Summary of the Pioneering Collaborative on
Improving Care for Behavioral Health Clients
in Emergency Departments
Managed by the Institute for Behavioral Healthcare Improvement
Overview and Aim
The hospital Emergency Department (ED) is sometimes viewed as the “early warning” system for a general and behavioral health care system which is often challenged to meet client needs.
It is estimated that approximately 2 million people seek care for behavioral health problems each year in hospital Emergency Departments. In a setting often overburdened and under-resourced there is much unintended variation in expertise and training in MH/CD problems. This can lead to inadequate care, negative patient experience and staff dissatisfaction. As common ground for behavioral and general health care needs and hospital and community connections, more integrated approaches to care in the ED can have dramatic, positive results. The Institute for Behavioral Healthcare Improvement (IBHI) saw this area as a place for a new initiative to stimulate improved outcomes in Behavioral Healthcare. Improving ED care for this population would also demonstrate the effectiveness of Quality Improvement efforts.
The Aim and intent of this Collaborative was to:
- Reduce the suffering of clients;
- Improve knowledge for better care of persons with behavioral healthcare needs in hospital Emergency Departments;
- Improve hospital functioning and effectiveness as measured by:
® Reduced overall time for care
® Reduced time from arrival to assessment
® Reduction of use and time in restraint
® Improved patient and staff satisfaction
- Reduce the congestion and conflict in Emergency Departments
- Establish subsequent collaborative efforts nationally
The demands placed on Emergency Departments today make it essential that every possible avenue be explored to improve flow and outcome of care. No consumer wants to spend many hours waiting for care or for placement in the appropriate service. While average length of stay
in Emergency Departments across the nation has risen to more than six hours, the stay for behavioral health clients is all too often measured in days. This has created untold trauma for clients, major issues for ED staff, lost revenue for hospitals and many wasted resources at a time of decreasing economic support.
These underlying problems created a wide consensus on the need for improvement in Emergency care. As a result, in late 2006, the IBHI Board of Directors decided to develop a collaborative in this area of hospital emergency care. No body of known ‘best practices” or ideas for change existed, although other improvement work in ED care was ongoing. The sponsor turned to the Breakthrough Series methodology of the Institute for Healthcare Improvement (IHI) and through an expert panel created a “Change Package” of ideas and faculty that could serve as a resources for a “Pioneering” Collaborative.
This pioneering collaborative was begun in January of 2008 and included six active participating hospital emergency departments. Over the next 10 months, significant improvement occurred in internal operations. Measurement issues were refined, and the need to balance internal and external connections was demonstrated. The Change Package is being expanded, and plans are underway for a subsequent national collaborative, as well as subsequent application of the approach in regional settings. The Institute for Behavioral Healthcare Improvement is a not for profit organization (501c3) formed in 2006 dedicated to improving the quality and outcome of behavioral health care. For more information on IBHI or the development of the Collaborative see the article Improving Emergency Care and Creating New Connections by Peter Brown, Jon Berlin, Stuart Buttlaire, Alden Doolittle, and Tammy Powell, or visit the IBHcI website. (www.ibhci.org) An excerpt of this article appeared in the September issue of the American Association of Emergency Psychiatry.
Formation and Operation the Collaborative
Participants were recruited to the Collaborative through internet mailings, spread of the information by national associations and word of mouth. An informational conference call preceding the initiation of the Collaborative attracted over 100 organizations. The pioneering group included hospitals from Colorado, Louisiana, Minnesota, New York, Oklahoma and Washington. They all agreed to share data on their results and to participate in the improvement process for the 10 months active phase of the Collaborative and to share data for an additional 6 months. A pre-work exercise provided a reference for, organizational readiness, baseline data, as well as, first hand reporting of patient experience such as:
- Obtain clear and firm support from the senior administration of the hospital;
- Form a team of people from general and behavioral health who would organize and develop the change process at the hospital;
- Have one of the members of the team go through the process of becoming a client of the emergency department;
- Interview two to four people who were recently served in the emergency department who needed behavioral health care
Participants presented these observations of their current situation at the initial learning session which was held in New Orleans in January, 2008. The stories reinforced the need and will to make change. This momentum grew as IBHI faculty provided a Model for Improvement, the Rapid Tests of Change process and the Change Package, which is intended to make good ideas readily available to teams. Measuring results is crucial to understanding any Breakthrough Collaborative and change. The Collaborators mutually agreed to collect a set of measures of success. These are:
- Overall length of stay in the Emergency Department
- Length of time from door to behavioral health provider who can evaluate the consumers condition
- Number and percent of total consumers presenting who must be placed in restraints
- Average amount of time consumers are in restraints
- Consumer satisfaction as measured by the portion of consumers who are highly satisfied or would be willing to recommend the service to others.
