C-L psychiatrists at the sharp end derive innovative service models
And… for the most part, this epidemic lands at the door of hospital emergency departments (EDs):
Now, more than 10% of ED admissions in the US are patients with conditions arising from substance abuse and suicidal behaviour— and, for many of these people, the ED is their first-ever encounter with a psychiatric provider, says ACLP’s Emergency Psychiatry SIG co-chair Scott Simpson, MPH, MD, Denver Health Medical Center.
Dr. Simpson—among the Academy’s C-L psychiatrist members facing up to the challenge—admits that the ED environment is not conducive to delivering psychiatric care. Data, he says, shows that “the longer you are in an emergency department, the more likely you are to become delirious.”
Environmental risks for delirium include:
The ED is “probably not the best place to be treating a lot of medical illness, and certainly not the best place to be treating psychiatric illness” compared with specialty, inpatient psychiatric units, says Dr. Simpson.
“It becomes a real challenge how we deliver care to so many patients, especially when we might have them for only a short period of time.”
So… Dr. Simpson set out to build new, innovative clinical programs, including a standardized evaluation process for psychiatric emergencies; a buprenorphine induction program in psychiatric emergency services; an integrated care program for urgent care settings; and enhanced suicide prevention efforts for the spectrum of emergency services.
Dr. Simpson and his team provide consultation services to Denver Health’s Level 1 Trauma Center and operate a dedicated psychiatric emergency service as part of the ED.
The emergency department at Denver Health Medical Center now uses standardized behavioral agitation rating scales which address agitation more rapidly and improve staff perception of safety.
Staff are trained in the use of the Behavioural Activity Rating Scale and record its use as part of routine vitals. These scales help staff communicate more effectively about a patient’s status and immediately offer behavioral or pharmacologic de-escalation.
Online training (tinyurl.com/verbaldeescalation) in the assessment of agitation is also offered to medical students and trainees. Providing and reinforcing training among staff builds a collaborative and trauma-informed culture of patient care, while also helping everyone feel safe and comfortable in a high acuity workplace.
What constitutes a good emergency psychiatric evaluation is also being reimagined. New standards of care implementation have been demonstrated to feasibly apply evidence-based interventions for reducing suicide risk and emergency department return rates. Perhaps the most important of these is writing a safety plan with the patient. “We can now do safety planning with two-thirds of patients, even though half of them are with us involuntarily and most are agitated.” (Watch Dr. Simpson demonstrate safety planning in an ACLP video pearl.)
Denver Health has made buprenorphine treatment for opioid use disorders available 24/7 through the emergency department. Patients need only present to the triage desk, and they will receive an evaluation for medication treatment and begin buprenorphine. Patients then follow-up at one of three area narcotic treatment programs. Not only can patients access care anytime, but this capacity allows the ED to offer substance use treatment to patients who present for other chief complaints—for example, they have pain or cellulitis related to intravenous drug use. Denver Health started more than 340 patients on buprenorphine in the ED in 2018. The success of this program led to a partnership with the City of Denver, which now funds a full-time, dedicated addictions counselling team to help ED patients connect to follow-up care.
Integrated care program
Although high acuity psychiatric presentations are common in the ED, many more patients present with less severe presentations—chronic somatic symptom disorders, panic attacks, crisis reactions without suicidality. Many of these patients are treated by emergency medicine clinicians with little formal training in psychiatry. Denver Health designed and embedded an integrated behavioral health service in the hospital’s pediatric emergency department and urgent care center. Staffed by emergency and consulting psychiatrists and psychologists, the integrated care team offers brief cognitive and behavioral therapy, motivational interviewing, and brief family interventions for patients and families receiving care. Patients might be presenting with non-epileptic seizures or procedural anxiety.
Suicide prevention in the ED
EDs offer an under-realized opportunity to engage patients at high risk of suicide. New Joint Commission regulations in 2019 will expect facilities to offer specific suicide screening and management to patients presenting with behavioral health complains to the ED. The Suicide Prevention Resource Center and Substance Abuse and Mental Health Services Administration (SAMHSA) endorse the Zero Suicide framework for helping institutions develop capacity to deliver suicide-relevant care.
With funding from SAMHSA and the state of Colorado, Denver Health is developing a novel implementation of the Zero Suicide framework across its emergency services system. Training in assessing and managing suicide risk will be offered to paramedics, nurseline responders, mobile crisis teams, and all emergency department personnel so that any ED staff can effectively engage patients with a behavioral crisis. These services account for more than 400,000 patient encounters annually—”testament to the huge impact produced by investing in psychiatric care in emergency settings,” says Dr. Simpson.
He adds: “ACLP is a critical supporter of efforts to improve psychiatric treatment in the emergency department. The Emergency Psychiatry SIG has more than 300 subscribers and an active group of faculty who have made ACLP’s annual meeting one of the most important exhibitions of original scholarship for emergency psychiatry in the country.”