EDs struggle with increased demand from patients with behavioral health concerns
Culture, education, and community links are key to positive outcomes
Already burdened with increased demand for medical services, EDs across the country are also seeing a spike in the number of patients who present with behavioral health issues. There are multiple factors involved, but Rachel Glick, MD, clinical professor of psychiatry and director of Psychiatric Emergency Services at the University of Michigan Medical School in Ann Arbor, MI, believes that much of this increase is directly related to the nation's fragile economy. "People are uninsured, people are more stressed, and people are unemployed. They are down and out, and when they have a crisis, the ED is their only option," she says. "It is really analogous to what we are seeing in the medical ED world. Folks don't have a lot of resources, so they go to the resource of last resort."
This is straining the capabilities of EDs that have been built, staffed, and equipped to manage medical emergencies. And further compounding the pressure on EDs is the fact that despite the increased demand, financially strapped states are slashing funds for mental health services. For example, just this past February, Alabama announced plans to shut most of the mental health hospitals in the state and to lay off nearly 1,000 mental health employees by 2013. Other states have initiated similar, if less dramatic, cutbacks. The result of such cutbacks is that patients are being inappropriately unloaded onto hospitals and EDs.
"In the past three years, there has been something like a 17% reduction in mental health services for the safety net," explains Stuart Buttlaire, PhD, MBA, regional director of Inpatient Psychiatry and Continuing Care, Kaiser Foundation Health Plan Northern California, Oakland, CA. "In addition to that, we are seeing more and more psychiatric hospital closures across the country. Part of that is because of low reimbursement. The other part is because hospitals are reorganizing, and when they reorganize, they find it more valuable to put in medical-surgical beds than psychiatric beds."
The upshot of all of these forces is that EDs are being left with the challenge of meeting the needs of increasing numbers of patients with behavioral health needs. And this tends to be an uneasy fit for many ED providers. "These are hard patients to deal with. They are complicated. Often, to do a really good job, you need to get corroboration, which isn't always easy in an emergency setting," says Glick. "Also, the patients can be dangerous. From their agitation, they may lash out and hurt you. All of these things make it uncomfortable for a lot of physicians and other health care providers to deal with acute psychiatric issues."
The situation becomes even more difficult when patients require specialized inpatient care because, oftentimes, such beds are in short supply. "Inside the ED, you have to work with your psychiatric colleagues in order to ensure that patients get appropriate care while they are waiting for a bed," explains Leslie Zun, MD, chair of the Department of Emergency Medicine, Mount Sinai Hospital, Chicago, IL. "So you have limitations on what you can do in the ED if you don't have a psychiatric unit, an acute stabilization unit, or community resources to send these patients to."
There are no quick or easy solutions for EDs that are struggling with these types of challenges, but experts suggest there are steps that hospitals and department leaders can take to not only ease the strain on their facilities, but also improve the care and overall experience that patients receive when they present to the ED with behavioral health problems.
First, look in-house for improvements
The Institute for Behavioral Healthcare Improvement (IBHI), a membership-based organization focused on identifying and developing quality improvements in the behavioral health space, has been looking at the challenges faced by busy EDs for several years. This has included a number of initiatives, including a multi-hospital learning collaborative aimed at establishing better methods for meeting the needs of patients who present to the ED in psychiatric distress or with underlying behavioral health issues, explains Peter Brown, the executive director of IBHI.
One of the key observations from this group is that while establishing links with community resources is critical to both connecting patients with appropriate care as well as maintaining effective patient flow in the ED, it is important for a hospital to look in-house for improvements, at least initially.
"If a hospital goes to the trouble of developing a better internal operation, it gives it significant credibility with the rest of the service package in this area," says Brown. "It does a number of important things: It improves the hospital's own operation, it reduces time-to-treatment, it improves the likelihood that the hospital won't have to hospitalize somebody, and it gives the hospital the opening to go to other organizations and say that the hospital has done its homework and now it is time for the community at large to respond to this."
What are some common problem areas for EDs? One of the biggest issues that IBHI's multi-hospital collaborative picked up on was that patients who present to the ED with behavioral health issues do not commonly have good things to say about their experience. "By and large, they feel like their problems aren't respected," says Buttlaire. "Part of the cultural shift that needs to take place in the ED is that [staff and clinicians] need to see that part of their mission is taking care of and treating behavioral health clients in ways they may not have had to before."
