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Strategies for ED Psych Patients

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   June 04, 2014

New models of collaboration (even among competitors) are producing shorter boarding times and fewer instances of aggressive behavior in the emergency department.

This article appears in the May 2014 issue of HealthLeaders magazine.

Three prominent scars on the forehead and cheeks of Virginia State Sen. Creigh Deeds are a recent and visible reminder that hospitals and health systems are straining to meet the mental health needs of patients across the country on a daily basis. Last November, Deeds' 24-year-old son, Austin "Gus" Deeds, attacked his father with a knife, slashing his head and torso, then killed himself—all within 24 hours of being released from a local emergency room because there wasn't a psychiatric bed available.

Deeds had taken his son, who was diagnosed as bipolar in 2011, to a hospital in November 2013, because of concerns about erratic behavior. With an emergency custody order in hand, Deeds as able to have his son in emergency care for six hours while hospital officials searched for a psychiatric inpatient bed. An appropriate bed couldn't be found within the time frame, so they returned home to what would be Gus Deeds' last night alive and the beginning of his father's fight for more mental health resources in Virginia's emergency rooms.

Not every psychiatric patient who is released too early from an ED commits violence or suicide, but nearly every ED in the country is struggling with the same issues: more psychiatric patients and not enough resources to properly treat them. In the face of this challenge, hospitals and health systems have had to form partnerships across departments and, in some cases, across town with competitors.

Success key No. 1: Collaboration among competitors

More and more patients with behavioral and mental health issues are showing up in EDs across the country because of the reductions in the number of psychiatric beds, mental health funding, and psychiatrists.

The National Alliance on Mental Illness, one of the largest nonprofit advocacy groups for people living with mental illness, estimates more than half of the states cut mental health budgets by $1.6 billion between 2009 and 2012. The Treatment Advocacy Center, another nonprofit aimed at helping mentally ill patients, released a 2012 study showing a 14% decrease in state-funded psychiatric beds from 2005 to 2010.

But as most states found out quickly, fewer beds doesn't mean fewer patients. Instead it means crowded EDs, says Jeff Klingler, CEO of the Central Ohio Hospital Council, which spearheaded an effort six years ago in central Ohio to coordinate psychiatric bed availability among competing hospitals.

"The situation had gotten so dire in 2008 that this was not an issue that a single institution was going to be able to manage by themselves," Klingler says. At the time, psychiatric patients were being boarded in hospital EDs for up to six days before a bed became available. "That's not good for the patients; that's not good for the hospital."

In May 2008, three large hospital systems serving the Columbus area joined together to form the Franklin County Mental Health Collaborative: Mount Carmel Health, a four-hospital system that is part of CHE-Trinity; OhioHealth, a nine-hospital nonprofit health system; and The Ohio State University Wexner Medical System, an academic medical center.

The purpose of the collaborative was to find psychiatric inpatient beds for the patients who were showing up in the hospitals' EDs no matter where the patient went for care initially.

"The hospitals agreed early on that the discussion was about the patients," says Klingler. "It was about getting the patient in the right bed at the right time, and we were able to kind of put aside all of the competitive stuff and really focus on getting a patient into a bed as quickly as we could."

After nearly a year of talks, the three health systems developed a simple protocol: The patient who has been waiting the longest for a psychiatric inpatient bed gets the first one available, no matter where it is located. If a patient is in a Mount Carmel ED, and an inpatient bed opens up at an OhioHealth hospital, the patient goes to OhioHealth.

"Right now the bed board is all about getting a patient into the bed quickly," says Klinger, who is in charge of managing the online bed board hospitals log in to daily to input and monitor the county's psychiatric patient load in the EDs.

The database has provided relief. In May 2009, there were 400 psychiatric patients in Franklin County EDs, when wait times for a bed could number up to six days. A year later in May 2010, the wait time had fallen to 30 hours, and by October 2013, the average length of stay for a psychiatric patient needing an inpatient bed was down to 19 hours despite an increase the number of psychiatric patients seeking care in Franklin County EDs.

