Throughout the United States, individuals with mental health conditions or substance use disorders frequently present to the hospital emergency department (ED) for care, yet many ED teams lack the capacity to adequately support them. Recognizing these challenges, the Maine Medical Center (MaineHealth) in Portland, Maine, streamlined processes and created protocols to improve the quality of their care. They also worked with community partners to better understand and strengthen their respective roles in support of patients and families. The following is an excerpt from Improvement Stories: Improving Behavioral Health Care in the Emergency Department and Upstream.
Like many US health systems, MaineHealth has been struggling to care for the growing number of patients with mental health issues who come to their emergency department (ED). The ED team wanted to make sure that these patients were receiving the same quality care as every other patient. “The fact that it’s a behavioral health patient shouldn’t make a difference,” said Nancy Goudey, RN, Manager of Emergency Services at MaineHealth.
While participating in the ED & UP Learning Community [convened by IHI in partnership with the Well Being Trust], the team introduced changes in multiple key areas. One major effort involved standardizing and streamlining ED processes for patients with mental health conditions and substance use disorders. With an ED staff of several hundred, the team realized it was crucial to clarify policies and protocols (e.g., the protocol for a suicidal patient, from door to discharge, and for patients who are in the ED longer-term). As a result, the ED team established guidelines for behavioral health programming for children and adolescents staying for prolonged periods in the ED; standardized an ED clinical pathway for patients with psychotic disorders; and developed ED protocols for ligature risk reduction.
It wasn’t enough to merely establish these new ED policies and protocols. The team also had to work continually to disseminate and reinforce them among ED staff using a variety of channels: written forms, orientation tools, and training. “We highlighted it in staff meetings and through individual supervision,” said Goudey.
One specific new protocol the team tested was interdisciplinary rounds for behavioral health patients in the ED. Initially, rounds were conducted twice daily, at 8:30 AM and 6:00 PM. All relevant staff members were expected to huddle in one designated location, to share information about each behavioral health patient in the ED. However, the team quickly discovered that the 6:00 PM rounds did not work as planned because, at that time of evening, shift changes occur and the ED is typically at its busiest and most chaotic. The 8:30 AM rounds, however, were successful. As a result, the team decided to conduct rounds once per day, in the morning only.
The ED team also worked with community partners, to educate them about what the ED can and can’t do for patients with mental health conditions and substance use disorders; to communicate about their respective roles in supporting these patients; and to identify ways they might collaborate. In-person meetings were especially helpful, to enable staff to put faces to the names and feel more comfortable reaching out afterward.
In particular, the ED team has a longstanding partnership with Opportunity Alliance (OA), a mobile crisis team for Maine’s Cumberland County. For years, the medical center’s ED has referred patients to OA in “warm handoffs.” Together, they developed a one-page referral form that includes the patient’s name, the reason for the patient coming to the ED, and what post-discharge support the ED is seeking for OA to provide the patient. Following ED discharge and handoff to OA, the OA team follows up with the patient. According to Maria Long, Manager of Hospital Social Work Services in the Department of Psychiatry, during the Learning Community the ED team worked with OA to ensure that patients referred from the ED to OA were a good fit for OA’s services. This project reinforced the value of their partnership and reminded ED staff members of the option to deploy warm handoffs.
One patient’s experience illustrates the success of all of these changes. “Jordan,” a 23-year-old man with schizophrenia who lives in a residential treatment facility, came to the ED for the third time in a month as a result of treatment non-adherence, exacerbation of psychosis, and behavioral dysregulation. He has a history of difficult inpatient stays, often requiring use of restraints and seclusion. This time, when he arrived at the ED, the care team implemented the psychosis treatment pathway and order set and was able to initiate treatment early in his stay. The patient’s behavioral health plan was discussed by the interdisciplinary team during morning rounds. He did not require restraints or seclusion during his stay. The patient stayed in the ED for four days and then the ED team completed a warm handoff to OA.
More broadly, the changes have resulted in impressive progress. The ED process standardization and streamlining have led to smoother operations. “There’s a lot less question among ED staff about who’s doing what and when,” Goudey noted. “That’s improving patient flow. I think patients are happier.” From 2018 to 2019, during the ED’s participation in the Learning Community, the average length of stay for mental health patients in the ED decreased by 16.8 percent.
An ongoing challenge is changing the ED culture. “We’re very quick to revert back to whatever we used to do before,” remarked Goudey. “We’re continually hammering away at, ‘That was then, this is now.’ Our population has changed; we need to change along with it.”
Participating in the Learning Community was valuable in a variety of ways, particularly in highlighting alternative approaches to ED care processes. In a fast-paced environment, it’s easy, said Goudey, “to get very locked into ‘that’s the way we’ve always done it.’ So, to hear what other [hospital ED teams] are doing and how those [changes] might fit in [our ED], and being willing to try something different, I think has been very helpful.”
Another important element was establishing connections with other hospital’s EDs, outside of their own health system. “We have a new resource bank,” said Maria Long. “If I delve into problems with child psychiatry, I know exactly who to call” from one of the other teams in the Learning Community. Long noted, “That’s one of the most valuable things. You have someone else to call.”
Editor’s note: For more on this topic — including practical tips, tools, and more Improvement Storieslike this — download the full Improving Behavioral Health Care in the Emergency Department and Upstream white paper.