NUBE 2025

Welcome to NUBE 2024 - Junji Takeshita, MD, FACLP, AAEP President. Conference Opening Remarks - Priyanka Amin, MD, and Jennifer Peltzer-Jones, PsyD, RN, NUBE Program Chairs.

Emergency departments have experienced a significant increase in visits from patients with behavioral health emergencies over the years. Unfortunately, this rise has not been accompanied by adequate national, regional, or state-level responses in acute care delivery, treatment development, care standards, or agreed-upon treatment goals and metrics. Consequently, millions of patients, both adults and children, spend extended periods in emergency departments each year without receiving proper treatment. This gap between the growing needs of these patients and the lack of a coordinated national response has prompted the development of numerous local solutions. These innovative approaches aim to transition from the traditional stabilization-boarding-disposition sequence to a treatment philosophy that views boarding time as an opportunity for active treatment and clinical improvement.

A key aspect of this new approach is the emphasis on understanding both patients' and healthcare workers' perspectives. Recognizing patients' experiences, wishes, and goals is essential for providing patient-centered care that is more holistic and therapeutic. Equally important is understanding the perceptions of healthcare workers who deliver care to boarding behavioral health patients. This dual perspective is novel and critical for developing effective and meaningful care strategies in emergency departments.

In this presentation, a panel consisting of a patient advocate and an expert in emergency medicine and behavioral health emergencies will describe the concordant and contrasting experiences of ED boarding, as well as the therapeutic goals envisioned and perceived by patients and healthcare workers. The presenters conducted semi-structured interviews with patients currently boarding for behavioral emergency care and with healthcare workers who provide care to these boarding patients in the same urban ED. Thematic analysis was performed to identify commonalities and disparities in the perspectives of the two groups. Based on these findings, the presenters developed a supportive, healing environment for ED behavioral health patients, focusing on interdisciplinary care with empathy and trauma-informed approaches to acute stabilization, treatment, and reassessment of both medical and psychiatric illnesses. The panelists will draw from their research, clinical experience, and programmatic expertise to discuss the design and implementation of interdisciplinary ED-based interventions informed by patient and healthcare worker perspectives and experiences, and share their learnings on what works and does not work in this novel clinical setting.

Learning Objectives:

Understand the Gap in Behavioral Health Emergency Care: Participants will be able to identify the critical gap between the rising number of behavioral health emergencies and the lack of adequate national, regional, or state-level responses in acute care delivery, treatment development, and care standards. This understanding will highlight the need for innovative local solutions.

Appreciate the Importance of Dual Perspectives in Care Delivery: Participants will take home concrete examples illustrating how a solid understanding of both patients' and healthcare workers' perspectives help provide effective and meaningful care. By recognizing patients' experiences, wishes, and goals, as well as the perceptions of healthcare workers, attendees will be better equipped to develop patient-centered, holistic, and therapeutic care strategies in emergency departments.

Implement Interdisciplinary Interventions in the ED: Participants will learn how to design and implement interdisciplinary ED-based interventions informed by patient and healthcare worker perspectives. Drawing from the research, clinical experience, and programmatic expertise presented, attendees will learn how to create supportive, healing environments for ED behavioral health patients, focusing on trauma-informed approaches to acute stabilization, treatment, and reassessment of both medical and psychiatric illnesses.

As the promise of 988 and other elements of a full crisis continuum have advanced, the realization of an ideal system of immediate access to care for anyone, anytime, anywhere has advanced. This emerging crisis continuum of services favors utilizing front-line crisis workers through crisis call centers, mobile behavioral health teams, and behavioral health crisis stabilization units (CSU's) rather than law enforcement and hospital emergency department (ED) use.

This presentation will explore this evolution of systems and the tension present in crisis care at all levels, involving balancing safety with minimizing trauma by using the least restrictive supports for an individual’s needs. It will explore innovations and best practices helping advance this shift in roles and partnerships of caring for higher acuities related to imminent risk of harm to self and others, substance use, and physical health challenges that often automatically connect those in crisis to law enforcement and Emergency Departments as the front-line care option. The session will examine (1) 911/988 coordination and management of risks other than harm to self with crisis call centers, (2) the coordination of law enforcement and emergency medical services with mobile behavioral health teams and mobile dispatch, (3) Emergency behavioral health CSU's infrastructure of medical tools, staff and training in triaging and managing medical, psychiatric, and substance use needs safely and effectively (4) and the balance of the opportunity for a near zero sequential intercept, inclusive coordinated system for all in crisis with care that feels like care in the face of challenges in overcoming barriers to this change.

