The presenters have nothing to disclose Transforming Emergency Psychiatry Karen Murrell, MD, MBA, FACEP Physician Lead-Emergency Medicine, Kaiser Northern California Assistant Physician in Chief- Hospital Operations, ED, Psychiatry/Process Improvement Kaiser South Sacramento Dec 2016 Orlando, FL How can we provide the same world class care to patients with psychiatric disorders? 1
Facts There is wide variation in the care being delivered in Emergency Departments nationwide Currently there are not enough inpatient psychiatric beds nationally Question? Why is a patient with a psychiatric disorder different than a patient with pneumonia or chest pain? (c) Murrell 2015 2
Patient #1 70 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. Patient #1 Found out he was a famous professor in his earlier life and 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? 3
Patient #2 A 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? Patient #2 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 and eating. Why did it take 24 hours to start treatment? 4
Treatment Goals of Emergency Psychiatry 9 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. New Paradigm Rapid assessment by medical and behavioral health teams Active treatment in the ED Medications Focused medical clearance Case Management Therapy (to the point- med compliance, substance abuse) Goal setting Reassessment by the team Discharge safely when possible 5
Medications Main goal is to alleviate the patients symptoms. The vast majority of patients will benefit from early medication administration. ED MD to start first dose of medications Psychiatrist to provide nuanced recommendations if patients are boarding Always use the least restrictive method- oral medications if possible before IM medications. Metric: door to medication administration Medication Recommendations Start patient meds if available but at lowest dose in case of noncompliance. Work with your psychiatrists to get medication recommendations. Set the standard that it should be the exception to not give medications. 6
Example of Medication Recommendations (c) Murrell 2015 Steps to Wellness Jensen, Murrell, Crane, Nolan, Balan 7
Pearls Medications much more important than lab tests unless you suspect a medical condition is causing psychiatric symptoms. If any questions about medications, call the psychiatrist on call. Don t delay psychiatry consultation while waiting for labs. Goal Drivers Focus Areas Key Initiatives Metrics Create a standard pathway for patients with psychiatric needs that present to the ED Initial assessment Ongoing treatment Reassessment Standards of care Communication (provider to provider; provider to patient; provider to family) Improve ED care for patients with behavioral health conditions while managing the impact on our EDs Highest quality care Training and Education Continuum of care Environment of care Clearly defined roles and responsibilities across the standard pathway Appropriate staffing for all roles Patient care training (Physicians, nurses, techs) De-escalation training To patients (resource utilization and treatment in ED) Outpatient Home Intensive case management Inpatient Crisis residential Detox residential placement The right care at the right time Call center Technology Communication strategy Transparency = focus area Demand capacity (community assessment) Inpatient psych beds Crisis residential Outpatient appointments Government relations liaison 16 8
Continuity of Care Along the System Establish clear metrics that reflect the continuum of care Hospitalization Percentage Length of stay in the ED for discharged patients (including d/c disposition: inpatient, crisis residential, home, etc) Decreased inpatient hospital length of stay after ED treatment Increase billing by payer mix considering observation time Time to consultation Readmission to ED Patient satisfaction Quality of care Impact on Quality Immediate medical care and alleviation of symptoms Collaboration between providers Safer work environment Decreased medical-legal risk Least restrictive modality of treatment for the patients 9
Deconstructing Stereotypes Leadership will be key Cultural change in our ED s emphasizing care and compassion using the same principles used for medical patients Changing the ED Culture 10
Thank you! 11