Participation among providers in the Franklin County Mental Health Collaborative has grown, too. When it began, only three hospital systems participated; now, Klingler says, every organization with psychiatric inpatient beds is a using the bed board.

"Before we started this process, the hospitals were calling each other saying, 'Hey I've got so many patients in my ED; do you have any beds open?' And the other hospital would say, 'No, I don't have any beds open,' when maybe they did have a couple of beds open but they kept them for themselves," he says. "Now, it's very transparent, and they're more trusting."

Success key No. 2: Regional psychiatric emergency service

Coordinating the emergency care of psychiatric patients among hospitals has also caught on in California's Alameda County, an 800-square-mile expanse that includes Berkeley, Oakland, and Fremont.

Scott Zeller, MD, chief of psychiatric emergency services for Alameda Health System, an integrated public health system based in the city of Alameda, says that routing psychiatric patients to a dedicated regional facility reduces the length of stay in the ED, and helps stabilize patients who are in a mental health crisis.

"The key idea is that there is a lot that can be done for a psychiatric patient in an emergency situation in the first 24 hours, and in too many places around the country, they're just sitting, waiting, when hospitals could probably have most of them much improved and on their way back home or somewhere less restrictive than an ER," says Zeller, who is also past president of the American Association for Emergency Psychiatry.

At AHS, Zeller developed what he calls the Alameda Model. In this approach, psychiatric patients are transferred from general hospital EDs to a regional psychiatric emergency service facility, which can receive direct transfers from other hospital EDs and assess and treat patients who are presenting with mental health emergencies. In this case, the PES is the John George Psychiatric Hospital, an 80-bed AHS facility in San Leandro.

Fewer than 10 of California's 58 counties use the PES model, something both Zeller and the California Hospital Association are hoping will change with the release of Zeller's 2013 study of the Alameda Model, published in the Western Journal of Emergency Medicine.

"This is a model that's evolved over several years," says Zeller, who wanted to prove that what AHS was doing as a PES would work for even the more difficult psychiatric patient emergencies, such as when police have an adult under an involuntary mental health hold. "We decided to set up a study and see if our assumptions were correct."

Zeller says 90% of psychiatric patients come into the John George Psychiatric Hospital because of an involuntary hold by law enforcement. In California, this type of psychiatric hold is called a 5150, which is short for the state code governing the treatment of psychiatric patients. Hold times also vary from state to state; in California, the limit is 72 hours. Ambulance crew members are the first point of triage for these patients (police who initiate this order call an ambulance for transport; they do not bring in patients) and will determine a patient's medical stability. If the patient needs medical care first, the ambulance will take the patient to one of the county's 11 EDs. If patients are considered to be medically stable, then they are taken to John George Psychiatric Hospital.

In the study, Zeller tracked the boarding times for psychiatric patients who were under an involuntary mental health hold. The study took place over 30 days and tracked patients from five area hospitals. He wanted to measure the difference in how long a patient was boarded. The comparison data he used was from a 2012 CHA study he also worked on that showed the average boarding time of these psychiatric patients as 10 hours.

After tracking boarding times for 30 days, Zeller found that the average boarding time in the Alameda Model was less than two hours (107.6 minutes). Zeller also says he found out something else equally important from the study's results: Only 24.8% of patients actually needed an inpatient bed. "The one thing that has been missing over the concern of a dwindling number of inpatient beds is any alternative to inpatient beds," says Zeller. "All too often the default solution for every mental health problem is to admit a patient to the hospital first and start treatment later. It doesn't make any sense to me. Not nearly enough places are considering trying to do urgent treatment on arrival, seeing what they can do in those first 24 hours when so many patients can have their urgent symptoms relieved."

Success key No. 3: Telepsychiatry on demand

Seton Healthcare Family in Austin, Texas, an 11-hospital system that is part of Ascension Health, is trying to make a dent in helping psychiatric patients within the first 24 hours of their presenting in an emergency room.

It just opened a new stand-alone psychiatric ED at its downtown Austin location, University Medical Center Brackenridge.