The presentation will reflect on real-life examples of challenges, successes, and opportunities encountered in managing high acuity situations, derived from ten years of experience in diverse crisis service levels and leadership positions. It will highlight the significance of effective high acuity management in fostering inclusive environments that welcome all, thereby reducing implicit bias in healthcare access and restricting law enforcement's role in crises to instances of immediate risk to public safety.

Learning Objectives:
The audience will understand how managing higher acuity at each crisis level is important to creating access to all that feels like care and minimizing Emergency Department boarding and legal involvement.

The audience will learn about current tensions in safety vs. creating access to care at each of the three major crisis levels with real-live examples and discussion with the audience.

The audience will learn about tools, training, and systems that support managing high acuity levels safely in this model.

Crisis services definitions can vary widely depending on one’s location; the concept of a CSU (Crisis Stabilization Unit) can even mean completely different things depending on what part of the country one is in. Understandably, this variation has led to confusion as well as difficulty in establishing federal guidelines, regulations, and reimbursements; an attempt for nationwide standardization has been long overdue. To address this, in 2024 national experts from the worlds of emergency psychiatry and crisis care were assembled by the federal Substance Abuse and Mental Health Services Administration (SAMHSA) division of the U.S. Department of Health and Human Services (HHS) in Washington, DC, to serve on the Crisis Services Standards and Definitions Workgroup. This Workgroup was given the marching orders to: build upon partner research, environmental scans, claims review, and experiential data, with a focus on addressing the widespread variability in crisis service definitions. This variability is particularly notable for mobile crisis and crisis stabilization services. This Workgroup was to propose draft model standards that can be used by State, Territory, Tribal, and local partners; providers; as well as public and private payers. SAMHSA and HHS stated a belief that this clarification of crisis services standards and definitions will promote widespread alignment, further payor adoption of crisis service coverage, and increased access to quality, equitable care.

Two AAEP leaders who were included in this project, along with one of the top Crisis Services and Suicide Prevention authorities from SAMHSA, will report to the NUBE audience, with a view from a participant’s lens on the deliberations and outcomes of the national consensus -- and offer insights on how the new federal standards will affect all aspects of individuals and organizations in the crisis and emergency psychiatry spectrum for the foreseeable future.

Learning Objectives:

Describe the problems created by the lack of standardization and consistent definitions of crisis care spectrum programs across the USA.

Identify the varied levels of emergency psychiatry programs and crisis care programs.

Differentiate between Behavioral Emergency and Crisis Stabilization levels of care.

This panel presentation aims to spark dialogue among attendees about the future of emergency psychiatry training and provide a roadmap for curriculum enhancement.

Emergency psychiatric care has significantly evolved since the American Association for Emergency Psychiatry (AAEP) published its model curriculum in 2004. This presentation examines the existing curriculum and proposes essential updates to align with current practices and emerging challenges.

The original AAEP curriculum, developed by consensus in the late 1990s, provided a comprehensive framework for training residents in core competencies like rapid assessment, crisis intervention, and risk management. These foundational skills remain crucial. However, the evolving nature of healthcare delivery, technological advancements, and shifting patient demographics necessitate a curriculum revision.

We will begin by reviewing the AAEP consensus process and the key components of the 2004 curriculum that remain relevant. These include prioritization skills, patient assessment and management, crisis intervention techniques, and professional communication. We will then introduce new areas for integration into the curriculum to address contemporary challenges.

Proposed additions include:

1. Telepsychiatry Competencies: Training residents to conduct remote emergency assessments and interventions effectively.
2. Substance Use Emergencies: Enhanced training to manage the ongoing opioid and stimulant crisis and evolving drug use patterns.
3. Cultural Competence and Health Equity: Skills to provide culturally informed care and address disparities in emergency psychiatric services.
4. Interdisciplinary Collaboration: Emphasizing effective teamwork with diverse healthcare professionals, as per ACGME “teaming”.
5. Community-Based Crisis Intervention: Working with the site-specific variety of emergency psychiatry service delivery modalities, such as mobile crisis teams and community-based emergency services.
6. Updated Psychopharmacology: Focus on newer medications and rapid-acting interventions for acute agitation, suicidality, and withdrawal management.
7. Legal and Ethical Considerations: Addressing challenges in involuntary treatment, capacity assessment, patient rights, boarding issues, and duty to protect.
8. Suicide/Violence Risk Assessment: Understanding evidence-based tools, improved EHR screening protocols, and technology integration. Personalized, collaborative safety planning and follow-up care.

We will also identify elements of the original curriculum to be de-emphasized or removed due to changes in practice patterns.

Finally, we will discuss strategies for residency programs to incorporate these updates effectively, including integrating new content into existing rotations, technology for education, and developing partnerships with community organizations.
By modernizing the emergency psychiatry curriculum, we can ensure that the next generation of psychiatrists is well-prepared to meet the complex needs of patients in crisis.

