Emergency Behavioral Health Research Articles

Veteran Returns to Homelessness following Exits from Permanent Supportive Housing: Health and Supportive Services Use Proximal to Exit

Permanent supportive housing (PSH) programs have been shown to increase housing retention for “hard to house” individuals and been used to address veteran homelessness. Departures from PSH (referred to as “exits”) can represent a positive outcome for some veterans, while others may return to homelessness. This study analyzed administrative and primary data to identify individual- and institutional-level factors associated with veterans' returns to homelessness following exits from a PSH program. Findings suggest that a number of factors increase the risk of a return to homelessness, including admissions to inpatient substance abuse and behavioral health treatment programs and emergency department visits both pre- and post-exit. Targeted interventions may reduce the likelihood of subsequent homelessness.

Clinical Manual of Emergency Psychiatry, Second Edition

Back to table of contents Previous article Next article Book ForumFull AccessClinical Manual of Emergency Psychiatry, Second EditionScott A. Simpson, M.D., M.P.H.Scott A. SimpsonSearch for more papers by this author, M.D., M.P.H.Published Online:1 Jun 2016https://doi.org/10.1176/appi.ajp.2016.16040381AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail edited by Michelle B. Riba, M.D., M.S., Divy Ravindranath, M.D., M.S., and Gerald Scott Winder, M.D. Washington, D.C., American Psychiatric Association Publishing, 2016, 375 pp., $70.00 (paperback).More than 12% of emergency department visits are for behavioral health emergencies, a large number resulting from inadequate outpatient resources and shrinking inpatient psychiatric bed capacity (1). To meet this demand, psychiatrists may consult in emergency departments, practice telepsychiatry, or manage psychiatric emergency services. Psychiatric emergencies are also being treated through free-standing crisis centers and regional referral centers (2). More providers are practicing emergency psychiatry in its different forms, and there is a need for research and education specific to this subspecialty. The Clinical Manual of Emergency Psychiatry offers a solid first step into the field of emergency psychiatry.The book is “not meant to be a textbook” for “first-year and second-year psychiatry residents” but is designed to introduce them to clinical management in “busy psychiatric emergency services”—where, for the first time, they face the combination of acute psychopathology, uncertainties of diagnosis, time pressures, medical comorbidity, and team management unique to emergency psychiatry (p. xxiii). Many trainees are intimidated by this environment, and this text makes the field feel accessible and manageable. The authors organize chapters by chief complaint in order to assist in the assessment and treatment of common presentations. The authors’ explicit goal is to help trainees to “review the key points, as needed, just before seeing a patient” (p. xxiv).How well, then, does this book achieve this goal? I brought the Clinical Manual to work in my urban psychiatric emergency service center to find out. There are immediate limitations to the chief-complaint-oriented approach: for example, when a hyperactive patient was brought in involuntarily by police, I was uncertain whether to start with the chapter on psychosis (chapter 5), agitation (chapter 7), substance-related emergencies (chapter 9), or even seclusion and restraint (chapter 11).The agitation chapter proved the right choice. I found a helpful differential of medical etiologies followed by a description of verbal de-escalation strategies espoused by Project BETA (3). As I began considering medication options, the authors provided a helpful table to summarize the dosing and pharmacokinetics of commonly used medications. However, understanding which medication was indicated required me to read 11 pages, which was not conducive to rapid decision making. The authors again use Project BETA’s approach to medication selection, although they do not build on those guidelines by introducing trainees to novel mechanisms of delivery (e.g., inhaled medications) or action (e.g., intramuscular ketamine, increasingly popular among our colleagues in emergency medicine).The not-a-textbook middle ground is frustrating. The text does not work well as a bedside reference because many of the clinical gems and decision-making advice are embedded in the text and are not presented visually. Such reading makes it difficult to do a quick review when busy. Although the authors do not intend to offer an encyclopedic text, the level of detail can be insufficient; for example, the authors rightfully recommend antiparkinsonian agents or benzodiazepines with intramuscular typical antipsychotics but do not provide dosing instructions. A differential of medical etiologies for acute agitation is emphasized, but no clear guidance is offered as to how extensive a workup is warranted. Perhaps it would have been helpful to describe several short scales validated for delirium screening in the emergency department.It speaks to the enjoyable writing, and maybe to the dearth of literature in emergency psychiatry, that I was left wanting more on contemporary topics, including managing boarding patients, identifying malingering (barely mentioned), and developing quality improvement metrics.But that is not the detailed textbook that the authors envisaged. Instead, they deliver a strong, if at times incomplete, introduction to emergency psychiatry for advanced medical students and junior residents. Most situations encountered in my psychiatric emergency service shifts were well-covered. My own copy will rest on the psychiatric emergency service center’s bookshelf to await anxious residents in need of a quick primer. And if trainees remain sufficiently interested to outgrow its scope, the Clinical Manual of Emergency Psychiatry should be considered a success.Dr. Simpson is an Assistant Professor in the Department of Psychiatry at the University of Colorado Denver School of Medicine and an emergency psychiatrist at Denver Health Medical Center.The author reports no financial relationships with commercial interests.

