Operational Strategies for Behavioral Health Patients in ... · 14/02/2011 · Operational Strategies for Behavioral Health Patients in the ED Karen Murrell, MD, MBA, FACEP Vice

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?

r© Murrell, Balan

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


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


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)


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


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


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.


One Improved ModelTriage

ED MD evaluation

Clinically indicated labs

Admit

Treatment initiated

Psychiatry team evaluation

Discharge

Re Assessment

Adjusted Treatment

TLC


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


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


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


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


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


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


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


Financial Repercussions

Decreased admission rate

Decreased nursing & security hours in ED

Decreased lab tests ordered

Cost conscious treatment & medication prescribing patterns


Impact on Quality

Immediate medical care & alleviation of symptoms

Improved collaboration between providers

Decreased medical-legal risk

Least restrictive modality of treatment provided


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.


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


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…


Changing the ED Culture


Changing the ED Culture






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

49

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.

51

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

Documents

Operational Strategies for Behavioral Health Patients in ... · 14/02/2011 · Operational Strategies for Behavioral Health Patients in the ED Karen Murrell, MD, MBA, FACEP Vice