Learning Objectives:

Identify core components of the 2004 AAEP emergency psychiatry curriculum that remain essential and those requiring updating or removal.

Describe at least five new content areas to be incorporated into emergency psychiatry residency training to address contemporary challenges.

Discuss strategies for implementing curriculum updates in residency programs, including integrating new content and leveraging technology for education.

Background: PSYCKES (Psychiatric Services and Clinical Knowledge Enhancement System) is a web-based, HIPAA-compliant platform developed and managed by the NYS Office of Mental Health that integrates statewide information on the patient’s mental health and general medical history including ER and inpatient services, medications, outpatient providers and service utilization, and high-risk alerts related to suicidality/self-harm and opioid overdoses. In 2018, the NYS Department of Health (DOH) and the Office of Mental Health (OMH) recommended emergency departments (EDs) use PSYCKES, and launched the Behavioral Health High Risk Quality Collaborative (HRQC) in 2019 which supported implementation of PSYCKES in as a tool to help identify and evaluate individuals with high behavioral health risks, including history of suicide attempts, overdose risk, and high utilization of emergency and inpatient mental health services. We examine the impact of HRQC learning collaborative participation on PSYCKES access and usage by ED staff, as well as lessons learned from implementing this health information tool in emergency departments.

Methods: The PSYCKES application was made available to all EDs in NYS in July 2018, and EDs were invited to enroll in the HRQC to support implementation. The HRQC was launched in January 2019, and participating EDs submitted action plans and participated in individual technical assistance calls to assess progress and troubleshoot implementation challenges. Notes taken during the calls identified implementation barriers and action steps to be taken by the ED project teams to address those barriers. We compared HRQC participating and non-participating EDs on PSYCKES use at baseline (year prior to launch) and monthly over the five years after the launch. Measures included the number of PSYCKES users per month by hospital/participation status (data source: PSYCKES usage logs), and the proportion of Medicaid patients receiving a behavioral health related ED service that had their PSYCKES clinical summary viewed (data source: Medicaid claims and encounter data, and PSYCKES usage logs). Additional information on PSYCKES use in the ED was obtained through a post-project survey administered in Spring 2024.

Results: The number of PSYCKES users, and the proportion of behavioral health presentation who had their clinical summary viewed in PSYCKES increased over time. We share the characteristics of hospitals with increased PSYCKES use including participation status, and ED type. Over half (52%) of HRQC-participating EDs reported implementing PSYCKES for all psychiatric presentations, and a third (32%) reported using for a subset of based on patient factors, with some EDs reporting variation in use by staff preference and ED shift. The PSYCKES clinical summary information EDs reported using most frequently was level of ER/inpatient utilization, identifying care coordination and outpatient providers, medication reconciliation, and risk information.

Lessons Learned: ED implementation experiences highlight the need for multi-department buy-in on the value of integrating behavioral health information into general ED processes, the challenge of incorporating external technology into ED workflows, and approaches for identifying and training staff during a time of significant bandwidth constraints and turnover. Despite challenges, the majority of EDs were able to successfully implement PSYCKES to support screening, assessment and discharge planning.

Learning Objectives:

Summarize the benefits of using a statewide mental health information sharing program in the emergency room.

Describe the strategies and challenges in implementing behavioral health information technology in general emergency services.

Explain the impact of the NYS High Risk Quality Collaborative on uptake of the PSYCKES application, a statewide mental health information sharing platform.

Background: The Behavioral Health High Risk Quality Collaborative (HRQC) for Emergency Departments focused on the development and implementation of consensus best practices for screening, assessment, treatment, and discharge planning in the emergency department for high-risk behavioral health populations including individuals at high risk of Opioid Use Disorder and/or opioid overdose, suicide, violence, and high utilization. We examine the impact and lessons learned in this statewide collaborative, focusing on overdose risk.

Methods: 64 hospitals with 90 emergency department services participated in the HRQC. In Phase I, EDs participated in a Best Practices Workgroup to develop consensus best practices for four high behavioral health risk presentations (overdose, suicide, violence, high utilization), and implemented a regional mental health information sharing application (PSYCKES) in their ED. In Phase II, EDs implemented the consensus best practices and assessed their implementation status quarterly (each best practice rated on a 1-5 Likert scale from no to full implementation). In monthly learning collaborative calls, presentations by participating EDs or external experts highlighted resources, strategies, and challenges in implementing best practices. The HRQC technical assistance team offered monthly individual meetings with ED point persons to review existing ED workflows, identify gaps and opportunities, review external resources and strategies used by other EDs, and develop action items. Highly engaged EDs were defined as those with 6 or more individual consultation calls with the technical assistance team.

