NUBE 2025

Day 2 Opening Remarks - Leslie Zun, MD, Conference Director, Priyanka Amin, MD, and Jennifer Peltzer-Jones, PsyD, RN, NUBE Program Chairs.

When most physicians hear the term “negotiation”, they immediately imagine an adversarial process…..typically tied to contracts, employment agreements, or payer partnerships.  This brief session is meant to note an alternative view of this term that is actually VERY much in line with the ethos and mission of those administering emergency psychiatric interviews.

This conversation will note how there are innate components of the negotiation process that not only are already in use by AAEP members but also strategies that (once consciously noted) can be maximized to the benefit of both the professional and the patient.

Inherent in this will be discussion of how this approach embraces a principle approach that is non-judgmental, non-adversarial, and rooted in compromise and partnership. Additionally, we will proffer the five types of active listening…with the goal of moving our daily work from levels 1-2 to level 5!

By examining all of the above, the attendees will be able to have a “rapid fire” approach on what they are doing well in their interview processes….and what can be improved/enhanced. Inherent in this will be a better understanding of utilizing and maximizing the tenets of actual negotiation!

Learning Objectives:

Examine what "negotiation" actually represents while removing any adversarial nature attributed to this term.

Provide clear examples of how negotiation principles can benefit engagement and outcomes when interviewing individuals in crisis.

Manifest how negotiation philosophy can relate directly to the field of emergency psychiatry, as it emphasizes interventions that are non-judgmental, non-dichotomous, and welcome to compromise/amendment.

Learning Objectives:

The audience will be able to define what constitutes “sex trafficking”.

The audience will be able to name 1 population at risk for adult sex trafficking.

The audience will be able to name 1 way an adult is brought into sex trafficking.  

Behavioral emergencies often occur in high-stress environments, where immediate and effective intervention is crucial. Traditional emergency response methods may inadvertently retraumatize individuals who have experienced trauma. Trauma-informed care (TIC) prioritizes the safety, trust, and empowerment of patients, ensuring interventions are sensitive to the effects of trauma.

This presentation explores the core principles and practical implementation of trauma-informed care in emergency settings. Key principles such as safety, trustworthiness, peer support, collaboration, and empowerment will be highlighted. We will discuss strategies for training emergency responders, assessing trauma, and implementing immediate interventions.

Through a case study, we will demonstrate the real-world application and effectiveness of trauma-informed approaches, showcasing their positive impact on patient outcomes. This session aims to equip mental health counselors and emergency responders with the knowledge and tools necessary to enhance the overall response to behavioral emergencies.

Learning Objectives:

Participants will be able to define trauma-informed care and identify its key principles, including safety, trustworthiness, peer support, collaboration, empowerment, and cultural sensitivity, and understand how these principles can be applied in emergency response situations to enhance patient outcomes..

Participants will learn specific techniques and interventions for assessing and managing trauma in emergency settings, including immediate stabilization methods, effective communication strategies, and tools for screening and assessing trauma. They will also gain insights into training and educating emergency responders to integrate trauma-informed care into their practice.

Participants will analyze real-world case studies that demonstrate the application and effectiveness of trauma-informed care in emergency situations. They will be able to identify successful interventions, understand the challenges faced, and apply these lessons to their own practice to improve patient outcomes and reduce the risk of retraumatization.

As an ER nurse for twenty years and now a psychiatric nurse practitioner, I have never had a case impact my practice as much as Amanda's. I took care of Amanda as an ED nurse in May 2024. I want to share this fascinating and impactful case with conference attendees. It is a case full of assumptions.

A homeless 40-year-old female, Amanda, comes to the ED via ambulance after people living in a home became worried about "a woman lying in their backyard on a mattress, incontinent to urine and without pants for three days". The patient is severely sunburned (Phoenix in May), has a temperature of 103 degrees, but is alert and oriented. Pt denies mental health and substance abuse. No medical history and takes no medications. No old records are found. Basic labs and UA ordered, fluids hung, and ice packs applied to the neck and groin. Through conversation, it is discovered that Amanda has her master's degree in accounting and lost her job one year ago. She has two children she sees occasionally, and when asked what she does during the day, she replies, "I am a ho on the streets." As the patient's RN, I could not reconcile her situation with her presentation. I left my shift that night with a strong feeling toward this patient. I felt so strongly at one point that I even half-heartedly considered taking her home! I came back to work four days later and learned that Amanda had been admitted to the hospital with Hyponatremia and discharged the day before. She was discharged with a ride home but instead fell asleep on hospital grounds in a bush. I raised concern about her condition to multiple parties, and upon a more extensive review of her medical record, it was discovered that she had been diagnosed with a brain tumor on her front lobe in 2021 and even admitted to our facility in the Neuro ICU in 2021. After being sent to her mother's apartment and trespassed by police there, A "BOLO" is issued for Amanda to all charge nurses in the ED, and amazingly, she appears that same night again via EMS for nausea and vomiting. A head CT is done on her second trip to the ED, and doctors discover that her tumor is now the size of a softball on her frontal lobe, and it is impacting her decision-making. She is taken to the ICU and has a craniotomy four days later. A day after surgery, she is alert, oriented, and trying to rebuild a life with family members who had given up on her. This story has many twists and turns that make it even more compelling. All types of medical professionals (doctors, nurses, social workers) who participated in Amanda's story made assumptions about her in some way. It tells a story of how we can mistakenly view patients in the ED judgmentally and perhaps how changing our mindset can and will save a life just like Amanda's.