"This is the Seton hospital which bears the brunt of psychiatric patients in the ED," says Kari Wolf, MD, vice president of medical affairs for psychiatry, who is overseeing the psychiatric ED. "It's located close to the local mental health center, and there's a large homeless population in the geographic area."

Wolf says Seton decided to include a 24/7 telemedicine suite in the new psych ED. She expects it to reduce the boarding time of psychiatric patients, inpatient admissions, and ED costs.

"We spend $30,000 a month at University Medical Center Brackenridge on sitters in the ED," says Wolf. "We anticipate that will be pretty much gone with new psychiatric ED because we're not going to need them. It's a safer environment."

Wolf says Seton began using telemedicine in its Brackenridge ED and then spread it to its more outlying hospitals in 2012.

"If someone gets brought in, we were able to get a psychiatric assessment right away and some were able to go home," says Wolf. "Before, if they came in Friday night, they would have had to wait until Monday morning for an assessment. Other times, we were able to treat people, so instead of waiting until Monday morning to start treatment, they could start Friday night."

The on-demand telepsychiatry even helped patients who were going to be admitted and were waiting for a bed, she says, because beginning treatment reduced their anxiety, which can be compounded by the chaos of an ED.

Success key No. 4: Behavioral emergency response team

Another aspect of treating psychiatric patients in regular EDs is the danger they can pose to staff. Furniture, IV poles, and trashcans that are typical in an ED room can become weapons if a patient is in an elevated state of agitation.

At SSM Health Care–St. Louis, a seven-hospital system, a new emergency response process is in place because of the results of a pilot program called BERT, for behavioral emergency response team.

BERT is a three-person team that is paged when a psychiatric patient begins to show verbal signs of anxiety.

"It has to do with vocal tones, pacing, shifting about, being more demanding," says Lawrence Kuhn, MD, medical director for behavioral health at SSM. "These are early signs of anxiety and frustration. If you address patients at these early stages, you can usually find out what's going on and they will respond and let you know, and that's the key to this."

The BERT protocol began at SSM St. Mary's Health Center in Richmond Heights, Mo., a 525-bed hospital, in August 2012.

"Before BERT, everything had been done at the leadership level," says Sarah Lohse, RN, BSN, director of behavioral health services for SSM St. Mary's. "What's great about BERT is that it is owned by the employees and the staff. The people who respond are not leadership. They are the frontline experts."

Each BERT team includes a charge nurse, house supervisor, and security officer. Each person has a role, says Lohse. The charge nurse takes the lead, the house supervisor determines what resources are needed, and the security officer tries to build rapport.

"Security is stationed in our EDs so a lot of patients know security," says Lohse. "They're not necessarily there as a use of force; they're there as a use of support. If things do escalate and it becomes a security issue, then we have a security officer there."

Since implementing BERT, there has been a decrease in Code Strongs, the code that indicates a psychiatric patient's behavior has escalated and physical intervention is needed, often the use of restraints. Lohse calls the decrease one of the "biggest successes" of BERT.

"BERT is for when someone is verbal; we have a different code for when someone is physical," says Lohse. "The Code Strong was originally the only method we had for when someone was escalated. BERT has been added as an additional layer to encourage people to call earlier. We want to continue to see Code Strong declining and BERT increasing."

From August 2012 to September 2013, just a little over a year, 209 calls for help with a psychiatric patient in the ED have gone out at SSM St. Mary's; of those 172 were BERT and 37 were Code Strong.

Kuhn says there's been another benefit, too.

"Overall, I think it's made a difference in the way many of the people in the ED—as well as on the medical floors—see psychiatry," he says. "It's improved the way in which our staffs are talking with one another. I've been asked to go to a medical floor, if they have a problem patient, and do some consultative work with the staff as to how to manage them. I think it's improved the overall profile of psychiatry within the hospitals."

Reprint HLR0514-6

This article appears in the May 2014 issue of HealthLeaders magazine.


Jacqueline Fellows is a contributing writer at HealthLeaders Media.

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