Photo by Ryoji Iwata | Unsplash
Memorial Herman Northeast Hospital has no psychiatric facilities or inpatient psychiatric beds, but they realized this was no excuse for not having standardized processes in place to treat patients with behavioral health needs. The following is an excerpt from IHI’s Improvement Stories: Improving Behavioral Health Care in the Emergency Department and Upstream.
Memorial Hermann Northeast Hospital is a 242-bed facility in the suburbs of Houston, Texas, located in close proximity to a major hub of health care facilities throughout the city. Over the past five years, an increase in the number of behavioral health patients presenting to the hospital’s 37- bed emergency department has created new challenges for appropriately managing these patients’ mental health issues and disposition once they are medically stabilized.
The Memorial Hermann Health System (Memorial Hermann) does not have psychiatric facilities or inpatient psychiatric beds. In order to meet the needs of this patient population, in 2000 Memorial Hermann launched a Psychiatric Response Team (PRT), a mobile team that provides 24/7 psychiatric consultation and dispositions to all psychiatric patients in the system’s acute care hospitals (EDs and medical units). Behavioral health patients presenting to the ED often experience prolonged waiting times before they are accepted and transferred to an inpatient psychiatric facility. Managing the behavioral health population requires collaboration with community partners and the challenges the health system faces are further exacerbated by the general lack of adequate resources for mental health in Texas.
“There was a feeling that we weren’t doing enough for these patients,” said Stephanie Masson, a nurse and Director of High Reliability and Safety at Memorial Hermann. This feeling, together with the system’s core value of safety, supported the motivation to join the ED & UP Learning Community. Masson noted, “We wanted to learn what is the best practice, what is the way to give the best quality care given the resources that we have.”
Over the course of the Learning Community, the team learned and adopted valuable information, including standardizing the ED intake process for behavioral health patients. “If a patient’s coming in with chest pain, the whole [ED] team knows just what to do,” said Jennifer Braren, BSN, RN, Clinical Manager of the ED. The ED team wanted to ensure a similarly reliable response for mental health conditions. Now, when a behavioral health patient arrives at the ED, the team follows a standard series of steps: assess agitation level; consult a medication algorithm and provide medication, if appropriate; and contact the psychiatrist for a consultation. If necessary, the ED team can implement de-escalation techniques. Taken together, all of these steps improve care delivery, reduce the risk of a safety event, and help reduce length of stay.
While Memorial Hermann had already integrated telepsychiatry (i.e., telehealth for psychiatric consults) in 2005, during participation in the Learning Community, the health system recognized a need to expand and enhance PRT telepsych operations more broadly. Over the 18-month Learning Community, the organization integrated wireless telepsych carts throughout the health system and expanded telepsych remote access to all medical units within the organization. “Our system’s promise to enhance models of care delivery in order to meet patient care needs and support operations is key to our culture,” remarked Theresa Fawvor, LCSW, Senior Director of Behavioral Health Services at Memorial Hermann. “Today, more than 60 percent of all consults are performed via remote access.”
When behavioral health patients arrive in the ED, they need a “safer room,” which contains nothing that could be used to harm themselves or others. However, the sheer number of behavioral health patients required the ED team to implement another change: standardize and rehearse the process of transforming a regular patient room into a safer room. To make a patient room safer, the team removes all equipment that is not medically necessary, such as storage bins for tongue depressors or ace bandages, and locks cabinets and locks or removes contents from drawers. The team assembled a room prep checklist and rehearsed it until they were able to consistently transition a room within two minutes (usually two staff members, a technician, and a nurse are responsible for this transition). Braren empowered the ED staff to share solution ideas throughout the Learning Community and they were highly engaged, taking it upon themselves to try new ideas for room safety and readiness. Several staff members bought magnet child locks to keep supplies safely locked in the cabinet.
Another important ED process improvement was establishing a post-psychiatric response consultation huddle, in which the nurse, ED provider, and the psychiatric response representative (a social worker or psychiatrist) discuss next steps after a psychiatric consultation. When the huddle was first introduced, the intended participants did not necessarily all convene at the same time. “Getting everyone in one place was difficult,” said Masson, because of the chaotic nature and demanding pace of the ED. It took several weeks to prioritize a real huddle, for the participants to say, “We’re all going to pause and have a conversation,” as Masson put it. Now, immediately following the consultation, the psychiatric response representative consistently huddles with both the nurse and the ED provider to discuss the consultation plan, overall assessment, disposition recommendation, safety plan (if applicable), and other details. The psychiatric response nurse then finalizes plans with the patient prior to documenting the note, which has resulted in improving throughput on discharged patients.
One change that both staff and patients most appreciate is the integration of trauma-informed care into the ED. This approach helps staff better understand that behavioral health patients, in particular, have previously experienced some kind of trauma, in addition to the ED environment itself being potentially traumatizing. The training equips staff with techniques to communicate with more compassion and understanding.
Looking for ways the team could take trauma-informed care further, Braren toured local behavioral health facilities to better understand the environment they create for patients. This knowledge enabled her and the team to make ED patient rooms safer while still incorporating emergency equipment as necessary. Lockers were added to store patient and family belongings.
The ED team also introduced a specific, less obvious element of trauma-informed care: a chalkboard wall and non-toxic chalk are now provided in four ED patient rooms. The chalkboard walls have been a big satisfier for both patients and staff. After helping the patient through their acute phase, patients can decompress and have an outlet by drawing, coloring, or communicating frustrations on the wall. Staff are also able to communicate via the chalkboard through notes of encouragement or “next steps.” Several patients have played tic-tac-toe with staff on the chalkboards, one patient wrote scientific equations in Chinese, and many have drawn pictures which can give staff and the Psychiatric Response Team an insight into their mental wellness.
For the team at Memorial Hermann, a key takeaway from the Learning Community, noted Masson, is that “the challenges that we thought were unique to us really are not.” Although the organization does not have inpatient psychiatric services, the team learned that even EDs that do have such services share many of the same challenges. “It’s not just about having a psychiatric bed,” said Braren. “It’s really about, ‘How do we best deliver care to these patients?’”
Editor’s note: For more on this topic — including practical tips, tools, and more Improvement Stories like this — download the full Improving Behavioral Health Care in the Emergency Department and Upstream white paper.