Obtaining satisfaction data proved most difficult due to the lack of simple stratification elements on BHC clients in existing data collection efforts. All the Collaborators ultimately developed systems for collecting this information.
Between the two subsequent Learning Sessions, the group participated in conference calls every two weeks, to share work and results. A second Learning Session was held in May and Collaborators shared their efforts and were provided additional information on making change occur and models of improved care. The third and final Learning Session was held in November and allowed for a review of progress and provided information on ways to assure the gains achieved are not lost. Conference calls have continued through out the Collaborative, and Collaborators continued to share their improvement efforts and their results and data for six months through May, 2009.
When the Collaborative was initially developed several specific goals were proposed for the participating hospitals. These included:
• Average length of stay of less than 120 minutes for discharged patients
• Average length of stay of less than 60 minutes for Fast Track patients
• Reduction in percent of patients returning to ED within hours, one week, two weeks and 30 days
• Increase patient and staff satisfaction
• Reduction in hospital costs by
– reduced length of ED stay
– reduction in boarding hours
– decrease returns to the ED
The group chose to adopt the specific measures cited previously, but nevertheless made progress on many of these issues as well. In most cases they did indeed reduce average length of stay and duration of average period of restraint. The proposed reduction to 120 minutes average length of stay is more readily achievable for hospitals which have developed an array of specific discharge possibilities. For those with more limited community resources the length of stay is often dictated not by the stability of the client, but by the availability of the appropriate placement. Several hospitals determined the need to work with their own hospital inpatient unit to assure more effective discharge practices for the inpatient service, to allow more expeditious placement for those who required this level of care. Improving the inpatient flow process is often found important in general medicine Breakthrough Collaboratives working to improve flow in Emergency Departments. It was no surprise to the Collaborative Faculty to find this was also a need for the behavioral health cohort, but participants found this a revelation.
Most of the participating hospitals decreased the average Length of Stay and the amount of time those placed in restraint spent in restraint. They also decreased the amount of agitation experienced by clients and reported improved client and staff satisfaction.
Some Specific Achievements Hospitals Have Made
Participant hospitals developed and/or adapted a significant number of changes. Some derived from other participants, faculty, the Change Package, and other benchmarking. While the overall goals of the Collaborative were useful, in order to be successful and sustained each hospital must develop its own set of changes. Imposing change from the outside is rarely successful and usually leads to other problems whether the specific change is instituted or not. A partial list is shown below to demonstrate the significant impact the Collaborative process can have on participants. In several cases one hospital initiated the change, reported it on a conference call and it was promptly tested and adapted by other hospitals. Examples:
• Held emergency de-escalation intervention training for everyone
• Decreased number of restraints thru IMAB training and use of de-escalation techniques, early use of anti-psychotics, use of time-out room, use of diversion activities, and one to one psych aide
• Focused on continuous education of staff
• Increase education and training to identify high risk clients, teach de-escalation, use medications in earlier and standardized fashion
• Intensive 2 day training involved hospital security on use of restraints
Operational modifications – shorten time- improve flow
• Provided a new procedure having patients medically cleared before transfer to Mental Health Emergency Room
• Developing a second triage area
• Developed Behavioral Early Response Team
• Developing an electronic alert system at entry
• Alcoholics when stable discharged from the ER vs transferring to MH
• Increased ED Psych bed capacity, opened short-stay unit
Operational modifications – improve patient staff safety-satisfaction
• Increased flexibility with patients, e.g. free phones, healthy snacks, grooming supplies, showering as requested
• Established a violation reduction protocol
• Improved physical space to increase safety
• Developing an electronic alert system at entry
• Substituted pajamas or scrubs verse hospital gowns
• Developed Behavioral Early Response Team
Operational Modifications – Professional Practice
• Increase of use of newer psychotropic medications
• Psychiatrists taking more responsibility- noon discharge
• Psychiatrists will manage patients vs. consultation model
• Conducted a Phone satisfaction survey
• Monthly meetings to review all seclusion/restraint
• Standardized high level measures for Collaborative;
Improved linkages with Stakeholders
• Improved ED/BH relationships, bi weekly workgroup meeting, monthly MD meetings
• Increased ED Crisis Social Workers, added psych with e-call rotation, moving from uniformed security guards to psych aids
• Developed round table leading to ability to divert ambulance traffic to other hospitals when needed
• Working more with referral resources.