Results: In Phase I, EDs developed 36 consensus best practices (≥80% participants endorsed) for high behavioral health risk patients, with 10 of those for OUD/overdose risk. In addition, participating EDs had increases in the number of PSYCKES users and proportion of behavioral health presentations where the statewide clinical summary record was reviewed. In Phase II, EDs reported an increase on average in their level of implementation of best practices from Summer 2022 to Spring 2024. The largest increases in implementation were observed for highly engaged EDs (52% of participating EDs with 6+ TA consultation calls), with the greatest gains related to OUD specific best practices including buprenorphine inductions in the ED and providing naloxone kits with harm reduction education prior to being discharged. EDs that implemented OUD screening and OUD safety planning/relapse prevention planning also had higher levels of implementation of best practices overall. Qualitative notes from ED meetings identified barriers and strategies to address challenges.

Lessons Learned: EDs were able to develop and implement consensus best practices, with greatest gains observed for EDs that were more engaged or focused on OUD best practices. The HRQC identified challenges in implementing OUD best practices, including staff discomfort with treating patients with OUD and knowledge gaps among staff about which patients had elevated risk for an opioid overdose. Effective strategies to address these challenges included staff education and training on risk factors for opioid overdose, harm reduction, naloxone use and patient education; learning from clinicians that had expertise in buprenorphine induction in the ED; and developing a workflow to support best practices.

Learning Objectives:

Summarize ED consensus statements on OUD treatment and harm reduction related best practices for emergency departments.

Describe challenges and barriers to implementing OUD best practices in emergency services.

Describe strategies and lessons learned to support implementation of OUD best practices in emergency departments.

As one of two healthcare systems within a Midwest city, Summa Health struggled to maintain continuity of care across encounters. The same individual seeking care for the same chief complaint might receive vastly different treatment based upon the clinicians caring for them from encounter to encounter. Furthermore, each encounter was treated by clinicians as a stand-alone interaction. Clinicians might “chart review” what had been done at a prior encounter, but there was no mechanism to share a comprehensive understanding an individual’s goals, needs, and challenges. Additionally, no structured way to incorporate community-based interventions into hospital-based care existed – patients effectively were “discharged” to find their way. As a result, the same patients with the same challenges were treated over and over with little forward progress made.

Among front-line clinicians of all varieties, this status quo was a source of frustration. Collaborating on care plans was time-consuming and ad hoc. Thus, Summa Health Department of Psychiatry developed a Complex Patient Treatment Planning Committee, involving clinicians from multiple disciplines and specialties to collaborate in the development of Complex Treatment Plans for a subset of individual patients who were not being well-served with an ad hoc process. A registry of patients was developed, multidisciplinary treatment plans were developed and vetted by experts across a variety of settings, and these plans were shared across the system and the community to support a unified approach to help individuals meet their goals.

As a result of this Committee, individual clinicians were supported in their care of these complex patients with a robust treatment plan that crossed between encounters and organizational boundaries, improving patient care and reducing clinician frustration.

Learning Objectives:

To describe the challenges of caring for complex patients within a fragmented healthcare system.

To provide an example of one approach to complex treatment planning within a healthcare system and community.

To examine the factors that may contribute to success for a multidisciplinary team approach to increasing continuity of care for behavioral health patients.

The Huntsman Mental Health Institute (HMHI) of the University of Utah, through active involvement and integrated efforts with our community, have developed an alternative to Emergency Departments for the evaluation, stabilization and treatment of people experiencing acute mental health exacerbations. In this presentation, we will discuss the HMHI Receiving Center, which provides emergency care for individuals experiencing a mental health crisis. It is also serving as a pilot program for the Kem and Carolyn Gardner Mental Health Crisis Care Center (MHCCC), affiliated with HMHI, which will open in March 2025. This presentation serves to introduce the HMHI Receiving Center purpose and to discuss initial findings of this pilot program to serve our community.

The HMHI Receiving Center provides walk-in treatment as well as EMS/Police/Fire drop off for patients to get services and treatment 24 hours a day, seven days a week. Services include short, highly intensive interventions focused on resolving crises in the least restrictive manner possible. Services include crisis evaluation, psychiatric assessment, medication prescribing, peer support, case management, and connection to on=going resources and support, and crisis observation, if needed for up to 23-hours. The HMHI Receiving Center also provides detox initiation for community rehabilitation programs, inpatient medical detox, and HMHI Bridge outpatient medication-assisted treatment program.
Through a collaboration with Salt Lake County and multiple community partners the MHCCC will be a centralized emergency psychiatric center for the county of Salt Lake City, Utah. Taking data and experience from the HMHI Receiving Center we have been able to further develop and trial how to best facilitate the needs of our patients and community partners.

Learning Objectives:

The HMHI Receiving Center is an alternative to psychiatric emergency rooms for the people of Salt Lake County.

