Long ED stays occurred because all behavioral health patients were treated the same way, said Dr. Meghan Stahulak, medical director of emergency services at St. Joseph. They received lab screening to be medically cleared for other underlying health concerns, which took time. Additionally, patients were often given strong psychiatric medications that usually caused them to sleep for hours, making it impossible for them to be assessed.
“When you put those two together, it causes patients to be in the ED for a really long time,” she said.
Given the problem, St. Joseph, along with three EDs at other hospitals that are part of the system, piloted a screening process developed by physician staffing agency Vituity to help behavioral health patients get discharged faster from the ED. Staff were also educated on different medications that are less sedative. Vituity staffs some of Amita’s EDs including St. Joseph’s.
Since making the changes last March, the evaluation time for behavioral health patients presenting to the ED at St. Joseph with minor concerns is down from an average of 113 minutes to 73 minutes. And 93% of physicians are prescribing newer antipsychotic medications that don’t make patients as lethargic.
The new screening process involves physicians risk-stratifying behavioral health patients into low-, medium- or high-risk categories.
The categories are determined by asking patients a series of questions to understand what brought them into the ED. The questions are in binders kept at all stations where physicians sit when at a patient’s bedside. For instance, if a patient comes into the ED for a medication refill, they’d be considered low risk. If a patient presents with suicide ideation, they’d be deemed high risk.
Labs are no longer conducted routinely. Rather, once it’s determined the patients have low-risk behavioral health concerns and don’t have other health problems warranting an inpatient admission, the physician refers the patient to one of the crisis health workers on call in the ED. These employees are trained to help behavioral health patients with long-term treatment needs such as follow-up appointments.
High-risk patients usually require an admission to the inpatient psychiatric unit. Amita has about 600 psychiatric beds across 11 of its 19 hospitals. To ensure patients are quickly given a bed, the health system recently changed its process, Novak said. Typically, crisis workers had to call each of the 11 hospitals to see if a bed was available, which could take from five to eight hours, he said. Now, the crisis workers call a 24/7 hotline staffed with Amita employees who are privy to the current availability of psychiatric beds at all 11 hospitals. Patients can now be placed within a few hours.
In terms of prescribing patterns, it was a matter of educating physicians about the options. Doctors “are creatures of habit,” Stahulak said. “I think when we took the time to actually educate them that we have these different options that are better for the patient, that is all it took for them to make the change.”