Hire appropriate staff, educate ED staff on management practices
This is not an easy transition for many traditional health care providers, explains Larry Phillips, DCSW, program manager, St. Anthony Hospital, Oklahoma City, OK. "One of things we found is that most of the people who go into emergency medicine are not prepared to deal with mental health patients. That is not their desire, it is not their interest, and it is not their focus," he says. "So from the very beginning, starting with the job interview and orientation, we start discussing that 10% to 12% of the population here at our ED are mental health patients, and about 25% to 30% of the patients who go through the ED and are admitted to the hospital are mental health patients." (Also, see "Create a welcoming, soothing environment for patients with behavioral health needs," below.)
The objective is to make sure that new employees fully understand what the hospital's expectations are and how they will need to prepare. "What we have to do is make our ED staff — including the techs, the nurses, and registration — aware of the fact that there is a large population of mental health patients who are going to come into our system, and they need to know that before they accept a position here," says Phillips. "They need to understand that and be willing to get training, starting with some special modules in orientation."
Using information gained from the IBHI collaborative, Phillips and colleagues at St. Anthony developed some of their own education modules, but they also got some help from the community. "Working with the Oklahoma City Police Department Crisis Intervention Team, we created a module called EDIT, which stands for emergency de-escalation intervention training," explains Phillips. "It is a two- to three-hour module that is required of everybody who deals with mental health patients, including the mental health triage professionals, and everyone is required to be re-certified [through this module] on an annual basis."
This type of training helps clinicians and other ED personnel learn how to calm patients and develop techniques for speaking with people who are agitated or are experiencing emotional distress, explains Buttlaire, noting that Kaiser provides training on a series of behavioral health issues as well. "We train all of our physicians in how to recognize depression and what to do about it once you have recognized it," he says.
Make suicide prevention for behavioral health patients a top priority
Most standard community EDs have a process for managing patients safely, but these practices do not always match the different needs of a mental health population. This doesn't mean that EDs have to change their entire process, but they do need to develop safe areas and dedicated staff to manage these patients. In cases involving behavioral health issues, clinicians can often avoid difficulties by simply interacting with people in a slightly different way, says Buttlaire. For example, he explains that many people with mental health disorders have a background of physical or sexual abuse. "The idea of disrobing in front of someone can be a lightning point for these individuals," he says. "ED personnel need to approach people with psychological problems in ways in which their responses will be more positive rather than making things worse."
One high-priority issue for ED personnel should be training in how to recognize patients who are suicidal, and then how to appropriately care for such individuals, stresses Buttlaire. "We know that one in every 10 suicides is someone who has been seen in the ED within two months of dying," he says. "A lot of people who work in the ED are concerned about asking a patient about suicide because they don't know what to do about it if a patient answers yes."
A strategy that can be particularly helpful to hospitals and EDs is to have behavioral health specialists available to consult with clinicians about a suicidal patient or any other behavioral health issue that is of immediate concern, explains Buttlaire. Hospitals that have in-house psychiatrists or other mental health professionals may have an easier time setting up this type of arrangement, but hospitals without in-house expertise can establish links with consultants in the community. Sometimes, all that is required is a phone consult or video conference.
"Having collaborations between EDs and crisis lines can make an enormous difference," adds Buttlaire. (Also, see "Study: Cause for concern regarding care of young patients who present to the ED following an episode of deliberate self-harm," below.)
One simple intervention that can have great impact with patients at risk for suicide is to reach out to them by phone after their ED visit just to check in on how they are doing, says Buttlaire. "That can make a big difference in whether the patient continues to seek services and continues to stay alive," he says. "This is the type of thing that EDs may not think about."
Start with culture
Change for the better doesn't happen overnight, but opening up the conversation about behavioral health to stakeholders in the community can lead to new resources and improved systems of care for behavioral health patients. "There is a cumulative process that we can point to in places like San Antonio, TX, Akron, OH, Pittsburgh, PA, and Southern California, where hospitals have worked effectively to advance the larger system of care," says Brown. (Also, see Management Tip: "To improve behavioral health care, find model-programs to learn from," below.)
However, Brown emphasizes that crucial to the success of such endeavors is the culture of the originating organization. "If the culture is closed, authoritarian, and not open to changing the way it does business, the process won't work, so the first stage in the overall process of improving care is to look at the culture of the hospital and the culture of the ED," he says.
