The ED at St. Joseph Hospital in Chicago has implemented a two-pronged approach aimed at improving the way behavioral health patients are managed. This includes a new risk-stratification process that categorizes patients as low-, moderate-, or high-risk based on their diagnosis, and also promotes using newer-generation antipsychotic drugs.
• The provider determines the risk level designation, driving what resources are brought to bear for the patient going forward.
• Typically, low-risk patients only require a physician intervention, while moderate-risk and high-risk patients require a crisis worker intervention.
• The newer-generation medications can be taken orally, and are less sedating than first-generation drugs, enabling providers to perform patient assessments faster.
• These tactics have shortened ED lengths of stays for low-risk patients. Also, administrators have documented a dramatic increase in the use of newer-generation antipsychotic drugs.
For a long time, Meghan Stahulak, DO, medical director of emergency services at St. Joseph Hospital in Chicago, believed there was something amiss in the way behavioral health patients were managed in emergency departments (EDs). “They are overprocessed, they are overmedicated, and they end up waiting a long time,” she says.
Consequently, when Stahulak’s ED took the opportunity to implement a new screening process for behavioral health patients, she was fully onboard. “The key for us is that 10% of our volume is psychiatric patients. We just wanted to try and streamline the way that we were risk-stratifying them, and then also provide them with better, less-sedating medications when they were agitated,” she explains.
Beginning in January 2019, the new approach was put into place at St. Joseph as part of a six-month pilot project, producing positive results. This included shorter lengths of stay in the ED among behavioral health patients deemed low risk and better prescribing practices with respect to a targeted group of psychiatric medications.
Today, the system is firmly ingrained into the way the ED operates, even as more improvements are in development.
Clinicians use a matrix to stratify behavioral health patients into low-, moderate-, and high-risk categories based on their diagnosis. The basic idea is that not every behavioral health patient needs to be treated the same. Risk-stratification puts each patient on a pathway that is most appropriate for his or her needs.
For instance, if a patient suffering from anxiety presents to the ED because he has run out of his medicine and cannot see his therapist, it is unlikely that patient requires an extensive workup, Stahulak explains.
“If the patient doesn’t feel like harming himself, he doesn’t feel that his life is out of control, and his anxiety is not impairing his day-to-day living, he is low risk,” she says. “[Low-risk] patients don’t need blood work, and they don’t need to be medically cleared because they are not going to be admitted to the hospital.”
A moderate-risk case might involve a patient who is depressed, perhaps because he lost his job or is grieving the loss of a loved one. “There might be a situational component to the patient’s depression, and it might be remedied by making an appointment for him to see a therapist the next day,” Stahulak offers. “This patient requires a little bit more intensive evaluation than a low-risk patient.”
Then there is the case of a patient who is thinking about ending her life. “Automatically, that puts [someone] into a high-risk category,” Stahulak notes. Such patients will require the most attention and resources, and they may need to be admitted.
While a triage nurse will identify that a patient has presented with a behavioral health issue, it is the medical provider who will evaluate the patient and determine the risk category accordingly, Stahulak explains.
In most cases, a low-risk patient will not require any added resources beyond the physician intervention. However, a crisis worker, usually a master’s-level social worker or licensed clinical counselor, may speak with both moderate- and high-risk patients. “The intake worker acts as a liaison for us [with] our psychiatric floor, as well as the psychiatrist to help with service planning, whether this involves follow-up the next day or admission to the hospital,” Stahulak observes.
Notably, the intake workers are available in the ED 24/7, and they already were on staff before the new system was implemented. No new staff members were required. “We just used what resources we already had in the department,” Stahulak adds.
Nurses have played a strong role, too, working alongside the providers when they perform their assessments, and following through on patients who will be discharged, observes Steve Meier, MS, RN-BC, manager of nursing operations in the ED at St. Joseph Hospital. “We make sure there is a safe discharge plan from a nursing perspective,” he explains.
While working on risk-stratification, St. Joseph staff also shifted prescribing practices toward newer-generation psychiatric medications that do not just put people to sleep.
