggression (DASA) to enhance patient safety, staff safety, and reduce the need for restraints.
Method
Pre-surveys were developed by an interdisciplinary safety committee and distributed to nurses and psychiatric technicians in the ED. The pre-surveys gauged views on existing safety measures. There were 22 nurses and 28 technicians who responded. Plan-Do-Study-Act (PDSA) cycles were used to implement recommended process changes. The safety committee developed a tailored nursing round protocol specifically for psychiatric emergency patients, with rounds scheduled every 3 hours to align with staffing levels. The Dynamic Appraisal of Situational Aggression protocol underwent refinement shifting responsibility from psychiatric technicians to nurses for a more thorough assessment of patient aggression risk. A minimum of 3 assessments per shift became required, alongside an agitation protocol order set that guided de-escalation techniques and a stepwise agitation protocol based on DASA scores.
Results
All patients (adults, children, and adolescents) admitted to BH observation from July 2023 to February 2024 were included in the assessment. Pre-intervention (July-October 2023) data showed 67 child restraint events, 85 adult restraint events, and 25 staff injuries. Chart audits showed that nurse rounding was 5%, and DASA scores completion rate was 100%. However, utilizing DASA scores for early identification and protocol intervention for aggression or follow up was at 62%.
Post intervention (November 2023-February 2024) data showed decreases in all areas: 45 children restraint episodes (55.22% decrease), 36 adult restraint episodes (57.62% decrease), and 8 staff injuries (68% decrease). Educational initiatives, such as DASA training, appear to have had an impact on reducing patient restraints and staff injuries. Reinforcement of the protocol during nursing huddles, improved staff proficiency and compliance.
Conclusion
We show that the integration of purposeful rounding, the DASA tool, and following stepwise interventions based on DASA scores has helped to mitigate workplace violence. This resulted in enhanced staff safety and decreased ED observation patients in restraints. Implementation of this protocol underscores the importance of proactive interventions and interdisciplinary collaboration in addressing complex healthcare challenges. Cost savings were achieved as there were 17 less staff being injured resulting in less time missed from work due to injury and less workman compensation claims.

Learning Objectives:

To reduce staff injuries

To minimize the need for patient restraints

Institute purposeful rounding and a stepwise agitation protocol with interventions based on DASA scores

Emergency psychiatry providers must frequently manage severe psychiatric and behavioral crises, which can be taxing for both patients and healthcare systems. While patient stabilization and safety will always remain the largest priority when determining the duration of treatment, protocols that reduce the length of stay while maintaining the optimal standard of care will allow psychiatric facilities to allocate resources to a wider range of the patient pool. The purpose of this article is to examine if the choice of neuroleptic medication played a role in the length of stay for hospitalizations due to acute psychosis. This was conducted through a retrospective review of patient records at Arrowhead Regional Medical Center’s Behavioral Health Unit for the umbrella of psychotic disorder, looking at seven commonly used neuroleptic medications. The retrospective review showed that the use of Aripiprazole resulted in a statistically significant lower length of stay when compared to the other neuroleptic medications, aside from Ziprasidone given its limited sample size. All other medications considered showed no statistical difference from each other in their length of stay. This finding could have important implications on a macro level in determining which medications to consider in patients who have not already displayed clinical improvement with a particular neuroleptic medication prior, in order to effectively utilize resources in an emergency psychiatry setting. Given this study is a preliminary analysis, there are some limitations that warrant further investigation to augment its significance. Suggestions for expansion of this research include differentiating the effects of neuroleptic medications on length of stay amongst specific subsets of psychotic diagnoses, evaluating possible confounding effects of commonly and concomitantly prescribed medications such as mood stabilizers or antidepressants, and determining the role of long-acting injectable medications in length of hospital stay. Overall, this article can provide a stepping stone for physicians looking at secondary factors in determining medication choice in an emergency psychiatry setting, integrating resource utilization with patient management.

