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Operational Strategies for Behavioral Health Patients in the ED
Karen Murrell, MD, MBA, FACEP
Vice President, Process ImprovementTEAMHealth
Disclosure
Big Book of Emergency Department Psychiatry:
A guide to Patient CenteredOperational Improvement
www.BigBookSeries.com
© Balan & Murrell 2017
Few things as difficult to change
(c) Murrell 2015
Critical to go out of the box…
(c) Murrell 2015
ObjectivesDiscuss cultural challenges impeding care of the behavioral health patient in the EDDiscuss changing the model of ED Psychiatry from assessment and boarding to active treatment in the EDReassess patients and discharge home safely if possibleDiscuss creation of meaningful metrics when developing an ED Psychiatry ProgramDiscuss community best practices
(c) Murrell 2015
An Introduction to Our Challenge: 2 million people seek treatment annually in the US for Behavioral Health
Care problems in hospital emergency departments at a cost of about $4 billion.
ED staff often feel burdened by behavioral health patients. There is much variation in ED expertise and training in mental health
problems, which can lead to inadequate care and negative patient and staff experiences
More than 62 million Americans (22.2%) have some form of mental disorder.
Of this group, 8.7% have what is categorized as severe mental illness.
Ninety percent of Americans with severe mental illness are unemployed and 50% do not receive psychiatric treatment.
6 to 12% of all US ED visits are related to psychiatric complaints
The average ED length of stay for psych patients is double that of non-psych patients (median 5.5 hours) exacerbating ED overcrowding.
Strategies for Expediting Psych Admits by J.D. McCourt, MD, Emergency Physicians Monthly February 14, 2011
A 2008 survey of 328 emergency room (ER) medical directors done by the American College of Emergency Physicians found that79% of the survey respondents said psychiatric patients were boarded in their EDs, with a third of the patients boarded for 6 hours or more; 62% said these patients received no psychiatric services while they were being boarded
American College of Emergency Physicians. ACEP psychiatric and substance abuse survey 2009 [Internet]. Irving (TX): ACEP; 2008
Patient #170 year old with history of schizophrenia is brought to the Emergency Department. He has been off of his medication for several weeks. Medications started in the ED, but it is clear he needs admission. No beds are available and he is kept in the ED for 12 days. On day 8, he is put into an enclosure bed for safety. Ultimately he is admitted to the hospital for several weeks until placed in a Psychiatric Hospital.
• Found out he was a well known professor in his earlier life & had won a National Book Award for Poetry!
Why didn’t we have more to offer this patient? What stereotypes did we have about this patient when he arrived?
(c) Murrell 2015
Patient #2A 35 year old female with a history of unknown psychiatric illness presents to the ED unresponsive. The family states she has been under a lot of stress. She will not interact with the treatment team or her family, refuses to eat or drink, and urinates on herself. Medical workup is negative including labs, CT and drug screen.
What are the next steps for treatment?
Catatonia• Patient was observed for
over 24 hours in the ED without any medications
• The next day treatment was initiated with high dose Ativan. By the end of the day, she was awake, alert, ambulatory & eating
Why did it take 24 hours to start treatment?
(c) Murrell 2015
What other group of patients would be put in a corner and not treated?
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Our challenge• In 2009, Sacramento
County closed the crisis stabilization unit and ½ of the inpatient psychiatric beds
• Direct shifting of patients into all of our ED’s
• Often 20/40 beds had psychiatric patients boarding with very long lengths of stay
Demand Doubled
© Balan & Murrell 2017
Flawed Treatment Model
Model of care: assessment by a therapist, then boarding
Often in ED for days with little or no reassessment, medication or therapy
Basic life needs were often neglected
Dangerous for patients and staff
© Balan & Murrell 2017
Other Comments It was clear that patients presenting were more ill than in the
past. This has led to an increased length of stay on the inpatient
side, further decreasing the number of available beds. For example, when we had an increase of only 0.3 patients
daily, if you look at our average daily census with the new length of stay we increased from an average daily census of 6.64 to 9.8 patients on average.