Utilizing community partnerships allows for a centralized psychiatric emergency center.

Discussing of initial data from our pilot program to show how this model can alleviate some burden on emergency departments.

We will walk through the case of a 10 year old child with a psychiatric history of complex PTSD, ADHD and DMDD presenting to the emergency department for “aggression”. The patient spent 20+ days boarding until a residential placement was found. In those days, there were more than 30 workplace violence injuries, 50 violent restraint episodes, and countless brainstorming sessions. When the “going got tough” and the facilities' process, resiliency, and resources were challenged, “the tough got going”. A multi-disciplinary team came together to optimize pharmacotherapy, behavior modification, therapies, and other modalities to remain true to our mission and “do what is right for kids”.

Learning Objectives:

Identify pharmacologic options for agitation.

Self report increase knowledge related to care of complex pediatric patients.

Self report increase in knowledge of non-pharmacologic agents of behavioral change.

Psychiatric assessment relies heavily on history; it is important for accurate assessment to have reliable information about a patient's past. Many times patients are unable or unwilling to provide such information themselves. Even when they do supply information, it may be incomplete or of questionable authenticity. This happens often enough to consider obtaining collateral information to get what is necessary to develop a diagnosis and treatment plan. Without such information errors may be made, with possible serious consequences. In emergency room assessments, often a decision must be made about potential dangerousness to self or others and the need for hospitalization. 

Current electronic medical records have embedded many tools to assist clinicians in providing care. Records of encounters within the institution can be easily searched. Some systems, such as Epic, have a function (in Epic's case, CareEverywhere) which can display records from other institutions. Other online sources exist, such as Prescription Drug Monitoring Programs, criminal justice docket sheets, general search engines and social media sites. Patients' insurers are also helpful sources of data, as are calls to pharmacies (often mandated by medication reconciliation requirements.) Phone calls to emergency contacts and others in a patient's life can yield vital historical and current data—whether patients must consent to such calls is debatable, and often waived if evaluation is truly emergent and care is taken not to release any information save that the patient is being evaluated.

Many laws and practices have weighed in to protect the privacy necessary for appropriate medical care, especially psychiatric and substance abuse services. In the US this is done notably by the Health Information Portability and Accountability Act (HIPAA) and Consolidated Federal Regulations Title 42 (42CFRPart 2) as well as applicable state laws. There is some confusion, as well as reasonable differences of opinion, concerning the balance between privacy and clinical imperatives.

We will present our experiences and informed opinions on the utility, bordering on necessity, of obtaining collateral information on nearly every patient assessed in an emergency setting. Legal and ethical concerns will be highlighted. Methods for doing such searches will be reviewed, as well as management of phone calls to other contacts. We will seek participation from our attendees on their use of collateral information in decision-making and work toward development of best practices for assessment.

Learning Objectives:

Describe the value added to assessment by including collateral information.

List applicable legal and ethical considerations in contacting collateral sources.

Demonstrate familiarity with searches within electronic health records and online.

Ethical issues, particularly those involving respect for patient autonomy, arise in emergency psychiatry practice all the time. Most clinicians working in this setting recognize that there is an ethical component when a patient is committed or determined to lack capacity to make their own medical decisions. In these cases we determine there is a good reason to override the person’s autonomy. Yet, the ethical issues are woven into the clinical care so tightly when the illness is directly impacting the patient’s ability to make decisions for themselves, that we often simply do not think about them. We think of ethics as the discussion of the complicated cases that cause disagreement among staff or catch media attention and we do not examine the ethics of the small decisions we make all of the time. If we did recognize and take a few minutes to explore these small decisions in everyday practice, we might discover that some are driven by systemic issues of bias toward our patients that have been written into our processes and procedures. Recognizing this may be the first step we can take in working toward change.

As an emergency psychiatrist who has recently completed a degree in bioethics, I now notice the small things we do every day that have ethical ramifications and deserve our attention. And I see how some of the dilemmas we face are created by how we do our work. Can we change? Maybe, but first we must see the problems. We are all busy doing our day-to-day work and stepping back to examine underlying ethical concerns is difficult. Thinking of ethics in the context of everyday work rather than as something separate and associated with only the complicated cases may help us provide better and more ethical care.

In this brief “rapid fire” presentation, I want to encourage audience members to recognize and begin to examine the small things, the “microethics” of our everyday practice. I will start by reviewing the concept of what is referred to as micro or everyday ethics in medical practice and will then use a case or two to further illustrate my points. This will be followed by a few minutes for audience members to share their own stories of every day ethical decisions. My hope is that this presentation and brief discussion will simply be a first step in beginning to think about ethics in our everyday interactions, while considering how this information can help us address procedural issues.