“When you just knock people out for a couple of hours, you can’t really assess them in a timely fashion,” Stahulak observes.
Consequently, to bring clinicians up to speed on the benefits of new medications, Stahulak and colleagues disseminated articles and research on the issue. “We had some input from pharmacy and from ED physicians who were more familiar with using the newer drugs to answer any of the questions the physicians may have,” Stahulak explains. “Any time you are asking people to change their practice habits, there are going to be questions. It is great to have that dialogue.”
Meier agrees, adding this is where nurses can be particularly helpful in ensuring physicians have all the information they need to guide their assessment and prescribing.
“Nurses are spending a lot more time at the bedside than the physician is during the initial assessment. [Nurses] are able to hone in on those very subtle cues that a patient might be agitating,” he explains. In some cases, the early identification of such signs can lead to prompt use of gentler oral medications as opposed to heavy sedative injections.
“Once a patient has reached 100% velocity, it is hard to offer them an oral medication,” Meier continues. “The nurse ... will assess the patient on an ongoing basis as well as reassess to make sure that any medications have impacted the patient appropriately.”
Following some initial education and open dialog about the new drugs, ED staff tracked the usage of both the older and newer medicines, comparing usage patterns from before the initiative was implemented to patterns in place following implementation.
“We saw a big change [following the implementation],” Stahulak reports. “We saw that 93% of the time, the second-generation antipsychotics were being used, which was a huge improvement. Before the implementation, [the newer drugs] were being used only 18% to 20% of the time.”
Stahulak acknowledges that as a small ED that sees only about 20,000 patients per year, St. Joseph physicians and nurses form a close-knit group that generally is open to fresh ideas. Thus, implementation went smoothly, although compliance was not 100% at first.
Stahulak notes there were one or two people who lagged behind other clinicians in dispensing the updated medicines. However, leaders continuously monitored the data so they could intervene in those cases. “If we saw trends like that, we would go and talk to those physicians, and ask if they had any additional questions,” Stahulak explains.
Early data show the initiative is making a difference on patient flow, too, particularly regarding the time low-risk people spend in the ED. “Before we did the project, they were in the ED around 114 minutes ... but after [implementation], we got the in-and-out time for the low-risk patients down to about 73 minutes,” Stahulak says.
Among the patients categorized as moderate-risk, there was about a 50/50 split in patients who were admitted vs. those who were discharged, Stahulak observes. For those who were discharged, the updated process shaved about 10 minutes off the time they spent in the ED. “A lot of the moderate-risk patients end up requiring blood work, which adds to their length of stay,” Stahulak notes.
To accelerate the time-to-treatment for behavioral health patients who require admission, Amita Health, the system that operates St. Joseph and more than a dozen other hospitals in the Chicago region, is developing an online hub to make it easier for facilities to locate an open behavioral health bed within the system. “All the psychiatric units are ... sharing what beds they have available. If our psychiatric unit is full, or if you are in a different ED that doesn’t have a psychiatric floor in your hospital, you can figure out where in the system you can send a patient for a psychiatric admission,” Stahulak shares.
This hub will be phased in with the gradual participation of additional hospitals and enhanced capabilities. “As we get rolled into this whole process, it has helped us in getting beds and in moving patients out of our ED and into the right place for them,” Stahulak says.
For those struggling with similar problems, Stahulak recommends gathering key stakeholders and mapping an action plan for change. The more staff who can engage in the project, the better the solution will be. “Getting nurse champions and a physician lead other than myself [involved], and getting the psychiatric folks on board and aware that we are changing some processes in the ED, was really huge for us,” Stahulak says. “That just helps you lay the groundwork for having a good, cohesive team to deal with any issues that are inevitably going to come up any time you make a process change.”
Meier echoes these sentiments, stressing the importance of a supportive culture. “All the players need to be on board. You can’t have any bad apples or sour grapes heading into a new process,” he stresses. “You need to have everyone on the same page supporting the process. That includes everyone from the housekeeper who works in the ED to the ED physicians. Everyone is integral to making sure the ED is a safe environment.”