This obviously means we have a long tail with some days going up to a census of over 20 patients.
These 8 arrivals a day increased our average length of stay in the department by an hour! (in a 400 PPD ED)
© Balan & Murrell 2017
Other CommentsThree patients may not seem alarming on average, but this
means a number of things: The ED Behavioral Health team is saturated and cannot
discharge low acuity patients quickly Additional nursing hours 24/7 for these patients Additional security hours for patients (from 14,000 hours in
2009 to over 40,000 hours) Lack of medical beds for patients presenting to the ED Pulling of resources from outpatient psychiatry creating a
vicious cycle for patients needing outpatient services
© Balan & Murrell 2017
Old modelTriage
ED MD evaluation
‘Med Clearance:’ standard Lab tests, utox
Psych?
Yes
Admit
Board
Psych Social Worker Assessment
Discharge
How many of you have this model?
(c) Murrell 2015
A simple question…Why aren’t you doing the exact same thing you do for your medical patients?
Why not demand the same level of service for consultants?
(c) Murrell 2015
• Exclude medical etiologies for symptoms
• Rapid stabilization of acute crisis
• Avoid coercion
• Treat in the least restrictive setting
• Form a therapeutic alliance
• Appropriate disposition and aftercare plan
Zeller SL. Primary Psychiatry. Vol 17, No 6. 2010.
Treatment Goals of Emergency Psychiatry
New Paradigm Active treatment in the EDReassessmentMedicationsAvoid unnecessary testingTherapyCollateralDischarge safely when possible
© Balan & Murrell 2017
Vision To provide world class care to all patients with behavioral
health needs. To ensure a continuum of care with the creation of One Data
Set for the entire department. Purpose: to remove fragmentation, acknowledge and reduce
potentially competing metrics, and to increase cross accountability between departments.
Goals: − to reinforce fluid transitions between points of care− to evolve at the same if not faster rate of our population's
needs.
© Balan & Murrell 2017
One Improved ModelTriage
ED MD evaluation
Clinically indicated labs
Admit
Treatment initiated
Psychiatry team evaluation
Discharge
Re Assessment
Adjusted Treatment
TLC
© Balan & Murrell 2017
Defined, refined and reliable approach
Value Stream Maps− Value added vs Non-value added− Eliminate waste− Improve flow
Look at costs of (considering length of stay at each point of care):− ED: RN, security, facility fees, MD, therapist− Hospital – facility fees, MD, therapist, case managers− Hospital alternative costs− Outpatient ability to provide access
Look at demand vs capacity
© Balan & Murrell 2017
ONE DATA SETOPERATIONS/FINANCE
EMERGENCYActive treatment
ED Psych/CDA/PUFF
Combine NV ED’s for best care
Research/Fellow
Consult Service
Staffing for demand
INPATIENTStreamline Access
Maximize MD Productivity
Lean Call Center
Goal to Internalize
Staffing for Demand
OUTPATIENTTeam based practice
Staffing for demand
Internalize ASAP
Specialty Clinics
Primary Care Psychiatry
CONTINUUM OF CARE
© Balan & Murrell 2017
Results: 10% Drop in Admission Percentage
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
January February March April May June July August September October November December
Admission Percentage32% average since ED Psychiatrist start
© Balan & Murrell 2017
Results
325 admissions saved in one ED in the first year!
Goals:• Optimize ED Care to Decrease Admissions• Create Capacity for Patients Who Need Inpatient
Psychiatric Care
© Balan & Murrell 2017
Operational Solutions
The only way we can improve our current statistics is to:
–Decrease length of stay on the inpatient side–Decrease the admission rate to inpatient psychiatry–Match staffing in the ED to the new demand–Prevent recidivism of patients
© Balan & Murrell 2017
Why is this different? Start to think “door to doctor” for these patients tooMost patients benefit from rapid medication administrationTry to get patients better and discharge safely if you can
Think Basic Service Operational Principles!
