Method of Participation: To earn AMA PRA Category 1 Credit™
- Complete the post-test and evaluation (Note: A score of at least 80% must be achieved to earn CME credit)
- Participate in the discussion/debate thread about specific articles
- Process your online payment of $10 (fees are non-refundable).
- A certificate of attendance will be forwarded within 4 to 6 weeks of participation
Release Date: May 9, 2013
Expiration Date: May 9, 2014Estimated Time of Completion: 1 hour
Fee: This CME activity costs $10, payable by credit card at the completion of the activity. Fees are non-refundable.
The Center for Emergency Medical Education (CEME) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The Center for Emergency Medical Education (CEME) designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
This activity is designed for emergency medicine physicians and other health care providers interested in the treatment of patients with cardiopulmonary arrest.
The Center for Emergency Medical Education (CEME) offers a one-credit content-specific posttest and evaluation based on an article in the Emergency Physicians Monthly magazine as each issue is published.
Disclosure of Faculty Financial Interests or Relationships:
It is the policy of Center for Emergency Medical Education (CEME) to insure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities, and that all contributors present information in an objective, unbiased manner without endorsement or criticism of specific products or services and that the relationships that contributors disclose will not influence their contributions. In accordance with the Standards for Commercial Support issued by the Accreditation Council for Continuing Medical Education (ACCME), the Center for Emergency Medical Education (CEME) requires resolution of all faculty conflicts of interest to ensure CME activities are free of commercial bias. Those involved in the planning and teaching of this activity are required to disclose to the audience any relevant financial interest or other relationship.
All faculty, planners, and staff in a position to control the content of this CME activity have indicated that he/she has no relationship, which, in the context of the article, could be perceived as a potential conflict of interest:
Kevin M. Klauer, DO, FACEP, Director, CEME
Logan Plaster, Editor/Creative Director, Emergency Physicians Monthly
Ginger Brake, CEME Program Coordinator
Participants must have access to the Internet:
CEME Program Coordinator
Emergency Medicine Physicians
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STEP 2: READ THE ARTICLE
STEP 3: TAKE THE QUIZ
STEP 4: PROCESS PAYMENT
After evaluating this article, participants will be able to:
1. Understand the current issues associated with mental health patients that present to the Emergency Department
2. Incorporate into practice strategies to appropriately risk stratify patients for suicide risk
3. Develop mechanisms to more appropriately utilize mental health resources
The ED is increasingly serving as the gateway for mental health crises. Here are four strategies for reducing psych patient boarding and getting your mental health patients where they need to go faster.
The last 40 years have seen enormous changes in the way the healthcare system handles psychiatric patients. The first shift transitioned psych patients from the inpatient to the outpatient setting, which led to a reduction in the number of available inpatient psychiatric beds. The total number of inpatient psych beds has decreased by 62% since 1970 and the total number of state and county beds decreased by 89%. The increase in outpatient psych cases coincided with the closure of many community mental health facilities and other outpatient resources. Not surprisingly, as these resources became more and more limited, these patients found their way to the one place that will still accept them, any hour, day or night – the emergency department. The result is a critical lack of psychiatric beds in the ED, which has led to a patient boarding dilemma.
Psych Patients in the ED: A Growing Population
Dealing with psychiatric patients in the emergency department is a challenge even when we aren’t overburdened, but the system is bursting at the seams. The number of psychiatric patients seen in the emergency department in the country is reported at 53 million mental health-related visits per year. This number has been increasing in the last few years, growing from 4.9% in 1992 to 6.3% in 2001. The diagnoses are primarily substance use disorders, mood disorders and anxiety-related disorders. This burden is also found in the pediatric population where 1.6% of pediatric emergency patients present with mental illness; 20% of these are admitted. The diagnoses include substance use disorder, anxiety disorder, attention deficit and disruptive disorder and psychosis.