Learning Objectives:

Define microethics, the ethics of everyday clinical practice.

Identify an ethical issue in your everyday practice and explain why it is an ethical issue.

Explain how recognizing a microethics issue can help you identify underlying processes and procedures that may need critical reexamination.

Working in the emergency department, often means psychiatrist will hear about trauma. In the child psychiatry world, this trauma is often abuse. As a mandated reporter, a psychiatrist is obligated to report abuse. This task can often feel daunting. It can feel daunting due to lack of understanding about the child welfare system. In addition, there is often guilt about what the child protective services (CPS) will do to the child. Hence often psychiatrists will skirt around having these difficult conversations with the child and family.
 
This session will highlighting several child protective cases. During the case presentations, it will to utilize three separate areas interviewing skills, review of common roadblocks with using child protective services, and how to use multidisciplinary teams when working with a traumatized child and to overcome the challenges when working with CPS.
 
Although each case will have elements of all three practical skill. Case one is about a child whom is not talking but there is a high suspicion of abuse. Case two involves a case where CPS is already involved but you still have concerns about their welfare and are concerned about the child going back to abuser and you are unable to contact their case worker. Case 3 involves a child that is abandoned in the emergency department. All three of these cases involve a wide variety of problem solving to help child and the emergency department/hospital needs.
 
Pooja Amin will provide a brief overview of the child welfare system. Pooja Amin and Dr Meghan Schott, will provide an overview of the cases. Finally, Dr Schott, a child and adolescent psychiatrist will share her experiences of serving on DC’s citizen review panel, a federally required entity for each state to review child protective services.

Learning Objectives:

Equip participants with effective interviewing techniques and communication strategies to help children feel safe and comfortable discussing their experiences with ongoing abuse.

Enable participants to identify common roadblocks in working with Child Protective Services (CPS) and develop strategies to effectively navigate these challenges.

Explore the roles of various professionals (e.g., social workers, psychologists, legal representatives) in managing and supporting child abuse cases within the emergency psychiatry setting.

Objective: This scoping review aims to summarize the current state of research literature on the management of agitation and aggression in the care of youth with Autism Spectrum Disorder (ASD) in the emergency department (ED). Clinical guidance for the management of agitation in this patient population will be outlined.

Method: This study used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) extension for scoping reviews searching PubMed and PsycINFO databases (May 1, 2013 through July 24, 2024) for studies that reported management of agitation or aggression in the care of youth with ASD in the ED.

Results: Management of agitation and aggression in the care of youth with ASD in the emergency department has been documented. Approaches include beginning with a rapid assessment and functional behavioral assessment. There exists a typical differential diagnosis followed by non-pharmacologic and pharmacologic treatment strategies. Restraint and inpatient psychiatric hospitalization are discussed.

Conclusion: There exists a growing literature on the management of agitation and aggression in the care of youth with ASD in the ED. Recommendations for the management of this patient population in the ED are outlined.

Learning Objectives:

Attendees will understand the current evidence base for the management of agitation of pediatric patients with ASD in the ED.

Attendees will understand clinical recommendations for the management of agitation in pediatric patients with ASD.

Attendees will learn how to integrate both non-pharmacologic and pharmacologic strategies for managing agitation in pediatric patients with ASD in the ED.

Despite increasing psychiatric and behavioral health presentations to emergency departments, Emergency Medicine (EM) residents and physicians have limited training in caring for these patients. The training that is received is not standardized across residency programs and is primarily focused on didactic lectures. During this session, we will discuss our own approach to bridging this gap and the development of a fellowship designed for EM-trained physicians. Our fellowship is housed at a large, urban, tertiary-care medical center and includes rotations with the Department of Psychiatry’s inpatient units, inpatient consult-liaison service, emergency consult service, and addiction medicine service as well as an outpatient continuity clinic.  Finally, we will discuss the observed and anticipated effects of escalating training for EM-trained physicians.

Learning Objectives:

Summarize the current state of psychiatric and behavioral health training for Emergency Medicine physicians.

Describe the development of a psychiatry and behavioral health fellowship at an urban, tertiary-care medical center.

Discuss the anticipated effects of increased psychiatric training for Emergency Medicine physicians.

AAEP has been intensely involved in the idea of emergency psychiatric training for decades. Our mission notes that we want to advance this knowledge base for the good of all involved.  As such, the idea of specialty certification and/or fellowship is paramount.

The purpose of this conversation is to update attendees on steps/process/progress made on this topic from the AAEP perspective. This will include examining past attempts, the current state of affairs, and the details on this endeavor going back approximately 3-5 years.