Basic Service Operational Principles
Define the incoming behavioral health patient streams. Measure pt demand by shift or by day of week and design a system to handle it Process flow chart the current service process(es) Define resource needs and resource availability Whiteboard the “ideal state” for the level and quality of service desired Match your service delivery options to your patient streams Remove all work that does not add value Commit to the right staff, space, supplies and services
Creative Solutions at South Sacramento
Transitional Lounge for Care
Reduction in clinically unnecessary testing
Staffing solutions
Work with state and local officials on commitment for community treatment access
Technological solutions for enhanced information exchange
© Balan & Murrell 2017
Creative SolutionsCollaboration with Local Medical Society and California Hospital Association BoardImproved collaboration with outpatient & inpatient and substance use treatment providersCollaboration with Community Providers for Case Management and housingAutism SummitPeer Navigators in the ED
© Balan & Murrell 2017
Financial Repercussions
Decreased admission rate
Decreased nursing & security hours in ED
Decreased lab tests ordered
Cost conscious treatment & medication prescribing patterns
© Balan & Murrell 2017
Impact on Quality
Immediate medical care & alleviation of symptoms
Improved collaboration between providers
Decreased medical-legal risk
Least restrictive modality of treatment provided
© Balan & Murrell 2017
Psychiatry Rounds in the ED Multidisciplinary rounds – ED MD, RN, ADM, Nursing Director
and Manager, PCC, SW, MFT, Security Manager, med students, residents, fellows, community liaisons, ICMs, Peer Navigator and ED Psychiatrist− Every morning at 8:30am− ED Psychiatrist creates 'Plan of Care' Note to document
HPI, clinical course, treatment in ED, vitals, meds, behavioral issues, legal status, barriers to placement, medical clearance, treatment planning.
− Each member of team assigned patients and specific tasks to ensure safe discharge of each patient from ED.
© Balan & Murrell 2017
TLC: Transitional Lounge for Care
Observation and treatment area in the ED
Used for behavioral health needs that can be assessed and treated for potential discharge within 24 hours of acceptance
Structured milieu– Medication management– Psycho-educational & coping skills groups– Supportive therapy– Substance use counseling
© Balan & Murrell 2017
Benefits of the TLC
Decreased admission rates Decrease inpatient admission times if admission
ultimately required Improved quality of care Increased space in ED for medically ill patients
Created in our old conference room…
© Balan & Murrell 2017
Changing the ED Culture
© Balan & Murrell 2017
Changing the ED Culture
© Balan & Murrell 2017
© Balan & Murrell 2017
© Balan & Murrell 2017
© Balan & Murrell 2017
© Balan & Murrell 2017
Order Set for MedicationsThese are just guidelines and not medical recommendationsAGITATION:
For agitation due to dementia or delirium, evaluate for underlying medical issues, avoid deliriant medications, and try behavioral interventions before using medications. Age < 65: Haldol 2.5-5 mg PO/IM; consider adding Ativan 1-2 mg PO/IM/IV. Avoid antipsychotics if long QTc or in Parkinson’s. Avoid benzodiazepine in cognitive impairment/dementia/delirium. Age > 65: Haldol 1 mg PO/IM OR Risperdal 1mg PO. Avoid antipsychotics if long QTc or in Parkinson’s. Avoid benzodiazepine in cognitive impairment/dementia/delirium.
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Order Set for MedicationsThese are just guidelines and not medical recommendationsANXIETY:
Mild: Hydroxyzine (VISTARIL) 50 mg PO Avoid in patients who are > 65 or cognitively impaired Moderate/Severe: Ativan 2 mg PO OR Seroquel 25 mg POFor drug-seeking behavior with anxiety , avoid benzodiazepine, use hydroxyzine or Seroquel
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Order Set for MedicationsThese are just guidelines and not medical recommendationsCATATONIA:
Catatonia often initially responds to Ativan 1-2 mg IV. Catatonia occurs secondary to an underlying medical or psychiatric condition.Call Psychiatrist on call immediately for recommendations.