Learning Objectives

Examining length of stay for patients experiencing psychosis

Evaluating time for stabilization for neuroleptic medications

Investigating the cost analysis for neuroleptic medications

Background: Healthcare workers in the emergency department (ED) are the most vulnerable to be physically or verbally assaulted (Roppolo et al., 2020). Care delivery in the ED is complex given that decisions are often made under pressure, with limited information, and frequent interruptions (Wong et al. 2022). Evans et al (2019) identified that an embedded psychiatric provider in the ED most significantly augmented metrics such as wait times, provider satisfaction and number of inpatient admissions. Prior to implementation of the embedded Psychiatric Nurse Practitioner Team in the ED, it was estimated that 2000 behavioral health patients were seen annually at UCSF ED. The average length of stay (aLOS) for behavioral health patients was 26 hours. In 2023, over 160 patients with psychiatry consult were admitted to inpatient medical teams, often because no psychiatric beds were available. These patients had inpatient aLOS of 12.4 days. Significant safety concerns plague ED staff with an average of 10 workplace violence events per year, 4 of which are considered severe.
Initial goals post implementation of the PMHNP team include:

• Average Length of Stay reduction of 25-50%.  
• Decreased LOS would essentially create addition 1.5-3 additional bed capacity per day
• Decrease avoidable admissions to medicine by 10%
• Save 200 Inpatient bed days annually
• Reduce severe workplace violence injuries by 50%

Methods: Review of pre and post implementation data.
Results: The PMHNP model met or exceeded each goal. Overall, aLOS for psychiatric consult patients decreased from 22.8 to 17.2 hours, a 25% reduction. Saving 5.6 hours per patient, equivalent to building 1.2 staffed ED beds. There was a 40% reduction in aLOS for patients discharged to the community. Compared to 2023, admissions to medicine decreased 20%. Over one year, 32 admissions may be prevented, saving 397 inpatient bed days, almost twice the goal of 200 beds. This is equivalent to building 1.1 staffed inpatient beds. No severe ED workplace violence injuries have occurred in the 6 months since implementation of PMHNP compared to 4 total in 2023.
Lessons learned: Investment in an embedded PMHNP team had additional resource savings in avoided consults, 5150 holds and transfers. With responsive, timely consult available around the clock, ED providers were 32% more likely to forgo psychiatric consult after placing a patient on an ED hold. When consulted, the PMHNPs were 22% less likely to place patients on a 5150 than previous psychiatric staffing structure. Even when patients were placed on a 5150, reassessments happened around the clock. Psychiatric consult patients were over three times more likely to be discharged from 10pm to 9am. Transfer to inpatient psychiatric facility decreased by 8% and discharges to community increased by 16%. Patients placed on a 5150 who were ultimately discharged after serial exams had aLOS reduced by 11.4 hours. 

Learning Objectives
To explore the role of the PMHNP in emergency psychiatric care.
Identify barriers to psychiatric care in the emergency department
Discuss the post-implementation outcomes of the embedded ED PMHNP Team

Research has shown that post-discharge from an emergency department is a period of elevated risk for youth experiencing suicidal ideation. Data also suggests patients may experience barriers in accessing follow-up care, have limited support following a crisis, and feel resources do not meet their needs. Overall data trends show follow-up phone calls are an effective method to reduce suicide risk however more data is needed to confirm what aspects of follow-up phone calls are most effective in reducing suicide risk. Additionally, when working with pediatric populations there is limited data around engaging parents/guardians following an emergency department visit and strategies to support their child. To address this gap, a protocol to complete follow-up phone calls with all parents/guardians who were evaluated by the Consultation and Liaison Psychiatry Service at C.S. Mott Children's Hospital. This included identifying the target population, guidelines, scripts, and documentation processes. Staff education was developed and strategies to integrate phone calls into existing workflows to promote completion and ensure there is limited increased workload for staff. Phone calls engaged family’s around the youth’s mood after discharge from the emergency department, if they are experiencing suicidal thoughts, if they are aware of where their safety plan is, have they carried out lethal means restriction, and if they were able to attend follow-up appointments are establish care after discharge. Crisis resources and supports were also reviewed with family. Calls provided parents with coaching and positive praise for checking in with their youth and completing lethal means restriction. Calls also offered parents and opportunity to speak with providers on the CL service if additional questions or concerns were present. Overall, parents appreciated the phone calls. Calls also did not significantly add to workload for psychiatry team staff. This session will review steps to develop a follow-up phone call process in an emergency department setting. Strategies for data collection and monitoring of calls will also be reviewed.

