Emergency rooms devising safer ways to treat behavioral health patients
Matt is a 27-year-old with a good education, a promising job history and — on this particular afternoon — a heroin overdose that has sent him to the emergency room.
His distressed parents, who called 911 when they found him unconscious, tell hospital workers that Matt has bipolar disorder. The disease was well-controlled until he was hurt in an auto accident some months earlier. He became dependent on prescription pain killers and soon switched to heroin because it was cheaper and easier to buy.
After the accident, Matt’s life fell apart. He stopped taking his medications, was fired for threatening his boss, and moved back with his parents, who are now scared of him because he has threatened them (though he’s never hurt anyone).
A shot of naloxone awakens Matt from his overdose. Two hours later, alert and agitated, he refuses the hospital’s offer to transfer him to a detoxification program. He gets into a shouting argument with his father, frightening other patients and staffers in the emergency department, and stalks out alone — presumably to find a new fix.
Major threat to safety
“Matt” is a composite figure drawn from several cases described by Massachusetts health professionals that illustrate the challenges emergency departments face treating a growing number of patients with behavioral issues that stem from a combination of psychiatric illness and opioid addiction.
Emergency departments (EDs) are on the front lines of this challenge, which strains their resources and makes it harder to serve other patients.
The problem also poses a huge patient safety risk. The ECRI Institute, a national organization that examines safety, quality, and cost-effectiveness in healthcare, identified the problem of “inadequate management of behavioral health issues in non-behavioral-health settings” as among the top 10 threats to patient safety for 2016. The Institute describes the behavior as “frightening or frustrating for the staff, especially if they are ill-equipped to handle them,” and added that it “can lead to injury or even death of patients or staff.”
The problem has led to the testing of new models at community hospitals like Beth Israel Deaconess Hospital-Plymouth and Holyoke Medical Center aimed at improving health care quality for patients as well as the safety of staff members.
Emergency room physician Dr. Peter Smulowitz and social worker Sarah Cloud of BID-Plymouth provide counseling to emergency room patients who have behavioral health issues.
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An unforeseen crisis
Patients like Matt used to be relatively rare. But with the opioid epidemic — which has tripled the number of fatal overdoses statewide in the past dozen years — more and more EDs see several such patients weekly.
Many have multiple behavioral disorders. “That makes the case more complicated to treat,” says Sarah A. Cloud, LICSW, director of social work at BID-Plymouth, “just as if you had a person with heart disease, COPD [chronic obstructive pulmonary disease] and diabetes all at once.”
Sometimes, the patients are there against their will, so they are suspicious and resistant. A few must be restrained to be examined. And if the hospital or police need a court order to compel treatment, the laws are complex and differ depending on whether the person has a psychiatric or substance use disorder.
Some patients use the ED so often they begin to consider it their “medical home,” says Connie Clarke, MS MPH APRN, of the BID-Plymouth team. “They get criticized for recidivism [repeat visits],” she says. “But in fact we should not judge them. They should feel welcome to return, because that’s often a first step in motivating them to seek help.”
But finding the proper follow-up care is tough. And then there is the powerful stigma attached to both addiction and mental illness. As Clarke explains it, if a cancer patient who had chemotherapy came back with a recurring tumor, no one would blame the patient. But if a patient struggling with addiction who was sent to detox wound up back in the ED with an overdose a month or two later, he or she could face powerful shame.
Massachusetts psychiatric and detox facilities are so in demand that patients who do agree to treatment may have to “board” for several days in the ED, which drives up health care costs.
Melissa Perry, RN, director of Behavioral Health Nursing at Holyoke Medical Center says improved behavioral care in the emergency department has cut the need for restraints and helped get more patients into treatment.
State grants fund solution
For those and other reasons, community hospitals on the front lines of the epidemic need help improving outcomes for patients like Matt. BID-Plymouth and Holyoke Medical Center are using funding from the state's Community Hospital Acceleration, Revitalization & Transformation (CHART) Investment Program to expand behavioral health treatment. At their core, these efforts involve embedding behavioral health specialists in emergency departments and following up with patients in the community after their stay.
In Plymouth, for example, a $3.7 million CHART grant helped fund a special ED team consisting of a psychiatrist, a behavioral nurse practitioner, and social and community health workers. They get involved immediately when someone like Matt comes in.
“It’s like having any other medical specialists available,” says Cloud. “The rest of the staff appreciates it because we can navigate that part of the treatment.”
The grant also funded a similar team to support BID-Plymouth’s primary care settings, and a third to work with patients in the community.
Holyoke Medical Center used a portion of its $3.9 million grant to hire similar ED- and community-focused teams, says Melissa E. Perry, RN, Director of Behavioral Health Nursing.
The teams work within the ED and in nearby areas of the hospital. But in June of next year, the hospital will open a new emergency department (see the architectural drawing below) that includes a CHART-funded six-bed, six-recliner behavioral health unit. The CHART funding has also been used to fund a special clinic to care for behavioral health patients who are frequent visitors to the ED.
An architect’s sketch of Holyoke Medical Center’s new Emergency Department, slated to open next summer. The ED will include a six-bed, six-recliner behavioral health unit funded by CHART.
Both units will deliver care to such patients more effectively and economically than the ED could alone, serving across the continuum of care from the ED to the community, while also serving as a bridge to follow-up care at specificity facilities and other community-based resources.
The behavioral health team has already made a difference in the emergency room.
“We’ve been able to able to cut the use of restraints by two-thirds while helping prevent ‘elopements,’ meaning people who run away from care,” says Perry. “We still occasionally have patients who walk out the door, but at least there’s someone there who can go out and persuade them to come back.”
Rewarding results
Encouraging statistics notwithstanding, both Holyoke and Plymouth behavioral health specialists caution that there are no quick fixes. “Integrating behavioral health into other medicine requires changing cultures,” Clarke says, “and so the change in outcomes will be slow."
As Nancy Napolitano, a patient safety analyst at the ECRI, noted: “All staff need to be trained to work with patients with behavioral health needs and participate in frequent drills. It is important to be proactive versus reactive to these cases.”
Within 48 hours of discharge, a BID-Plymouth staffer pays a home visit to any patients with addictions who declined follow-up care after emergency room treatment. Sarah Cloud, LICSW, the hospital’s director of social work (center), is accompanied by Melissa Elliott, a detective on the street crimes unit of the Plymouth Police Department (right), who helps offer support.
Yet the individual success stories can be rewarding.
The Holyoke team, for instance, was recently able to find 24-hour supervised care for a mentally compromised young woman who had become a frequent emergency room visitor because of repeat episodes of self-harm, Perry said.
And at Plymouth, Cloud recently found help for a young man, not too different from Matt, who had overdosed twice and repeatedly refused detox.
“Two weeks later, I was sitting on the couch at his mother’s home when he agreed to go into a medication-assisted treatment program,” she says. “Now the mother, the provider, and everybody else are trying to wrap around this young person to get him going down that road of recovery.”
Coping with the influx of emergency department patients who have both substance use and psychiatric disorders and who require urgent overdose care, boarding time, and a broad range of support services.
The Data
Largely as a result of the opioid crisis, the number of ED patients in Massachusetts requiring dual treatment for addiction and psychiatric or behavioral disorders has nearly tripled in the last decade.
The Providers
Holyoke Medical Center; Beth Israel Deaconess Hospital-Plymouth.
The Takeaway
Embedding behavioral nurse practitioners, social workers, and addiction specialists in emergency departments is cutting down on repeat overdose and psychiatric cases, freeing doctors and nurses to tend to other crises, and contributing to greater patient and staff safety.
