60 Renfrew Drive, Suite 300 Markham, ON L3R 0E1 Tel: 905 948-1872 Fax: 905 948-8011 Toll Free: 1 866 392-5446 www.centrallhin.on.ca Improving Flow in the Emergency Department for Mental Health and Addiction Services CONTEXT Session Summary June 14, 2012 The Ontario government is continuing its emphasis on advancing a comprehensive strategy to improve quality and accountability within the health system. The release of Ontario s Comprehensive Mental Health and Addictions Strategy; the Mental Health Commission of Canada s national strategy, Changing Directions, Changing Lives; Ontario s Health Action Plan and the Excellent Care for All Act, 2010 all provide supporting frameworks for improving the quality of care within and across the mental health and addictions sector in Ontario. In alignment with the province s quality direction, and to advance quality improvement at the local system level, the Central Local Health Integration Network (LHIN) has embarked upon a series of Quality Collaboratives. These sessions are a key feature of the Central LHIN Quality Action Plan and are designed to help strengthen health provider capacity to support continuous quality improvement. Central LHIN was encouraged to facilitate this session entitled Improving Flow in the Emergency Department for Mental Health and Addiction Services by the Central LHIN Chiefs of Psychiatry/Directors of Mental Health and Central LHIN Emergency Department (ED) Lead, Dr. Rakesh Kumar. PURPOSE AND OBJECTIVES People seeking care for mental illness and addictions presenting to the ED often have complex health issues that require a multidisciplinary approach. On June 14, 2012, Central LHIN held Improving Flow in the Emergency Department for Mental Health and Addiction Services Quality Collaborative to share successful practices implemented in Ontario hospitals to identify opportunities to improve the quality of care that is being delivered for people seeking care for mental illness and/or substance abuse conditions. 1
The Collaborative s learning objectives included the following: Enhance implementation of standards for medical clearance for patients seeking care for mental illness or substance abuse in Central LHIN emergency departments (e.g. American College of Emergency Physicians Guidelines). Share strategies to improve the triage of patients to enhance flow and enable the quick release of police officers or other community resources. Share leading perspectives on the appropriate use of the physician application for psychiatric assessment (Form 1) and the implications for patients and the system. This Collaborative sought to explore specific strategies for collaboration between hospital mental health departments and ED with the goal to identify organizational and system-wide strategies for improvement. The discussion also provided an opportunity to hear examples of initiatives that are sustaining positive results within the local system. DISCUSSION SUMMARY The session began with opening remarks from Annette Marcuzzi, Director of Strategic Alignment at the Central LHIN. Ms. Marcuzzi outlined the context for focusing on strategies to enhance flow and quality of care in the ED for patient s living with a mental illness and/or substance abuse issues. The session provided Central LHIN health service providers with an opportunity to share meaningful knowledge regarding key initiatives, successes and challenges. Following Ms. Marcuzzi s opening remarks, Steve Lurie, Executive Director of Canadian Mental Health Association Toronto Branch, and the Collaborative moderator, provided welcoming remarks to Collaborative participants. Mr. Lurie shared his perspectives on the mental health and addictions system in the province and the country, and specifically reflected upon the role of community mental health providers in improving patient flow. Ontario s Comprehensive Strategy for Mental Health and Addictions released last spring, outlined the government s strategy to make investments in enhancing access to services, with the goal of being able to identify and intervene early and to close critical service gaps in an effort to create a mental health and addictions system that can truly meet the needs of people living with these conditions and their families. Mr. Lurie highlighted the government s proposed areas for improvement and investment are aligned with the recently released National Strategy for Mental Health and Addictions, Changing Directions, Changing Lives. He spoke of Ontario s Action Plan for Health Care, highlighting the priority on faster access and a stronger link to primary health care, as it is of particular importance for people living with a mental illness or substance abuse issue who need a coordinated care plan and help navigating the various parts of our system. 2