Learning Objectives:

Reflect on data indicating effectiveness of follow-up phone calls

Describe key aspects of follow-up phone calls when engaging parents after an emergency department visit

Formulate strategies for how to replicate a similar intervention in their healthcare setting.

Northside Hospital is a large hospital system with 5 acute care hospitals (1,890 inpatient beds) and over 400 outpatient clinics in the Metro Atlanta area (one of the fastest growing regions in the country), providing care across 25 counties. From 2016-2020, our system saw over 212,000 ED visits for mental and behavioral health disorders, comprising 38% of the state of Georgia's total. Our presentation focuses on strategies implemented to manage aggressive patients in an acute care hospital setting, to include the emergency department, across a multi-campus system. We'll discuss various strategies and tools utilized by clinical and non-clinical staff in the care and management of aggressive and/or violent patients. Our tiered approach includes utilization of Violent Patient Alerts, High-Risk Rounds and Behavioral Emergency Response Team. We'll share brief history of our system, the tiered approach we use today and its impact within our system, as well as plans for the future. Our tiered approach includes utilization of Violent Patient Alerts, High-Risk Rounds and Behavioral Emergency Response Team. We will provide detail on each aspect of our tiered approach. Our method involves clinicians of various disciplines - psychiatry, nursing, LCSWs/LPCs, as well as non-clinical staff (security, constant observer/sitters) and we will share the role of each, focusing on how they work together to manage the aggressive and/or violent patient. We will provide information on our tracking, reporting and management of these interventions in addition to data on our process to date.

Learning Objectives:
Implement strategies for diffusing aggressive behavior in a general medical setting based on the identified stage of conflict.
Identify safe options to prevent and manage patient aggression.
Identify strategies and tools to minimize risk when caring for the aggressive or violent patient.

Background: A patient can be medically admitted to the hospital over their objection if they lack the capacity to refuse admission. Any treatment or intervention over a patient’s objection can be emotionally distressing and impact their future interactions with the healthcare system, including willingness to seek care. A patient has capacity for a medical decision if they are able to communicate a choice, demonstrate understanding of the situation, appreciate the impact of their choice, and demonstrate a rational thought process. In the emergency department (ED), capacity assessment is limited by patients’ brief lengths of stay and lack of longitudinal relationships with their teams. While all physicians can assess capacity, there are circumstances when psychiatric consultation can assist not only with assessment but also identifying factors contributing to patients’ lack of capacity, counseling regarding expectations, and providing recommendations for maintaining patient safety. In this poster, we review two cases of patients admitted for medical workup over their objection.  
Results: Both cases reviewed involve adults over age 75 with minimal formal psychiatric history who demonstrated paranoia and other factors interfering with their ability to understand their medical situations. In both cases, psychiatry was consulted following over 12 hours in the hospital (including the ED). They both received intramuscular injections of antipsychotic medications while resisting transfer to the medical unit. Ultimately, both patients underwent workup in the hospital voluntarily.  
Conclusion: Literature regarding capacity assessment in EDs is limited. In these two cases, psychiatric consultation earlier-on may have elucidated specific barriers to the patients’ understanding of their medical conditions and reasons for admission. The psychiatry team can also assist with conversations related to expectation-setting, including the possibility of being kept in the hospital over objection. In patients who may require interventions for their safety, the psychiatry team can provide recommendations. Considering psychiatric consultation when a patient’s capacity to make a specific medical decision is in question, particularly for psychiatric reasons such as paranoia, is appropriate and could improve patients’ overall experiences. Not explored here but also worth investigating are the unique ethical considerations posed by admission for workup over objection, given the logistics of pursuing medical workup for a patient who is resisting.