The closures in inpatient and outpatient facilities have resulted in increased usage of the ED, which in turn has resulted in an increase in the practice of boarding psychiatric patients. The burden of boarding psychiatric patients in the ED is illustrated by two recent studies. In one study of ED administrators, it was found that 86% of the administrators surveyed indicated they are often unable to transfer patients. 70% of those ED administrators report boarding psychiatric patients longer than 24 hours and 10% report they board psychiatric patients in their ED longer than one week. Clearly, when you board psych patients in the ED, especially patients who spend long periods of time in the ED, it reduces the number of available beds for other patients. In another study, 67% of emergency physicians in California reported decreases in the number of psychiatric beds. 23% of these ED directors reported sending patients home without seeing a mental health worker primarily due to a lack of resources. The lack of psychiatric services is most critical in rural hospitals.
As we are all well aware, EDs are not the ideal place for patients that have prolonged boarding times, especially psychiatric patients. And yet, studies have found that psychiatric patients spend a longer time boarding in EDs than medical boarders. To make matters worse, these patients may spend hours or days in the ED without an appropriate psychiatric evaluation, treatment plans, medications and therapy.
The general lack of psychiatric facilities is compounded by the fact that too often the emergency department is used as a fail safe mechanism. Police, group homes, nursing homes and families frequently send patients to the ED rather than resolving the issue of conflict on site. Instead of using community mental health workers, social workers or psychiatrists to assist in resolution of their conflict, patients are sent to the ED. This places the ED in the difficult situation of having to not only determine how a patient’s mental illness affects their response to conflict, but also intercede in the conflict and to determine the patient’s need for psychiatric admission.
Strategies for Psych Boarding
1. Early deflection of psych cases through telemedicine and outreach
There are things that we can do to resolve this predicament. The key is to deflect patients from the ED that are inappropriate for the emergency department, properly determine the need for admission and provide treatment while they’re in the ED.
Deflection of psychiatric patients from the ED works similarly to medical patients who use the ED for medication refills or chronic complaints. The difference – and the added complexity – for psychiatric patients is the difficulty the patient has in knowing whether or not they need to be seen. That’s where tele-psychiatry, mobile crisis units, crisis call-in centers and law enforcement can come into play. Through tele-psychiatry, patients can be properly evaluated to determine the need for admission, which is useful in communities that lack appropriate psychiatric resources. Tele-psychiatry has been found to have a high rate of provider and patient satisfaction, can be used for a variety of diagnoses and complaints, and can be used for consultations, diagnostic assessments, medication management and family inpatient psychotherapy. Unfortunately, tele-psychiatry use has not been well studied in the emergency setting.
Mobile crisis units can be called for patients with chronic mental illness who are having a crisis. These teams go out to the patient’s home to counsel the patient and family and to determine whether the patient needs hospitalization, referral or consultation with a psychiatrist. Many psychiatric emergency services have a call-in center for patients with mental illness that may or may not be connected to mobile crisis units.
Law enforcement outreach has been utilized for psychiatric assessment in counties in Texas. In this model the police, mental health worker, psychiatrists and emergency department work together to determine whether a patient needs to be seen in an ED or whether other services can be determined at the scene.
2. Improve your psych admission criteria
It is important that appropriate criteria for admission is used for psychiatric patients rather than admitting every patient with the psychiatric complaint that presents to the ED. In emergency medicine, we use limited criteria to determine who needs to be admitted, but there are few studies that attempt to set admission criteria for psychiatric patients in the ED. One study looked at 10 psychiatric emergency departments in New York. The study found, using a regression model, that 87% of cases needed to be admitted. These factors included severity of mental illness, dangerous behavior, the hospital the patient presented to, current psychosis, diagnosis of major psychiatric illness and assaultive behavior. Another tool used is a decision-support tool with the criteria of suicide potential, danger to others and severity of symptoms. The third model that is commonly used scores patients in three categories: dangerousness, support system and inability to cooperate.