We will look at the differences in categories (fellowship vs. certification vs. focused practice designation) as well as how this affects the abilities for this work to affect psychiatrists, emergency medicine physicians, or both!
Part and parcel to the past years' work will be a explanation of our partnerships with multiple important stakeholders. This includes but is not limited to ABEM, ACEP, ABPN, and the APA. Additionally, we will note how conversations were had with many other important components (AADPRT, CORD, NAMI, ACLP, etc…).

Further examination will be given to the need to examine the core population of who would be utilizing this (emergency medicine, psychiatry, or others) as well as what this process would look like. We will also examine the synergy that exists when combining two professional medical groups as opposed to solo efforts within one specialty silo.
Lastly, we will provide data on where any pertinent processes stand, including public commentary, support, and criticisms. As such, this talk will serve not only to educate on this SPECIFIC topic but also to show a more GENERAL example of how to advocate on important emergency psychiatry topics over an extended period of time.

Learning Objectives:

Discuss the need/rationale of a formal emergency psychiatric certification/recognition.

Process the varying degrees of certification and fellowship that exist, as well as the benefit/risk towards exploring each category.

Inform and update attendees on AAEP progress and related partnerships with ABEM, ABPN, ACEP, APA , and others as a means to the operationalization of this goal!

The AAEP Rising Scholars Program recognizes and supports the development of junior faculty and trainees who have the potential to make substantial contributions to the practice of emergency psychiatry. This one-year Fellowship offers a year-long, mentored experience. The program seeks to help emerging scholars deepen their connection to AAEP and develop a professional network that can accelerate innovation and collaboration.

Join us as we present the Rising Scholars Awards to the 2024 awards recipients:

Christine DeCaire, MD
Katherine Dowdell, MD  
Christina Jones, DNP, PMHNP  

Background: Emergency Department (ED) visits for psychiatric concerns are increasingly common, comprising >10% of more than 130 million ED visits annually (Theriault, 2020). Despite the growth of ED-based psychiatric care, there are limited data available regarding staffing and service models, productivity, resource utilization, and clinical quality of emergency psychiatric care (Bruffaerts, 2008; Lofchy, 2015). This study aims to address this gap by characterizing existing service models, quality-/value-based metrics, and best practices across a spectrum of Emergency Psychiatry practice settings nationwide.

Methods: Invitations to complete a voluntary, anonymous, 30-question Qualtrics survey were disseminated to the email listservs of two national Emergency Psychiatry organizations between 12/5/2023-2/23/2024. Potential participants entered their primary practice institution into a Google-based worksheet, and survey links were sent to the first respondents from an identified institution to mitigate duplicative responses. 30 complete survey responses were received. The survey and project proposal were reviewed by the IRB, and a determination was reached that the project did not meet criteria for human subject research on 11/21/2023.

Results: 30 respondents representing all geographic regions of the United States reported on coverage hours by psychiatrists (averaging 24-35 hours per week), accessibility and delivery of services across different shifts (with in-person services predominant, particularly during business hours), and annual ED patient volumes (ranging from <10,000 to >100,000 annual visits). Over 70% of respondents reported having access to inpatient psychiatric units. Frequent ED boarding of psychiatric patients was observed in approximately 60% of settings, with identified causes including community inpatient psychiatric bed shortages and transportation issues. Most respondents expressed uncertainty or dissatisfaction with the adequacy of training for emergency medicine (EM) physicians and trainees in managing acute psychiatric presentations; some institutions offered psychiatry-specific EM training. Quality metrics were commonly utilized to measure service performance and value, with metrics including service response time, restraint use, ED readmissions, and length of stay. Clinical best practices included initiation of medication-assisted treatment for substance use disorders, completion of suicide safety plans, provision of bridge psychotropic medication prescriptions, and naloxone dispensing.

Lessons Learned: While Emergency Psychiatry is practiced using diverse models of service delivery and staffing, there are common practices and challenges across settings and geographic regions. These data can be utilized to drive practice benchmarks and best practice guidelines for a growing subspecialty while supporting efforts to enhance the quality and effectiveness of services in this critical area of healthcare.

Learning Objectives:

Characterize Service Models and Staffing in Emergency Psychiatry.

Evaluate Resource Utilization and Clinical Quality Metrics in Emergency Psychiatry.

Identify Common Challenges and Best Practices in Emergency Psychiatry.

Background: Homelessness is a risk factor for Emergency Department (ED) utilization.(1) Additionally, people who are unhoused are more likely to have a mental health diagnosis compared to the general population. Among persons with mental illness, homelessness increases ED utilization.(2) In most healthcare systems, frequent ED users are more likely to have a mental health diagnosis.(3)

In context of the above discussion, it is reasonable to suggest that access to shelter impacts ED utilization. During cold weather months, the incentive to avoid cold exposure may increase ED use, especially if there is scarcity of shelters or other housing resources outside of the hospital setting. However, there is limited research — particularly in the United States — describing this phenomenon. In October 2023, the City of Detroit made a significant change to its shelter access policy: intakes were limited to Monday through Friday 8AM-6PM, and walk-ins were no longer allowed. We hypothesized that the reduction in shelter access would lead to an increase in ED visits due to homelessness.