Mr. Lurie referenced successful programs in the Central LHIN that assist with patient flow both from of our hospitals and between community agencies including: the North York General Hospital and Humber River Regional Hospital Emergency Department Diversion Project, the York Support Services Network Mental Health Support Team and the Centralized Access Program. It was noted that each of these programs is based on partnerships established across sectors which resulted in developed models for collaboration and integrated service delivery. He noted that we need to build on these programs and encourage spread across the LHIN. Mr. Lurie encouraged participants to take advantage of the opportunity provided by this Collaborative to come together, to share their expertise, to challenge one another and to look for opportunities for creativity and innovation. Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department The first Collaborative speaker, Dr. Ian Dawe, Physician-in-Chief at Ontario Shores Centre for Mental Health Sciences and an Associate Professor in the Department of Psychiatry at the University of Toronto, discussed critical issues in the diagnoses and management of adult psychiatric patients in the emergency department. The framework for his discussion focused on the critical questions addressed in the clinical policies published by the American College of Emergency Physicians (ACEP) and endorsed by the American Association of Emergency Psychiatry, including: 1. What testing is necessary in order to determine medical stability in alert, cooperative patients with normal vital signs, a noncontributory history and physician examination and psychiatric symptoms? 2. Do the results of a urine drug screen for drugs of abuse affect management in alert, cooperative patients with normal vital signs, a noncontributory history and physical examination, and a psychiatric complaint? 3. Does an elevated alcohol level preclude the initiation of a psychiatric evaluation in alert, cooperative patients with normal vital signs and a noncontributory history and physician examination? 1 Dr. Dawe relayed that universal laboratory testing and drug screening was found to be of very low yield if a history, physical and vital signs screening was completed and clearly documented by the attending physician. Evidence has shown patients correctly self-reported alcohol use 95% of the time and drug use 91% of the time. 2 As a result, in adult ED patients with primary psychiatric complaints, diagnostic evaluation should be directed by the history and physician examination. Routine laboratory testing of should not be required as part of the ED assessment. Dr. Dawe also highlighted that clinical evidence found weak recommendations supporting the use of routine urine toxicological screens for drugs of abuse in alert, awake, cooperative patients, as it does not affect ED management and need not be performed as part of the ED assessment. Therefore, urine toxicological screens for drugs of abuse obtained in the ED for the use of the receiving psychiatric facility or service should not delay patient evaluation or transfer. 3
In addition, Dr. Dawe shared that there is no evidence-based data to support a specific blood alcohol concentration at which psychiatric evaluation can accurately commence, nor are there any studies that show that individuals regain adequate decision making capacity when the blood alcohol concentration reaches the legal limit for driving. The finding suggests that a patient s cognitive abilities, rather than a specific blood alcohol level, should be the basis on which clinicians begin the psychiatric assessment. Hospitals should consider using a period of observation to determine if psychiatric symptoms resolve as the episode of intoxication resolves. Based on the evidence published by the ACEP, St. Michael s Hospital Psychiatry-ED Collaborative developed a protocol to achieve greater consistency in the application and procedures of medical screening to minimize inappropriate placement, enhance the collaboration between psychiatry and emergency medicine departments, streamline the flow of psychiatric patients through the ED, avoid the use of unnecessary tests and procedures, and maximize the use of current medical directives and allow the timely initiation of applicable medical tests. The protocol includes a focus on symptom-based evaluation and focused medical assessment that includes: vital signs, a relevant medical history, a brief review of the systems, physical examination and mental status examination. The protocol has been deployed in both Toronto Central and the Central East LHINs. Organizing Emergency Services in Psychiatry: The University Health Network Experience The second speaker, Dr. Jodi Lofchy, Director of Psychiatric Emergency Services at the University Health Network (UHN) and an Associate Professor in the Department of Psychiatry at the University of Toronto, spoke about UHN s experience developing a short-stay unit in the emergency department for people seeking care for mental health and addictions. Dr. Lofchy posited that the key system components for psychiatry evaluation must take into account patient needs, including: a quiet environment, restraint, seclusion, and/or an environment free of potential hazards. At the same time, services should create an environment that allows people to feel there is hope from first contact through to treatment interventions. In 2005, in collaboration between the UHN Psychiatric Emergency Services (PES) and the ED, the Psychiatric Emergency Services Unit (PESU) was developed to create a comfortable environment physically situated in the Toronto Western Hospital (TWH) ED. The PESU is a safe, secure setting with the capacity for 8 patients, 4 stretchers, 2 loungers and 2 wait spaces. The unit has dedicated psychiatric nursing staff, psychiatry assistance, crisis clinicians and on-site resident and staff psychiatrists and supports team decision-making. Dr. Lofchy highlighted the impact of the PESU for patients presenting with a mental health and/or addictions complaint to be seen straight 4