Pediatric Use of Emergency Medical Services: The Role of Chronic Illnesses and Behavioral Health Problems

Objective: The increasing use of prehospital emergency medical services (EMS) and its contribution to rising emergency department use and healthcare costs point to the need for better understanding factors associated with EMS use to inform preventive interventions. Understanding patient factors associated with pediatric use of EMS will inform pediatric-specific intervention. We examined pediatric patient demographic and health factors associated with one-time and repeat use of EMS. Methods: We reviewed data from Baltimore City Fire Department EMS patient records over a 23-month period (2008–10) for patients under 21 years of age (n = 24,760). Repeat use was defined as involvement in more than one EMS incident during the observation period. Analyses compared demographics of EMS users to the city population and demographics and health problems of repeat and one-time EMS users. Health comparisons were conducted at the patient and incident levels of analysis. Results: Repeat users (n = 1,931) accounted for 9.0% of pediatric users and 20.8% of pediatric incidents, and were over-represented among the 18–20 year age group and among females. While trauma accounted for approximately one-quarter of incidents, repeat versus one-time users had a lower proportion of trauma-related incidents (7.2% vs. 26.7%) and higher proportion of medical-related incidents (92.6% vs. 71.4%), including higher proportions of incidents related to asthma, seizures, and obstetric/gynecologic issues. In patient-level analysis, based on provider or patient reports, greater proportions of repeat compared to one-time users had asthma, behavioral health problems (mental, conduct and substance use problems), seizures, and diabetes. Conclusions: Chronic somatic conditions and behavioral health problems appear to contribute to a large proportion of the repeat pediatric use of this EMS system. Interventions may be needed to engage repeat users in primary care and behavioral health services, to train EMS providers on the recognition and management of behavioral health emergencies, and to improve family care and self-management of pediatric asthma and other chronic conditions.

Behavioral Health Emergencies

Behavioral Health Emergencies

Medical Evaluation of the Behavioral Health Emergency Patient

Medical Evaluation of the Behavioral Health Emergency Patient

Effect of Pediatric Behavioral Health Screening and Colocated Services on Ambulatory and Inpatient Utilization.

The study sought to determine the impact of a pediatric behavioral health screening and colocation model on utilization of behavioral health care. In 2003, Cambridge Health Alliance, a Massachusetts public health system, introduced behavioral health screening and colocation of social workers sequentially within its pediatric practices. An interrupted time-series study was conducted to determine the impact on behavioral health care utilization in the 30 months after model implementation compared with the 18 months prior. Specifically, the change in trends of ambulatory, emergency, and inpatient behavioral health utilization was examined. Utilization data for 11,223 children ages ≥4 years 9 months to <18 years 3 months seen from 2003 to 2008 contributed to the study. In the 30 months after implementation of pediatric behavioral health screening and colocation, there was a 20.4% cumulative increase in specialty behavioral health visit rates (trend of .013% per month, p=.049) and a 67.7% cumulative increase in behavioral health primary care visit rates (trend of .019% per month, p<.001) compared with the expected rates predicted by the 18-month preintervention trend. In addition, behavioral health emergency department visit rates increased 245% compared with the expected rate (trend .01% per month, p=.002). After the implementation of a behavioral health screening and colocation model, more children received behavioral health treatment. Contrary to expectations, behavioral health emergency department visits also increased. Further study is needed to determine whether this is an effect of how care was organized for children newly engaged in behavioral health care or a reflection of secular trends in behavioral health utilization or both.

CARES: improving the care and disposition of psychiatric patients in the pediatric emergency department.

Pediatric psychiatric emergencies are a nationwide crisis and have contributed to an increase in behavioral health emergency department (ED) visits. A collaborative response to this crisis was the creation of the Child & Adolescent Rapid Emergency Stabilization (CARES) program. The objective of this study is to determine how the CARES unit influenced length of stay (LOS) and costs for psychiatric patients in the pediatric ED. A retrospective review of ED patients was conducted. Children presenting 1 year before CARES, October 13, 2006, to October 13, 2007 (pre-CARES), were compared with 1 year after, October 15, 2007, to October 15, 2008 (post-CARES). The study population includes all patients presenting to the ED with psychiatric illnesses. The primary outcome is mean LOS in hours. Supplemental analyses of total charges, payments, and costs were performed. There were 1719 visits before and 1867 visits after CARES, with 1190 and 1273 unique patient visits, respectively. Children in both groups had similar age, gender, and ethnicity. Pre-CARES had a mean LOS of 19.7 hours (SD, 32.6), whereas post-CARES had 10.8 hours (SD, 19.9) (P < 0.0001). Evaluating only unique visits, the difference remained highly significant. Post-CARES, compared with pre-CARES, the average charge per patient decreased by $905 (P < 0.0001), average payment decreased by $111 (P < 0.06), and average total cost decreased by $569 or 38.7% (P < 0.0001). The total cost savings the year after CARES opened was $1,019,168.55.

