NUBE 2025

Background: Emergency Medical Services (EMS) play a critical role in the initial 9-1-1 response to individuals exhibiting suicidal ideation and behaviors, often leading to emergency department encounters. However, there is a significant lack of standardized training and guidelines for EMS personnel in this area, resulting in varied outcomes for those in crisis. In early 2024, Los Angeles (LA) County’s EMS Agency, the largest in the country, launched a quality and performance improvement initiative to evaluate the current evidence for EMS assessment and management of individuals with suicidal ideation and behaviors. This initiative has led to key recommendations for LA County to develop new standardized policies, practices, and training. This general session will review the current findings and status of LA County’s efforts to enhance the 9-1-1 EMS response to patients with suicidal ideation and strategies that can be deployed in local jurisdictions.

Methods: A multi-stakeholder, community-partnered, performance improvement committee consisting of representatives from EMS, law enforcement, emergency department physicians, psychiatrists, nurses, and the Department of Mental Health was formed to conduct a comprehensive evaluation of existing protocols, identify gaps, and develop recommendations for policy enhancement and training improvement. The committee conducted a comprehensive literature review, including policy review from 34 county EMS agencies across California and national guidelines, and identified strengths and deficits in the current EMS response through case studies of base hospital radio calls and robust interdisciplinary discussions. The committee also designed and deployed a cross-sectional survey to capture LA County EMS personnel’s experiences with current protocols, identifying common challenges they face in assessing and managing suicidal patients. These processes collectively led to identifying key areas to enhance EMS policy, education, and training.

Results: 0 out of the 34 California counties evaluated had dedicated policies for the evaluation and management of patients at risk for suicide nor were any substantive practices identified in national guidelines. References to “suicide” or “danger to self” were often embedded within broader contexts such as “restraints,” “refusal to transfer,” or “behavioral crisis,” with limited, non-specific guidance. Survey results quantified the current state of providers’ education and confidence in evaluating and managing patients at risk for suicide. These results, along with committee case reviews, identified domains for quality improvement including written protocols that define terminology and provide guidance on: use of an evidenced-based screening tool, determining disposition, safety planning, and protocols for interacting with law enforcement.

Conclusion: This general session will describe the critical gap in standardized EMS protocols for evaluation and management of patients at risk for suicide, including results of an LA County EMS provider survey and a robust committee process following a quality improvement framework. A thorough analysis of the current state identified opportunities for system-wide improvements and innovation in EMS quality of care for 9-1-1 patients at risk for suicide. Leaders in emergency psychiatry will understand strategies to collaborate with key stakeholders to develop appropriate policy, education, and training.

Learning Objectives:

Examine a performance improvement committee’s approach to evaluate the current state of EMS field evaluation and disposition of individuals at risk for suicide, including a review of best practices and an analysis of current field protocols across California.

Review the results of a cross-sectional survey designed to understand EMS providers’ perspectives regarding opportunities and barriers to improve care for patients at risk for suicide.

Explore strategies for improvement or innovation in EMS policy, practices, and training to enhance quality of care for 9-1-1 patients at risk for suicide.

Background: Currently, youth seeking emergent mental healthcare are often required to complete routine laboratory assessment, regardless of presentation, to ensure “medical clearance” prior to consideration of inpatient psychiatric care. These laboratory tests are often low yield and have the potential to cause significant trauma and avoidable restraint, particularly with youth. Furthermore, this introduces excess cost, spurious lab findings and delays in care for a system that is already constrained by long lengths of stay, inefficiencies, and excess cost. Several states have adopted evidence-based tools, or SMART clearance, and workflows to eliminate the use of routine laboratory findings for medical clearance and based this clearance on clinical presentation and judgment of medical and psychiatric staff.

Methods: We describe the project design and implementation of the MI-SMART tool (adapted from the Sierra Sacramento Valley Medical Society SMART project), via an initiative by the Michigan Department of Health and Human Services, at a large, academic, tertiary care children's hospital in the State of Michigan. This includes initial stakeholder development, including mental health professionals in consultation-liaison psychiatry, inpatient psychiatry and emergency psychiatry, pediatric hospitalists and intensivists, pediatric emergency department (ED) professionals, administrative and information technology staff, as well as partners at Community Mental Health and the Department of Health and Human Services. This stakeholder group met iteratively from January 2024-June 2024 to design workflows in the pediatric ED and psychiatric ED setting, as well as parallel workflows with the inpatient pediatric floors and pediatric critical care setting. The result was the piloting of a electronic medical record navigator with a standardized MI-SMART checklist and template for documentation, page alerts and best practice advisory alerts, workflows, tip sheets, and standardized education to operationalize the implementation of the MI-SMART resources. A data dashboard with key performance indicators was created to track process and outcome measures over time. The first three months of pilot data will also be presented as it relates to the relevant care of the pediatric population in the children's hospital.

Results: We will present stakeholder working group development, collaborative design of the MI-SMART resources, as well as pre-implementation data from the first three months of launching MI-SMART across the children's hospital. This will include review of process measures including number of MI-SMART forms utilized, acceptability of by providers and staff in the ED and hospital setting, number of youth successfully transferred to an inpatient psychiatric facility using the MI-SMART build and resources, time to triage in the ED to completion of the MI-SMART form, time to completion of the MI-SMART form and psychiatric consultation. Additional outcome measures that will be shared include routine labs and diagnostic studies gathered, cost, restraint use, as well as patient and family satisfaction.

Lessons Learned: Use of an evidence-based set of resources to mitigate the use of potentially unnecessary and traumatizing routine labs for medical clearance of youth requiring psychiatric admission may be a feasible, acceptable, and cost-efficient alternative to current medical clearance practice, while improving safety practices and patient, family and staff experience.

Learning Objectives:

Understand current evidence related to best practice for medical clearance of individuals, particularly youth, who require psychiatric admission from emergency settings.

Describe the process of designing an evidence-based tool to employ clinical judgment and best practice in supporting medical clearance of youth in the ED setting, rather than routine labs.

Review process measures and clinical outcomes resulting from initial data gathering on the implementation of the MI-SMART form and resources at a single, academic children's hospital.