from triage, resulting in the reduction wait times and decreased use of security. Since its implementation the PESU has: Increased the percentage that crises response times are under 2 hours from 64% (2004) to 82% (2012); Decreased the number of admissions in an environment where the hospital is seeing increased overall volumes; Decreased the average percentage of admits compared to the total patients seen from 38.6% (2004-2005) to 13.6% (2005-2012); and Reduced average patient length of stay from approximately 8 days in the 'holding unit' of the time (2005, prior to the implementation of the PESU) to 9.8 hours in 2011-2012 in the PESU. Throughout the development of the model, Dr. Lofchy found that communication was and continues to be key in maintaining and improving relationships between the ED and Psychiatry Emergency Services, as well as continued support from hospital administration. Enhancing the Police Response: York Regional Police Crisis Intervention Training The third presentation, delivered by Constable Mark Kowalchuck of the York Regional Police (YRP), outlined the YRP Crisis Intervention Team (CIT) training program which is designed to assist and educate police officers on how to respond to people in crisis. The CIT training is comprised of a 40 hour training week of educational sessions delivered by subject matter experts in partnership with local community resources and is designed to create an effective forum for problem solving between the law enforcement and mental health care system. In York Region, health service provider partners include Southlake Regional Health Centre, York Support Services Network and Ontario Shores Centre for Mental Health Services. YRP has committed to train all new Recruit Constables with the 40 hour comprehensive CIT training. To date 90 front line officers have completed the 40 hours of CIT training and all 1467 sworn officers have completed 4 hours of CIT training in YRP. The CIT program is designed to increase the knowledge of police officers to aid in identifying persons in crisis, identifying major psychiatric illnesses and disorders including childhood psychiatric and development disorders, understanding and interpreting the Mental Health Act, and to provide effective listening, negotiation and de-escalation techniques. Based on the Memphis Model which has widespread use in the United States CIT training is focused around improving the safety of the police, the community, the consumer and their families. Improving Triage: an Example from St. Joseph s Health Centre The fourth speaker was Dr. Marco Duic, currently the Chief of Emergency Medicine at Southlake Regional Health Centre and formerly the Chief of Emergency Medicine at St. Joseph s Health Centre Toronto. Dr. Duic discussed the care model used in the Emergency Mental Health Crisis & Intervention Program (EMHCIP) at St. Joseph s Health Centre (SJHC) in Toronto. 5
Dr. Duic highlighted that care begins at triage where one nurse responsible only for triage identifies patients presenting with mental health or substance abuse conditions and ensures those individuals go to the EMHCIP. Of the 97,203 patients presenting to the ED in 2011/12, 5,541 were sent to this crisis area. These include patients presenting with psychiatric illness exacerbations, substance abuse, delirium, dementia, and out-of-control behaviour; but excludes patients requiring an IV, oxygen, suction and those unable to walk. Care is delivered in a team based approach based on the principle of parallel processing where any of the EMHCIP staff could attend to the patient in any order (i.e. a crisis worker did not have to wait until the patient was seen by an emergency physician before providing care). SJHC found having a crisis area where patients could be cohorted allowed the hospital to: Use less security; Allow nursing to be more efficient; Reduce the opportunity for patients to provide any disturbance to the provision of care in other areas of the hospital; Reduce medical errors that may have occurred as a result of those interruptions; and Lower the cost of security. The EMHCIP is expected to have significantly lowered the admission rate and quick release of community resources including police officers. Dr. Duic stated that the optimal hospital environment for caring for patients with a mental health and/or substance abuse condition who are in crisis is within a secure area. SJHC observed this approach to be less expensive and that it promotes the creation of a healing environment is not possible in the conventional ED environment. Form 1: Common Myths and Mistakes The final presentation of the day was delivered by Dr. Howard Ovens, Director of Schwartz/Reisman Emergency Centre at Mount Sinai Hospital and an Associate Professor in the Department of Family and Community Medicine at the University of Toronto, who spoke to the common myths and mistakes related to the use of Form 1 in hospitals. His discussion included an overview of Ontario law as it applies to the ED and psychiatric services within Ontario hospitals, the clinical implications to be considered in the use of the Form 1, the proper completion of the form, as well as, supporting policies and tools. The perceived problems with the use of Form 1 include: too high of a threshold for certification, ensuring the form is properly completed, understanding of the nuances of the law as it pertains to the form, and the widespread myth that patients cannot be held or restrained unless they have been certified through the completion of a Form 1. 6