3. Understand the spectrum of suicide risk and handle cases individually
In emergency medicine, we tend to admit all patients who mention that they are suicidal. However, not all of these patients need to be admitted. A common example is an adolescent who has a fight with his or her boyfriend and uses a suicide gesture to modify their behavior. It is preferred to use dynamic and static factors to determine the suicidal risk. Static risk factors do not change over time and are based on historical factors. Static factors include mental illness, addictive illness, personality disorder, advance age, male gender, prior suicide attempts, family history of completed suicide, newly diagnosed medical illness and LGBT youth. Dynamic risk factors are current, changing and are important in imminent outcomes.
It is easy to decide who has a high risk. For instance, those that have used lethal means, didn’t want to be found, have a chronic psychiatric illness and a family history of psychiatric illness. It’s also appropriate to get a psychiatric consultation for those patients that are found to be in the medium risk group. The low risk group is the one where emergency physicians can consider sending home. If the decision is made to send this patient home, key components in this decision must be arranged and documented. These components include follow up within 2 or 3 days, removal of lethal means, observation by a reliable person and a crisis plan.
4. Start psychotropic therapies in the ED
The last way to deal with psychiatric boarders in the emergency department is to start therapy while they’re in the ED. Many chronic psychiatric patients who stopped their medication can get back on track with their medications while in the ED. Within hours to a few days, these patients can actually be sent home. Emergency physicians need to feel comfortable prescribing psychotropic medications for patients who have been on these drugs. Tele-psychiatry and consultation liaison services can assist in the determination of appropriate medications when patients have new psychiatric diagnoses, complex treatment needs or adverse reactions to the medications they were prescribed.
Whether we like it or not, emergency medicine is facing an increased burden to care for psychiatric patients. This burden is made worse by the fact that many of these patients spend an inordinate amount of time in the ED. This is another instance where our duties and responsibilities have expanded. We need to work to see that patients are sent to the right place initially, that the right patients are admitted, and we need to develop a comfort level with medicating psychiatric patients in the ED.
Although Accountable Care Organizations will provide funding for those with chronic mental illness, it will not put enough pressure on hospitals to increase their psychiatric bed capacity. Rather, the ACOs will be looking for alternatives to admission. Alternatives to admission include ED interventions, observation care for psychiatric patients, short stay units and acute stabilization units. The opportunity for emergency medicine is to establish acute stabilization units in the ED in collaboration with psychiatry. These units will provide the opportunity to clarify the diagnosis, provide crisis management, restart and start psychotropic medications and ensure connection to outpatient psychiatric services.For more information on a conference on behavioral emergencies and psychiatric boarders go to www.behavioralemergencies.com
ReferencesAlakeson, V, Pande, N, Ludwig, M: A plan to reduce emergency room boarding of psychiatry. Health Affairs. 2009;9:1637-1642
Baraff LJ, Janowicz, NA: Survey of California emergency departments about practices for management of suicidal patients and resources available for their care. Ann Emerg Med. 2006 Oct;48(4):452-8, 458.e1-2. Epub 2006 Aug 21.
Bengelsdorf, H, et al: A crisis triage rating scale: brief dispositional assessment of patients at risk for hospitalization. J Nerv Mental Disease 1984;172:424-430.
Breslow, RE, Klinger, BI, Erickson, BJ: Crisis hospitalization on a psychiatric emergency service. Gen Hosp Psych 1983:15:307-315.
Kennedy, SP: Emergency department management of suicidal adolescents. Ann Emerg Med 2004;43:452-480.
Shre, JH, Hilty, DM, Yellowlees, P: Emergency management guidelines for telepsychiatry. Gen Hosp Psych 2007:29:199-206.
Sills, MR, Bland, SD: Summary statistics for pediatric psychiatric visits to US emergency departments, 1993-1999. Pediatrics 2002;110; 1-5.
Way, BB, Evans, ME, Banks, SM: Factors predicting referral to inpatient or outpatient treatment form psychiatric emergency services. Hosp Commun Psych 1992;43:703-708.
STEP 3: TAKE THE QUIZ
STEP 4: PROCESS PAYMENT