Brown advises that one way to assess hospital culture is through the Hospital Survey on Patient Safety Culture, a tool available through the Agency for Healthcare Research and Quality (http://www.ahrq.gov/qual/patientsafetyculture/userged.htm). While the tool has a safety focus, it will provide hospitals with a level of evaluation for the culture of the organization, and that is a start, says Brown. "Getting through that initial step is an opening for change at the hospital level, and then you can expand the concept of improving the practice of care throughout the community by having other organizations connected informally to the hospital."
Sources
- Jeffrey Bridge, PhD, Principal Investigator, the Center for Innovation in Pediatric Practice, Nationwide Children's Hospital, Columbus, OH. E-mail: [email protected].
- Peter Brown, Executive Director, Institute for Behavioral Healthcare Improvement, Castleton, NY. E-mail: [email protected].
- Stuart Buttlaire, PhD, MBA, Regional Director, Inpatient Psychiatry and Continuing Care, Kaiser Foundation Health Plan Northern California, Oakland, CA. E-mail: [email protected].
- Rachel Glick, MD, Clinical Professor of Psychiatry and Director of Psychiatric Emergency Services, University of Michigan Medical School, Ann Arbor, MI. E-mail: [email protected].
- Larry Phillips, DCSW, Program Manager, St. Anthony Hospital, Oklahoma City, OK. E-mail: [email protected].
- Leslie Zun, MD, Chair, Department of Emergency Medicine, Mount Sinai Hospital, Chicago, IL. E-mail: [email protected].
To improve behavioral health care, find model programs to learn from For hospitals that are just getting started on a process of improving the way they care for behavioral health patients, it can be very helpful to identify models that they can look to for guidance and assistance, advises Stuart Buttlaire, PhD, MBA, Regional Director, Inpatient Psychiatry and Continuing Care, Kaiser Foundation Health Plan Northern California, Oakland, CA. "EDs tend to listen to other EDs," he says, noting that this was a vital element in a learning collaborative that the Institute for Behavioral Healthcare Improvement (IBHI) sponsored so that hospitals could learn from other organizations on ways to better manage the care of patients who present to the ED with behavioral health concerns. The IBHI (www.ibhi.net) can be a source for hospitals or EDs that would like to link up with a model program or join a learning collaborative. In addition, ED leaders should consider attending an annual conference that focuses exclusively on issues involving the care of behavioral health patients in the ED environment. The National Update on Behavioral Health Emergencies Conference will be held in December 2012. For more information about this event, visit the conference website at http://www.behavioralemergencies.com. |
Create a welcoming, soothing environment for patients with behavioral health needs In an ideal world, every ED would have a specialized psychiatric emergency services unit available to it so that patients who present with behavioral health issues would have ready access to the kind of care that they need. That, at least, is what Rachel Glick, MD, clinical professor of psychiatry and director of Psychiatric Emergency Services at the University of Michigan Medical School in Ann Arbor, MI, sees as the optimal set-up for both patients and providers. And she feels fortunate that this is the kind of care environment that she works in on a daily basis. "We are adjacent to the main ED. Patients can come directly to us, and many of our patients know we are here, and know if the issue is psychiatric, that they should come directly to us. However, we also get transfers from the medical ED," explains Glick. The arrangement works well because when a patient's medical assessment is completed and there are no active medical issues, then he or she can be quickly transferred over to the separate, but adjacent psychiatric unit where specialized care can commence, and throughput to the main ED is optimized, adds Glick. In fact, with demand for psychiatric emergency services growing, the unit was recently renovated and expanded with the specialized needs of behavioral health patients in mind. "We designed a nursing station with three rooms that could be used for seclusion, restraint, or even just for patients to quietly rest, but the rooms have lots of windows with built-in shades so if a patient doesn't need to be observed, we can shut the shades so they have that privacy," explains Glick. "Having enough space so that people aren't crowded in together, and having clear lines of observation so that you can keep everyone safe, are [key features] of the space." Many of the patients the unit receives from the main ED are people who have physical complaints, but also depression, anxiety, substance abuse, insomnia, or some other behavioral health issue that the ED provider believes can more optimally be addressed in the psychiatric unit, but the patients don't always agree, says Glick. "Sometimes the ED will call and ask one of us to come over and talk to a patient for a few minutes to see if we can talk him into getting some help, so we try to be flexible about that," she says. "There are patients who we simply can't convince to come into our setting, but having staff [nearby] who can help ED physicians who are busy taking care of medically sick patients ... can at least open the door for these patients to get help, even if it is not sending them down the hall, but rather getting them a referral for care out in the community." Demand for emergency behavioral health services continues to increase, says Glick. "When we first built the space 10 years ago, we would sometimes have