Dr. Ovens discussed the myth that lawsuits resulting from the application of Form 1 are commonplace; in fact they are rare, however actions based on the improper completion of the form more commonly occur. Common errors in completion include: a failure to complete the demographic information, failure to date and/or sign or inconsistent dating on the form, a failure to deliver the Form 42, and confusion over the boxes. A myth prevalent among staff including security, nurses and police, is that a Form 1 must be completed in order to prevent a patient from leaving the hospital. However, Dr. Ovens communicated that a large volume of common law experience upholds the rights of any citizen to act to prevent harm. Additionally, model observation policies approved or encouraged by bodies such as the Healthcare Insurance Reciprocal of Canada and the Ontario Hospital Association require only an order to security from any nurse or physician for someone to be kept on premises. A Form 1 should only be applied where a psychiatric assessment is required; it is not needed to restrain patients from leaving hospital who are confused or demonstrate a lack of competence due to medical conditions. Dr. Ovens stressed that hospitals should ensure front line staff know that if a patient comes in who might be a danger to themselves or others, they should call security first, and it is security s responsibility to stay with that patient until the doctor cancels the watch. In summary Dr. Ovens suggested: that hospitals and front line staff need to be aware of the law as it applies to their practice, the threshold for Form 1 certification should be placed appropriately low, there should be careful attention to the proper completion of forms, hospital policies should be supportive of utilizing security for patient observation, and that organizations should place appropriate attention to ancillary features including design, surveillance and quality assurance. To aid any hospitals interested in improving their processes related to use of Form 1, Dr. Ovens has made available a Template Handover Protocol for Patients Brought to ER by Police and a document outlining Form 1 Completion Guidelines. These resources, in addition to all speaker presentations, can be found on the Central LHIN website. 3,4 GOING FORWARD The Improving Flow in the Emergency Department for Mental Health and Addiction Services Quality Collaborative was an important step in foster inter and intra-organizational multidisciplinary collaboration to identify organizational and system-level opportunities for improving ED mental health and addiction services in Central LHIN. Follow-up discussions through the Emergency Department Work Group, Central LHIN Chiefs of Psychiatry/Directors of Mental Health and directly with our hospitals will focus on opportunities to implement some of these changes, including immediate, short and longer-term actions. 7
As a key next step, and as informed by the Collaborative feedback/discussion, Central LHIN proposes leverage its current structures and bring the collaborative findings back to Central LHIN Chiefs of ED and Psychiatry to encourage the appropriate consideration of what findings could be appropriate for implementation at their organization, and to discuss joint-implementation opportunities for common initiatives. This report is a component of the Central LHIN Quality Action Plan. In addition to being shared with all Collaborative participants, the final report will be provided to other key stakeholders and will also be posted on the Central LHIN website with the speaker s presentations. EVALUATION An evaluation survey was distributed to all participants to gather their perspectives and feedback on how to improve future engagement sessions. Evaluation feedback showed strong support for the Collaborative model, with the majority of participants indicating that it provided value for the health service providers in attendance, and a request for the LHIN to facilitate more similarly structured sessions. REFERENCES 1 Lukens, Thomas W., et al. "Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department." Ann Emerg Med, 2006; 47: 79-99. 2 Olshaker JS, et al. "Medical clearance and screening of psychiatric patients in the emergency department." Acad Emerg Med, 1997;4:124-128. 3 Ovens, Howard. 2012. Template: Handover Protocol for Patients Brought to ED by Police. http://www.centrallhin.on.ca/uploadedfiles/public_community/engaging_our_communities/past_engage ment_events/h%20ovens-template%20handover%20protocol%20for%20patients%20brought%20to %20ER%20by%20Police.pdf 4 Ovens, Howard. 2012. Form 1 Completion Guidelines. http://www.centrallhin.on.ca/uploadedfiles/public_community/engaging_our_communities/past_engage ment_events/h%20ovens_form%201%20completion%20guidelines.pdf 8