Learning Objectives:

Identify opportunities for psychiatric consultation related to capacity in the emergency department

Understand reasons for counseling patients regarding next steps in care

Explore challenges related to capacity assessment specific to ED settings

SAFER was created by collaboration between PES faculty, staff, and security services at the University of Michigan. The program aimed to improve the PES staff’s skills needed to maintain the safety of patients and staff in the busy PES service. It was built based on evidence-based recommendations for structuring these programs to fit the unique needs of the physical space where the program will be applied. The training was completed over a structured three-hour program, repeated eight times over two months to accommodate all staff with varying work schedules. Training included a one-hour didactic session followed by interactive role-playing learning activities. Staff were surveyed before and after the training, and results showed increased confidence in responding to behavioral emergencies that come or arise in PES.
In this presentation, we will discuss how SAFER was structured, including examples of interactive practical sessions and data collected from staff exploring their subjective perception of confidence in handling behavioral emergencies before and after the training.

Learning Objectives:

Explain how SAFER was structured as an example of training program for emergency responses

Highlight the importance of structuring such programs to fit the unique needs of the physical space

Show changes in staff confidence in handling behavioral emergencies before and after the training.

Background: First responders, by the nature of their high-stress roles, are exposed to conditions that significantly elevate their risk of mental health issues such as PTSD, depression, anxiety, and even suicidal ideation. Research indicates that over 50% of firefighter deaths can be attributed to stress and exhaustion, and Emergency Medical Services providers often report insufficient recovery time between traumatic incidents, leading to heightened stress and associated health problems (Psychiatric Times, 2023). To support the mental health of first responders, organizations must prioritize and invest in tailored stress reduction interventions. This includes implementing comprehensive mental health training and ensuring access to counseling and support services, which benefit the individuals and enhance their operational effectiveness (Columbia Southern Education, 2023).
Methods: A comprehensive literature review was conducted to assess the efficacy of various stress reduction techniques tailored to first responders.
Results: The literature suggests several promising techniques for stress reduction.
1. Heart Rate Variability (HRV) Training
HRV training has been shown to reflect vulnerability to stress and can play a role in quantifying physiological elasticity and behavioral flexibility (Kim et al., 2018). Find a quiet and comfortable place to sit or lie down

• Place your fingers on your pulse points (wrists or neck)
• Focus on your breath and try to slow down your heart rate
• When you feel your heart rate slowing down, take a few deep breaths and focus on the sensation
• Repeat this process for 10-15 minutes, 2-3 times a day

2. Interoception and Exteroception
Research has shown that interoception (awareness of your body's internal state) and exteroception (awareness of your environment) can modulate the stress response (Chen et al., 2021).

• Notice how your body is responding to your environment (e.g., sounds, smells, and sensations around you)
• Try to integrate your internal and external awareness by focusing on how your body is responding to your environment
• Repeat this process for 10-15 minutes, 2-3 times a day

3. Sensory Integration
Sensory integration has been shown to play a crucial role in adaptive responses to stress (Levit-Binnun and Golland, 2011).

• Find a comfortable place to sit or lie down
• Focus on one sense at a time (e.g., sight, sound, touch, taste, or smell)
• Notice the sensations and feelings associated with each sense
• Try to integrate the sensations and feelings from each sense by focusing on how they interact with each other
• Repeat this process for 10-15 minutes, 23 times a day

4. Body Perception Distortions
Research has shown that body perception distortions can be related to stress and anxiety (Viceconti et al., 2022).

• Stand or sit in front of a mirror
• Notice how your body looks and feels in the present moment
• Try to focus on the sensations in your body without judgment
• Repeat this process for 10-15 minutes, 2-3 times a day

Conclusion
The techniques reviewed have all shown significant promise in mitigating stress and enhancing the mental well-being of first responders. Incorporating these scientifically proven methods into their routine training improves their psychological resilience and effectiveness in high-stress environments.

Learning Objectives:

Understand various scientifically proven stress reduction techniques beneficial for first responders.

Identify how regular application of HRV Training, Interoception and Exteroception, Sensory Integration, and Body Perception Awareness can significantly alleviate stress.

Acknowledge the importance of integrating these stress reduction methods into the daily routines of first responders to enhance their mental health and operational readiness.