Methods: A preliminary analysis of ED visits at an urban Level I Trauma Center in the Midwest (90,000+ visits per year) after the change in shelter access revealed an increase in total visits related to homelessness in 10/2023-12/2023 as compared to the previous year. To quantify the overall impact of this change, we conducted a retrospective chart review of ED visits during cold weather months by unhoused individuals before and after change in shelter access occurred (10/2022-3/2023 and 10/2023-3/2024). Unhoused individuals were identified through multiple avenues using homelessness-related ICD-10 codes and ED chief complaints. Additional variables collected included: total ED visits and ED length of stay, and presence/absence of psychotic disorders, bipolar disorders, alcohol use disorders and substance use disorders (also using ICD-10 codes).

Results: Initial analysis in this review demonstrated a 10% increase in the total number of ED visits by unhoused individuals between the two time periods. There was also a 4% increase in the number of different patients who made ED visits between the two time periods. Not all data has been abstracted or analyzed (expected complete date: 9/30/2024) though the next steps include: calculating ED LOS (average and total) for these groups, ED disposition, frequency of psychosis/bipolar disorders/substance use disorders and alcohol use disorders in each population. We hypothesize that the reduction in shelter access led to a disproportionate increase in ED visits by those with severe mental illness and/or substance use disorder diagnoses who are unhoused.

Conclusions: The ED perceived an increase in presentations and boarders after shelter access changed. This study will quantify if there was an actual change and, if so, what risks factors/vulnerable populations were affected. This study contributes to the understanding of how social determinants of health, such as housing, interface with the healthcare system. Our findings draw attention to and reflect a potential need to revisit shelter accessibility in urban areas, as a vulnerable population is being affected in a manner that is increasing the strain on the healthcare system.

Learning Objectives:

Audience members will be able to describe one example of how social determinants of health (e.g. shelter availability) affect emergency department utilization.

Audience members will be able to describe how unhoused individuals with severe mental illness and/or substance use disorders are affected by shelter availability.

Audience members will be able to describe how access to shelter affects length of stay (LOS) and frequency of emergency department encounters.

Background: The United States continues to be in the midst of an opioid epidemic with the number of deaths due to overdose compounding each year. Although various measures have been employed to fight this epidemic, improving medication access is paramount. Buprenorphine is a very effective medication for OUD (opioid use disorder) that can significantly reduce the risk of overdose and improve recovery outcomes. The emergency department (ED) is primed to serve as an effective access point for initiating OUD (opioid use disorder) treatment, offering utility and ease of access to buprenorphine for patients in need.

Our poster presents a literature review of buprenorphine induction in the ED.

Methods: A systematic literature review was carried out based on the PRISMA model on PubMed. Search terms included (buprenorphine OR suboxone) AND (opioid use disorder OR Opiate misuse OR opioid abuse) AND (management OR treatment) AND (psychiatric emergency room OR CPEP). Papers published between 2012-2024 were included in this literature review. The literature review led to an initial discovery of 69 hits on Pubmed. After abstracts were reviewed for relevance, 28 comprised randomized clinical trials, observational studies, and implementation protocols.

Results: ED-initiated buprenorphine significantly improved patient engagement in addiction treatment at 30 days (78%) in comparison with a brief intervention (45%). It also led to higher retention rates (62-65%) and follow-ups indicating the potential for long-term sustained recovery. The effect of high-dose induction (up to 32mg) was studied which showed its effectiveness in rapidly stabilizing patients. From a financial standpoint, ED-initiated buprenorphine proved to be cost-effective ($54,000 per quality-adjusted life year) compared to standard care. However, there exist barriers to effective implementation such as additional clinician training and infrastructure that may not be available in EDs nationwide. For the maintenance of sustained treatment, ongoing support and resources are pivotal, requiring an integrated care model with ED physicians, primary care doctors, and psychiatrists.

Discussion/Conclusion: This literature review emphasizes the importance of buprenorphine induction in the ED as an effective and economic intervention for OUD. Evidence in the literature indicates improved patient engagement and better long-term outcomes. Future research should focus on understanding barriers to initiation to ensure equitable access, optimizing its implementation by training providers, having standardized treatment protocols, and providing appropriate referral channels.

Learning Objectives:

Understand the impact of ED-initiated buprenorphine on OUD treatment.

Identify barriers and challenges in implementing buprenorphine induction in the ED.

Discuss the role of integrated care models in supporting ED-initiated buprenorphine treatment.