Boston, Mass. and Oakland, Calif., January 23, 2020 —Today, a White Paper, providing actionable guidance for hospital emergency departments and their community partners to create a compassionate, seamless, and effective system of care that is respectful of and works with patients with mental health conditions and substance use disorders who present to the emergency department (ED), has been released by the Institute for Healthcare Improvement (IHI) and Well Being Trust (WBT).
The white paper, Improving Behavioral Health Care in the Emergency Department and Upstream, describes current gaps in care, tested improvements to close those gaps, and resources and tools that may provide additional support to ED care teams, patients, and their families.
To develop these solutions, IHI, in partnership with WBT, convened eight U.S. hospitals in an 18-month learning community. By the end of the project, participants had tested strategies for improving patient outcomes and experiences of care, while decreasing avoidable repeat ED visits for individuals with mental health and substance use disorders who present to the ED. Additionally, some participants were able to reduce the ED length of stay, the number of patient-to-staff assaults, and the use of restraints.
“The experiences of these participating organizations demonstrate it is possible to improve the care, experience, and outcomes for these patients,” said Dr. Trissa Torres, chief operations and North America programs officer, IHI. “We have so much to learn when we center our approach around what matters most to the people we are serving. We hope other hospitals and communities are inspired to work together to implement the changes described in this paper and improve care nationwide with their patients, families, and ED care teams.”
The eight participating hospitals were Abbott Northwestern Hospital (Allina Health), Minneapolis, MN; Cohen Children’s Medical Center (Northwell Health), New Hyde Park, NY; Hoag Memorial Hospital Presbyterian (Providence St. Joseph Health), Newport Beach, CA; Kaiser Permanente South Sacramento Medical Center, Sacramento, CA; Maine Medical Center (MaineHealth), Portland, ME; Memorial Hermann Northeast Hospital, Houston, TX; Providence Regional Medical Center Everett, Everett, WA; and South Seminole Hospital (Orlando Health), Longwood, FL.
“This work is incredibly heartening, timely, and necessary—the nation must do better to support these patients,” said Tyler Norris MDiv, chief executive, WBT. “It is so inspiring to see how the learning community created a culture of caring that will continue to drive change and improvements system-wide—moving from triaging problems to cultivating well-being among patients and staff.”
The paper includes recommendations based on the experiences of the learning community teams, including, but not limited to:
- Recognize that community partnerships are vital—The ED cannot provide patients with all they need, nor should the ED create in-house services that are already in the community.
- Prioritize trauma-informed care training, which is crucial to providing compassionate care, preventing burnout, and promoting resilience in providers.
- Begin working on culture right away—Teams saw the impact of trauma-informed care training for ED staff in two ways: better care for patients as teams learned how to engage with patients better; and a reduction in workplace injuries as ED staff gained skills in calming agitated patients.
- Institute policies and practices to remove the “old way”—To enhance communication and coordination with community providers, the Providence Regional Medical Center Everett team observed community-based crisis counselors to better understand how they supported patients. The team also invited community partners to the hospital to participate in a patient flow exercise that mapped the experiences of patients across care settings.
- Use resources and equipment to enhance care—Abbott Northwestern Hospital created a special six-bed observational unit adjacent to the inpatient psychiatric unit, to serve as a quiet and supportive area for mental health patients. The team involved patients as they designed the unit, and the ED team was often able to help patients avoid an unnecessary psychiatric admission.
- Smooth information flow to create standardization and accountability—The Memorial Hermann Northeast Hospital team standardized their ED intake and triage process to ensure a reliable care experience for patients. When a patient arrives, the ED 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.
- Update hiring procedures to support new roles—To enhance the ability of the ED team to care for these patients, the Providence Regional Medical Center Everett team added nurses with special psychiatric training to their ED teams. These nurses serve as an internal resource of expertise, enhancing the ability of the entire team to care for patients.
- Don’t do anything in a vacuum—Involve all parties in planning and testing, including all ED staff and those engaged in other efforts within the health care system or hospital related to care for patients with mental health conditions and substance use disorders.
- Make sure to solicit family input in how treatment should work—This will build sustainable partnerships that work for the hospital, patient and family, and community partner.
- Standardizing ED processes is important, but culture also needs to support the process changes—Identify and address perceived barriers (e.g., the attitude that “these patients are different from medical patients and we can’t care for them here”).
“This was an initial step in ensuring we have the research and practical knowledge to ultimately build systems of care in every community—to prevent needless pain, suffering, and deaths from mental health conditions and substance use disorders,” said Dr. Arpan Waghray, chief medical officer, WBT.
Well Being Trust is a national foundation dedicated to advancing the mental, social, and spiritual health of the nation. Created to include participation from organizations across sectors and perspectives, Well Being Trust is committed to innovating and addressing the most critical mental health challenges facing America, and to transforming individual and community well-being. www.wellbeingtrust.org. Twitter: @WellBeingTrust
About the Institute for Healthcare Improvement—The Institute for Healthcare Improvement (IHI) is an independent not-for-profit organization based in Boston, Massachusetts, USA. For more than 25 years, IHI has used improvement science to advance and sustain better outcomes in health and health systems across the world. IHI brings awareness of safety and quality to millions, catalyzes learning and the systematic improvement of care, develops solutions to previously intractable challenges, and mobilizes health systems, communities, regions, and nations to reduce harm and deaths. IHI collaborates with a growing community to spark bold, inventive ways to improve the health of individuals and populations. IHI generates optimism, harvests fresh ideas, and supports anyone, anywhere who wants to profoundly change health and health care for the better. Learn more at ihi.org.