Teen Mental Health Literacy: One School District’s Post-Pandemic Response
Mental health challenges are becoming a significant public health issue for adolescents, and primary interventions are focused on mental health education. Because adolescents spend most of their time in school, primary mental health interventions should be prioritized in this setting. An Arizona suburban school district of 45,000 students struggles with increased social/emotional referrals and seeks solutions. A PICO question was developed to determine if mental health literacy (MHL) in adolescents would improve while decreasing stigma and improving help-seeking behaviors after a program of enhanced mental health education. Partnering with the school district’s social work department, a teen Mental Health First Aid (tMHFA) pilot program was implemented for a class of nine (n = 9) adolescent students (aged 17-18 years) old during the school day. tMHFA was delivered in three 90-minute class days. Using the Mental Health Literacy questionnaire (MHLq), a pre and post-test design revealed a significant (p value=less than 0.05) increase in the students’ MHL, help-seeking behaviors, and decreased stigma after delivery. This quality improvement project was IRB approved, and all human subjects’ rights were protected. The project showed that enhanced mental health programming, such as tMHFA, effectively educates adolescents about mental health challenges and, perhaps, could promote behavioral changes in future generations. Subsequently, after the pilot project, the school district successfully expanded the project to all junior-level students in one high school (800 students) and expanded again to 1300 students in the 2023-2024 school year. The school district has decided to implement tMHFA curriculum to all juniors in the school district for the 2024-2025 school year (4,300 students) making it the first school district in the state of Arizona to integrate tMHFA into its curriculum.
 
 
*This research/quality improvement project won the annual “Advancing Nursing Excellence Award” from the American Academy of the Colleges of Nursing in 2023 and is also currently being considered for publication.

Learning Objectives:

Discuss how a mental health professional can collaborate with a school district to improve the quality of mental health education.

Appraise teen Mental Health First Aid (National Council of Mental Wellbeing) as quality mental health education for teenagers.

Demonstrate the statistical impact of this programming on teens.

*The full abstract will be shared once approved for public viewing.

Learning Objectives:

To better understand what care looks like for those visiting an ED for mental health reasons

To highlight current struggles in providing evidence-based care to those visiting the ED for mental health reasons

To understand how our EDs are ill equipped for the growing number of patients presenting with mental health crises

There has been explosive growth in the design and development of crisis and behavioral emergency centers—some prototyped and prefabbed—that divert mental health patients from law enforcement or overburdened hospital emergency departments. In this session, we will share how Trauma-Informed Design informs environments of care and elevates the care culture for providers. Recent projects include the templated model for CHS Kirkland Crisis Response Center, CHS Dauphin Crisis Walk-in Center and CHS Chantilly Crisis Center as recent case studies to review. Our team of internationally recognized experts in mental health design will discuss these issues and trends to further elevate, educate, and advocate for crisis care design. In this way, a holistic clinical and design approach seeks to humanize mental health environments for patients, harmonize staff safety, and enhance the comfort of visiting family and friends for the communities we serve.

Learning Objectives:

Understand Trauma-Informed Design

Analyze planning considerations to crisis care settings

Apply design strategies for emergency psychiatric environments of care

In 2021 the CDC declared racism as a “serious public health threat”, yet in the three years since this declaration, very little has been done in the way of addressing this epidemic in clinical practice. Racism places a huge mental and physical demand on groups and individuals, creating a significant deficit in cognitive and physiological resources. Such a demand on resources can lead to overall poor physical health as well as lead to inattention, impulsivity and the overall inability to make clear and concise decisions. Such deficits in cognitive resources can contribute to significant and unique mental health challenges in health care settings where there has historically been little acknowledgement of the impact that racism has on health and well-being. The following is a proposal to present on the topic of recognizing racism as a health crisis and exploring ways to address racism in acute care settings. This presentation was developed based on an in-depth literature review and aims to highlight the ways racism can impact patient presentation and response to treatment. This presentation also aims to introduce ways that clinical staff can help mitigate negative healthcare experiences and the behaviors associated with those experiences. This presentation outlines the many ways in which racism is enabled and reinforced in healthcare settings due to its intrinsic nature and proposes an anti-racist clinical approach to care. The presented approach is based on the anti-racist clinical model presented by Legha and is intended to be utilized by direct care staff though it can be adapted to work across all clinical domains. The approach includes two action based intrapersonal interventions: 1) acknowledging all the ways in which racism exists; and 2) making a commitment to critical consciousness. As well as two explicit action-based interventions: 1) patient advocacy; and 2) anti-racist clinical practice. It is believed that such an approach will yield positive benefits for clinical staff and patients alike.

