BOARDING S

OLUTI

ONS

INCREASE P

ROFITS B

Y ENDIN

G ER G

RIDLO

CK

© COPYRIGHT 2011 VIRGINIA COLLEGE OF EMERGENCY PHYSICIANSEm

erge

ncy

Medici

ne

Summ

it 5/4

/2011

Menta

l Hea

lth B

oard

ing in

the

ED“P

ATIE

NT OVERBOARD!”

Damon

Kueh

l MD, F

ACEP

Carilio

n Clin

ic Dep

artm

ent o

f Em

ergen

cy M

edici

ne

VTC S

choo

l of M

edici

ne

© COPYRIGHT 2011 VIRGINIA COLLEGE OF EMERGENCY PHYSICIANS

Mental Health Patients: Days per Month where

Avg ED Stay >800 minutes

0

5

10

15

20

2503

/200

9

06/2

009

08/2

009

10/2

009

12/2

009

02/2

010

04/2

010

06/2

010

08/2

010

10/2

010

12/2

010

02/2

011

08/2

011

12/2

011

Day

s

The Problem…

7 Steps to Solving MH Boarding

1 Quantify the problem

2 Improve psychiatric care in the ED

3 Make existing capacity more efficient

4 Collaboration with community agencies

5 Law enforcement collaboration

6 Community crisis services investment

7 Continuity of care

Vidhya Alakeson, Nalini Pande and Michael Ludwig A Plan To Reduce Emergency Room 'Boarding' Of Psychiatric Patients Health Affairs, 29, no.9 (2010):1637-1642

Improvement…

Mental Health Patients Days/Month Average ED Stay >800 minutes

0

5

10

15

20

2503

/200

9

06/2

009

08/2

009

10/2

009

12/2

009

02/2

010

04/2

010

06/2

010

08/2

010

10/2

010

12/2

010

02/2

011

08/2

011

12/2

011

Day

s

(C) COPYRIGHT 2011 VIRGINIA COLLEGE OF EMERGENCY PHYSICIANS

State Medicaid Population of High Utilizers of ED: Percent of Enrollees with Various Disease

0 20 40 60 80 100

Psychiatric illness

Drug Use

Alcohol

Pulmonary

Gastointestinal

Migraine

Hypertension

Diabetes

CAD

CHF

ED Mental Health Patients are Complicated…

Improving Front EndAll mental health patients = Level 1 triageStandardized patient intakeCreation of dedicated ED Mental Health Unit

Triage process changes and direct to ED Mental Health Unit

Law Enforcement/Magistrate-DIP ProgramCare plans for unique patients

ThroughputStandard order sets and ED zone placement

Dedicated ED Psych Nursing Staff Additional 1 fte RN, 1 fte med tech for ED psych unit

Psych RN coordinators (Connect Team)

Improving Care in the ED throughput continued…

Parallel evaluations (med clearance and Connect team)

ED Physician rounder on boarders (2hrs/day)

Chronic disease management ECO and placement concurrentlyTransportation protocols (EMS and Law Enforcement)

Back Door“One Call” for all Mental Health PatientsExpanded weekend bed capacity1 to 1 communication with ED physician and Psychiatric team

County/City Mental Health Coordination with Connect Team

Automatic Psychiatry Consult for ED >24 hrsDirect Facility Protocol Placement for Unique Patients

Mental Health Patients ED LOS in Minutes

300.0

400.0

500.0

600.0

700.0

800.0

900.0

03/2009

06/2009

09/2009

12/2009

03/2010

06/2010

09/2010

12/2010

03/2011

QUESTIONS?

© COPYRIGHT 2011 VIRGINIA COLLEGE OF EMERGENCY PHYSICIANS

THANK YOU!

© COPYRIGHT 2011 VIRGINIA COLLEGE OF EMERGENCY PHYSICIANS