• Increased focused on community resources and discharge planning including NAMI referral form, vouchers for transportation, 2 ACT teams, homeless shelter, and med refills
Preliminary Lessons Learned
When this pioneering effort began it seemed likely that improving flow would require improved connections to outside the hospital providers. However, IBHI was persuaded to make the initial focus the operations within the hospital. As the Collaborative developed it became ever clearer that full improvement in ED care requires much improved connection and collaboration with community providers. Indeed, 5 of 6 participants now have some new or improved external connection as an element of their improvement plan. IBHI is prepared to help ED providers make this bridge to the community. Beginning improvement efforts within the hospital, building understanding and improving processes, are essential first steps. Subsequently, extending the effort to include community connections and resources outside the hospital can then occur from a more stable base.
In addition, in nearly all cases the hospitals were interested in dealing more effectively with agitation and aggression without the use of restraints. They are also especially concerned about assessment for suicidality, dealing with children and adolescents and some fairly simple issues such as transportation systems and the need to require disrobing. In each case IBHI has worked to provide expert assistance to address the issues.
This Collaborative has opened the door to addressing the issues of Emergency Department care in more humane and responsible ways. We have helped hospitals reduce client agitation, expedited referral both to outpatient and inpatient services, decreased time in restraint of those placed in restraint and improved client outcome. The Collaborative also helped hospitals reduce the overall cost of care by reducing the length of stay and frequency of return for these clients. Much more needs to be done in improving both the operation of Emergency Department care and the connections between Emergency Departments and other levels of care. This “Pioneering” Collaborative has successfully tested and demonstrated ideas for improvement, and provides momentum and guidance for these additional improvements.
Peter C. Brown, MA Executive Director , Alden (Joe) Doolittle MS Co-Executive Director Institute for Behavioral Healthcare Improvement
Acknowledgements: IBHI is grateful for the commitment and energy demonstrated to the Pioneering and continuing aspects of the Collaboarative by Co-Chairs: Tammy L. Powell, FACHE Vice President and Chief Operating Officer, St. Anthony Hospital, Oklahoma City, Oklahoma and Stuart Buttlaire, PhD, MBA Regional Director of Inpatient Psychiatry & Continuing Care Kaiser Northern California;
Faculty and resources Jon S. Berlin, MD Medical Director Crisis Services, Milwaukee County Behavioral Health Division, Milwaukee, WI, former president American Association for Emergency Psychiatry David Hnatow, MD Emergency Medicine Physician Greater San Antonio Emergency Physicians San Antonio, Texas Former Medical Director University Hospital Emergency Center, Chief of Staff University Health; Darcy Jaffe, ARNP,Psychiatry Director Harborview Medical Center Seattle , WA; Steve Miccio, People, Inc., Kingston, NY: Susan Stefan, JD Center for Public Representation, Newton, MA; the 20 plus members of the expert panel; Kirk Jensen, MD, and Marie Schall, RN, and others in the IHI Breakthrough College faculty who have guided the effort, and most importantly the
“Pioneer” participating organizations: Bon Secours Health System – St Mary’s Hospital, Richmond, VA; LSU Medical Center New Orleans, LA, Memorial Hospital- Pikes Peak Behavioral Health Center, Colorado Springs CO; NYCH&H, North Central Bronx Hospital; Health Partners -Regions Hospital St Paul, MN, Provident HS, Sacred Heart Medical Center Spokane, WA; SSMHS, St Anthony’s Hospital Oklahoma City, OK
To learn more about the IBHI Collaborative on Improving Care for Behavioral Health Clients in Emergency Departments go to the IBHI web site (www.ibhci.org) or e-mail or call Peter Brown at Peter@ibhci.org or phone 518 732-7178; or Alden (Joe) Doolittle at
Joe@ibhic.org, or phone (518) 384-1700.