eight or nine patients a day, and now we see 20 or 30 patients a day," she says. Get feedback from behavioral health patients Having a separate space and staff for patients with behavioral health issues may not be an option for most EDs. After all, most were not built to manage large volumes of these patients, and they must take care of medical emergencies as a first priority. However, administrators should, nonetheless, think about accommodations for the behavioral health population, observes Stuart Buttlaire, PhD, MBA, regional director of Inpatient Psychiatry and Continuing Care at Kaiser Foundation Health Plan Northern California, Oakland, CA. "Emergency departments are not the optimal space for behavioral health clients," he says. "There is lots of noise and lights and people running around, but what you want is some place that helps people become soothed, settled down, and calm." Buttlaire says some EDs have addressed the issue by designing one room or perhaps a corner that is away from all the action. Also helpful is a quick triage process so that patients with behavioral health needs can be identified and connected with appropriate care quickly, he says. While most EDs are not in a position to build a brand new unit or even to launch a major redesign, it can be helpful to ask patients who have spent time in the ED with behavioral health issues about the existing environment and what changes might be helpful, advises Peter Brown, executive director of the Institute for Behavioral Healthcare Improvement (IBHI). "Have a small group of people who have been ED users for behavioral health purposes give their impressions of what might be done," he says. "Another alternative is to have a member of the ED staff go through the process of becoming a patient. These types of things will give you an idea about how your ED is affecting people when they become consumers there, and it will open up a conversation about what changes or modifications might be helpful." Buttlaire adds that any ED can improve the environment for behavioral health clients by "thinking through how you can make the ED more welcoming and comfortable for people who are in heightened states psychologically." While having a distinct area designed with the needs of behavioral health patients in mind can be helpful, Brown cautions that it is not a good idea to have the psychiatric or behavioral health component completely removed from the general health setting. "You need to have the potential for dealing with serious physical issues for the behavioral health population," he says. "You still need to have the capacity to deal with the physical aspects of whatever the issue is." |
Study: Cause for concern regarding care of young patients who present to the ED following an episode of deliberate self-harm A common reason for a visit to the ED by a young person is deliberate self-harm, and experts say that the vast majority of these patients meet the criteria for at least one psychiatric disorder. However, a national study of Medicaid data suggests that a high percentage of these patients leave the ED without a mental health assessment, and a similar percentage of patients receive no follow-up outpatient care within a month of the ED visit.1 The study, conducted by researchers at Nationwide Children's Hospital in Columbus, OH, suggests that strategies need to be developed to promote ED mental health assessments, and that physician training should be strengthened with regard to pediatric mental health, according to Jeffrey Bridge, PhD, the lead author of the study and the principal investigator at the Center for Innovation in Pediatric Practice at Nationwide Children's Hospital. In addition, Bridge says that it is clear from the findings that coordination between ED services and outpatient mental health care is often inadequate. "The reasons for this troubling pattern are not clear. However, providing specific outpatient appointments rather than contact information, short waiting times between ED discharge and the initial outpatient mental health appointment, and telephone reminders of the outpatient appointment may improve this aspect of care," says Bridge. Of particular concern is the association between incidents of self-harm and suicide. Bridge explains that deliberate self-harm is the main risk factor for completed suicide, and the greatest risk for suicide occurs in the period immediately after an episode of self-harm takes place. "Emergency departments can play an active role in suicide prevention by routinely assessing the mental health of youths who present with deliberate self-harm, and helping them get the care they need after they are discharged from the ED," adds Bridge. In the study, Bridge and colleagues reviewed 2006 Medicaid Analytic Extract files from all 50 states and Washington, DC, pertaining to youth between the ages of 10 and 19 who presented to the ED for care following an episode of deliberate self-harm. They found that most of these patients were discharged to the community rather than referred for inpatient care, but that only 39% of the patients who were discharged to the community received a mental health assessment while in the ED. Bridge observes that the findings suggest that decisions about whether to conduct a mental health assessment are determined more by staffing patterns or established ED evaluation protocols than by the clinical characteristics of individual patients. Reference
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Already burdened with increased demand for medical services, EDs across the country are also seeing a spike in the number of patients who present with behavioral health issues.
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