Behavioral Health Emergencies Managed by School Nurses Working With Adolescents

As members of interdisciplinary teams, school nurses provide behavioral health services. Studies indicate that school nurses may lack sufficient continuing education in adolescent behavioral health and in the management of behavioral health emergencies, specifically. We conducted this study to describe the adolescent behavioral health emergencies managed by school nurses. We used data from a New Mexico public school nurse workforce survey to describe the involvement of school nurses in managing adolescent behavioral health emergencies. We included all respondents who self-identified as working in a secondary school (N = 186). We conducted descriptive analyses. Two thirds of survey respondents had provided emergency management in the prior school year for child abuse or neglect, depression, and violence at school. Over 40% had provided emergency management for a suicidal student in the prior school year. Although almost 80% of respondents identified "violence at school" as a very important continuing education topic, 40% reported having received continuing education on this topic in the prior 5 years. In New Mexico, public school nurses provide substantial amounts of emergency management for adolescent behavioral health problems. Continuing education received by school nurses on behavioral health emergencies may not be commensurate with their clinical responsibilities.

Clinical Practice Guideline: 1-Hour Face-to-Face Assessment of a Patient in a Mechanical Restraint

Face-to-face assessment within 1 hour after placing a patient in a restraint has been the standard of care following regulatory requirements set forth by the federal government in 1999. This rule, although widely followed and applauded as optimum patient care, has little evidence of a standardized format for what constitutes the examination. Health care providers agree that a face-to-face assessment is warranted; however, no set parameters exist for what constitutes the key elements of such an assessment. This clinical practice guideline offers a specific outline to follow that emphasizes the safety of the patient being placed in a mechanical restraint for a behavioral health emergency.

Reduction of Physical Restraint Use in Emergency Behavioral Health Patients after Logistic Modification of Infrastructure and Implementation of Evidence-based Care Guidelines

Reduction of Physical Restraint Use in Emergency Behavioral Health Patients after Logistic Modification of Infrastructure and Implementation of Evidence-based Care Guidelines

6. Implementation of an emergency behavioral health unit (EBH)

Clinical Topic: The emergency department experienced an increased volume of behavioral health patients requiring acute intervention. The intent of this project was to create a separate care area that provided consistent clinical practices for the behavioral health patient requiring emergency services.

Comprehensive Emergency Mental Health Care

Back to table of contents Previous article Next article Book ReviewFull AccessComprehensive Emergency Mental Health CareDonna M. Moores, M.D.Donna M. MooresSearch for more papers by this author, M.D.Published Online:1 Jul 1998https://doi.org/10.1176/ps.49.7.976AboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail This very readable, practical book presents an excellent outline of emergency behavioral health services. The authors describe their text as presenting a model of effective mobile emergency treatment services, providing a core of information legitimizing high-quality mental health crisis services in nontraditional settings, and serving as a training manual. The book fairly admirably reaches these goals.The authors are practicing psychiatrists and teachers, and their expertise in both of these areas is evident in their writing. Their level of comfort with this subject and their low-key approach is obvious even in the section titles, such as Nuts and Bolts of Program Operation, and Crash Course in Medical Psychiatry for the Nonphysician.Comprehensive Emergency Mental Health Care is written for a multidisciplinary audience, assuming a team approach to treatment. It moves from organizational theory, with attention to fiscal and political realities, to operational detail. Attention is given to the position of emergency and mobile services on the full continuum of mental health care. The emergency treatment team, as the authors envision it and have organized it, moves out of the confines of a particular building or institution—away from the traditional triage service to one that can provide definitive treatment in an impressive, modern-day version of the house call.The unifying focus is the patient who typically presents in a multifaceted crisis involving psychiatric symptoms, social stressors and support failures, medical-status questions, and safety issues. Thoughtful, sound approaches to care as well as specific protocols, forms, and other tools are included. Rich clinical detail and useful case examples are interspersed in a helpful, enlivening manner. The authors also attend to the needs of the practicing clinicians, offering strategies to combat burnout, and enhance clinical effectiveness through education, involvement in the process, and intense supportEmergency psychiatry is a very hands-on practice that requires a high level of organization and integration. Patients must be thoroughly yet efficiently evaluated. Individuals who are out of control or out of touch need humane, respectful attention. Important linkages must be made with the family, community supports, systems of mental health care, and medical services. Each emergency intervention is a unique opportunity to have a positive impact on a vulnerable person, an overwhelmed family. The accompanying risks are high.It is into such a high-pressure environment that this book brings order and optimism where there so often can be chaos. Front-line staff need training and support. Administrative organization must be logical and accessible. The services should have a sense of overall mission as well as day-to-day goals to focus the work. Drs. Zealberg and Santos have faced these challenges and given us a guidebook that can be useful to those in training, in practice, and in management.Dr. Moores is chief of clinical programs in psychiatry at the Boston Medical Center and vice-chair for clinical programs in the department of psychiatry at Boston University School of Medicine.by Joseph J. Zealberg, M.D., and Alberto B. Santos, M.D., with Jackie A. Puckett, L.M.S.W.; New York City, W. W. Norton & Company, 1996, 290 pages, $37 FiguresReferencesCited byDetailsCited ByNone Volume 49Issue 7 July 1998Pages 976-976 Metrics History Published online 1 July 1998 Published in print 1 July 1998