Learning Objectives:

Gain an enhanced awareness and understanding of racism as a health risk.

Be able to identify some of the ways in which experiencing racism can lead to and exacerbate challenging behaviors in the health care setting.

Identify an anti-racist approach to care aimed at mitigating the negative health impact of racism.

Background: The Fordham Risk Screening Tool (FRST), a five-item clinical decision-making tool, was developed to streamline violence risk assessment and more efficiently screen patients for whom greater violence risk workup is warranted [1]. Because treating patients with mental health needs and working in the emergency department are both risk factors for experiencing healthcare violence, the utility of the FRST is especially promising in the emergency evaluation of patients in mental health crisis [2]. In 2023, the Maine Medical Center (MMC) FRST research team found that the FRST was 84% sensitive and 93% specific in screening psychiatric patients who later tested positive for risk of violence using the current gold standard violence risk assessment tool [3]. No violence risk assessment screening tool has ever been directly connected to actual violent outcomes. The MMC FRST research team recently sought to explore whether FRST results correlated with markers of violence during inpatient psychiatric hospitalization. In conducting this evaluation, the MMC FRST research team observed that roughly 10% of the study participants experienced multiple psychiatric hospitalizations during the study enrollment period. 
Objective: To analyze the differences in FRST performance and inpatient violence incidence between patients in the MMC FRST study who experienced multiple inpatient psychiatric admissions (multiple-admission patients or “MAP’s,” n=53) and patients in the study who experienced only one inpatient psychiatric admission (single-admission patients or “SAP’s,” n=366). 
Hypotheses: (1) MAP’s will show a higher risk of violence as tested by the FRST compared with SAP’s and (2) MAP’s will demonstrate violent inpatient behavior at a higher rate than SAP’s. 
Design/Methods: Cohort study with admission status as exposure and FRST performance and violence incidence as outcomes. MAP’s and SAP’s were defined as patients who experienced >1 or 1 inpatient psychiatric admission during the six-month study enrollment period, respectively. Because each MAP had 2-3 FRST test results and 2-3 violence records throughout the course of the study, their performances were consolidated into one equally weighted aggregate score to be compared with the single FRST result and single violence record of each SAP. Statistical analysis was completed using IBM SPSS software.
Results: MAP’s appeared more likely than SAP’s to screen positive for violence risk using the FRST, with FRST positivity rates of 37.0% and 25.5%, respectively (RR: 1.45, 95% CI: 0.97, 2.17). Additionally, MAP’s tended to show higher rates of violence incidence across nine violence metrics compared to SAP’s (RR: 1.19, 95% CI: 0.89, 1.60). 
Conclusions: These results appeared to be consistent with initial hypotheses regarding FRST performance and violence incidence, but the data did not reach the threshold for statistical significance. Trends present in these data warrant follow-up work to increase statistical power and determine if MAP’s are in fact at greater risk of both testing positive with the FRST and demonstrating inpatient violence compared to SAP’s. Further research could improve the ability of clinicians to use the FRST to anticipate violent behavior in psychiatric patients who experience repeated hospitalizations in short timeframes.

Learning Objectives:

Understand the available research regarding violence risk screening tools.

Understand how violence risk screening tools, such as the FRST, can be applied in clinical settings.

Understand the potential utility and limitations of implementing use of a screening tool such as the FRST.

In 2020, the Substance Abuse and Mental Health Administration's "National Guidelines for Behavioral Health Crisis Care" report gave unprecedented attention to crisis observation and stabilization units. While state regulations vary greatly for this level of care, common definitions and function are crucial to improving treatment approach and outcomes. In this brief presentation, learn the results of a national survey of crisis stabilization and observation units, revealing places of common design and function and recommendations for uniform practice standards.

Learning Objectives:

Participants will understand the 23-hour crisis stabilization model of behavioral health crisis care and its national variations and iterations.

Participants will be able to identify two treatment criteria and three preferred outcomes for crisis stabilization

Participants will be able to articulate crisis stabilization & observation's place in the ideal crisis continuum, including its strengths and limitations amidst the other programs and services available