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Order Set for MedicationsThese are just guidelines and not medical recommendationsDEMENTIA WITH AGITATION:
For agitation due to dementia or delirium, evaluate for underlying medical issues, avoid deliriantmedications, and try behavioral interventions before using medications. Haldol 1 mg PO/IM or Risperdal 1mg PO. Avoid antipsychotics if long QTc or in Parkinson’s. Avoid benzodiazepine in cognitive impairment/dementia/delirium.
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Order Set for MedicationsThese are just guidelines and not medical recommendationsMANIA:
Zyprexa 10 mg PO/IM; consider adding Ativan 1 mg PO/IMConsider repeating Zyprexa 10 mg PO/IM if not improved in 2 hours.Maximum 30 mg Zyprexa in 24 hours
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KEY POINT53
Partnership between ED and PsychiatryNuanced medication for all patients in ED for more than 8 hours and psychiatrist available on call at any time
Research
• Markers /Crayons : $1 per box
• Composition Book : $0.25
• Amazon Fire with Protective Cover: $70 times 3
• Roku: $30
• Newspapers: $1 per day or $7 per week
• Games: Addition $0.50 per week
• Chair Yoga Video: Free through streaming
• Magazines/Games: $70 per year
• Inspiring Videos: Free - $145
• Dementia Resources: $25
• Children Resources: $125
• Self Help Books/Library Cart $425 / $480
2017 Kaizen: Activities
2017 Kaizen: Human NeedsWasher/dryerCommunal DiningAdditional ShowerService Dog RoundsTelevisionED tech assigned
Rapid Assessment: up to 75% discharged from lobby
P.A.R.T.E.– Psychiatric Assessment and Rapid
Triage Evaluation
Creating Space
-9am-3pm interview in Rapid Care room-Designated waiting space
Patient Care
-Chief complaint education-Add PSY to Assignment System
Current Metrics
-August through Oct 41.5 patients per arriving via lobby
© Murrell, Balan
Kaizen: A Day in the LifeScheduled Time Activity Responsible Person
6 am Vitals RN
7:30-8 am Lights on/personal hygiene ED tech
8 am Breakfast ED Tech
8:30 am Behavioral Health Rounds RN/BH team
9 am Medications RN
10 am Educational Videos ED Tech
Noon Lunch, video ED Tech/RN
2 pm Medications/Vitals RN/ED tech
2-4 pm Activities: coping skills BH team
3 pm Snacks ED Tech
5 pm Dinner ED tech
Best PracticesTele -psychiatry to leverage staff (just be sure reassessment and treatment incorporated)Community engagement to increase clinic capacity and delivery of medications to homelessLow cost collaboration: community mental health clinicians can train ED staff in management and care of patientsLook for every community resourceWork with Law EnforcementCommunity paramedicine
Best Practice: John George Psychiatric Hospital
(c) Murrell 2015
Best Practices: John George24 hour observation unit with attached psychiatric hospitalParamedics can drop off directly if patients meet criteria for medical clearanceIf being transferred from ED, turnaround time 90 minutes for acceptancePatients met by a psychiatrist at the door and meds orderedTreatment given for 24 hours and high percentage of patients are able to be discharged home
Telepsychiatry BenefitsLess expensive than locumsPatients treated fasterCan help improve flow in the ED increasing revenueMitigates the shortage of psychiatristsCan improve the discharge rate for behavioral health patients
If implemented be sure key operational principles are discussed: active treatment and discharge rates
Hope for the Future… Psychiatric patients will get the same great care we give
our other patients Cultural change emphasizing care and compassion
using the same principles used for medical patients.
DiscussionWhat are your challenges currently?
What is your current workflow for patients?
What are your best practices we can learn from?
What is something you can take back and start tomorrow?
(c) Murrell 2015
Questions?
(c) Murrell 2015