Learning Objectives:

Listen to a fantastic and heart warming story from an ED nurse who took care of a homeless patient (5/24) and changed both of their lives forever. This story is extremely relevant to all conference attendees.

Describe educational initiatives related to this case.

Discover how this case was presented to the “ER Behavioral Core team” to inspire participation and ignite a passion for improving the care of behavioral health patients in our ED.

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.

A patient dying by suicide is one of the most difficult aspects of providing mental health care. Many providers struggle with coping in the aftermath of a patient death by suicide. Despite providers’ difficulty in accurately predicting who will go on to attempt or die by suicide, there is increasing pressure from regulatory bodies for healthcare organizations and providers to prevent suicide, with much scrutiny when a patient dies by suicide as well as emphasis on zero suicide. The Joint Commission (TJC) changed their definition of a sentinel event pertaining to suicide to one that occurred within seven days after last contact with levels of care, including the emergency room. As the timeframe of patient death by suicide has been expanded from three to seven days post-discharge, with broadening of the levels of care included in TJC’s revised sentinel event policy, it is anticipated that there will be increased reporting to TJC and investigations within healthcare organizations to evaluate contributory factors and root causes associated with these patient deaths. Providers who are struggling with coping in the aftermath of a patient death or other adverse outcome may have difficulty effectively contributing to a patient safety investigation such as a root cause analysis (RCA) following the death of a patient. There are existing data showing that when providers impacted by an adverse outcome are appropriately supported, they can meaningfully contribute to improving the culture of safety in an organization.

This presentation will review the intended goals of patient safety investigations such as RCAs and the unintended impact these investigations can have on providers who worked directly with patients. Participants will learn about expected acute stress reactions and strategies for coping. The session will also review ways to support providers impacted by these events, both individually and through support programs.

Learning Objectives:

Describe the intended purpose of a root cause analysis (RCA).

List three acute stress reactions and three strategies for coping after an adverse event.

Identify resources for providers impacted by adverse events.

Junji Takeshita, MD, FACLP, AAEP President.

With rising incidents related to workplace violence, Emergency Department leaders at UCHealth in Fort Collins, CO found ourselves at a loss for how to best to support our staff in continuing to provide excellent care while facing increasing concerns of violent and disruptive behaviors within the workplace. After taking steps to address workflows within the department, we knew that we needed to get creative and look outside of the walls of the hospital to address the gap seen within our community. Partnering with local law enforcement and our cities municipal court system, we have developed the Healthcare Accountability Restorative Program (HARP) which aims to address common violations within the healthcare setting to hold individuals accountable while providing opportunities for treatment. By using a restorative justice model, HARP focuses on showing the impact the incident of violence has on the victim, community and the individual with opportunities to give back to each subsect with a variety of healthcare related tasks.

In this presentation we address what workplace violence is within healthcare, impacts these disruptions have on healthcare systems nation-wide, our experience with why violent and destructive acts are not being reported, and what we have created to address these gaps within our own community. We will discuss the development process of HARP along with the implementation of the program in April 2024. We will review our initial findings including barriers, opportunities for future growth, and the successes we have discovered along the way.

Learning Objectives:

Define workplace violence in the healthcare setting.

Identify common violations within the healthcare setting that would qualify for municipal court restorative justice programming.

Learn about the Healthcare Accountability Restorative Program (HARP) implemented in Fort Collins, Colorado and understand barriers and results from the first 8 months of programming post go-live in April 2024.

Emergency Departments (EDs) are seeing a rising number of visits related to behavioral emergencies. Evidence indicates that ED healthcare staff face increasing safety threats from workplace violence (WPV) while treating episodes of acute agitation. Historically, experts have often viewed Agitation and Workplace Violence (WPV) as two separate issues, with separate management and prevention strategies. A handful of researchers have begun to question this approach citing potential conflict between patient and staff safety goals within the recommended guidelines for management and prevention of acute agitation and workplace violence. In this context, Wong et al have proposed that agitation and workplace violence are not two separate issues, but rather, two sides of the same coin. ¹

In this presentation, a multi-institutional panel consisting of behavioral emergency and patient safety experts in emergency medicine, will present (i) findings from recent literature review, using a novel conceptual framework on the overlap (and conflict) between patient and staff safety goals within current best practice recommended guidelines for management and prevention of agitation and workplace violence (ii) in-depth discussion on the challenges posed by the above conflict, including duality of “patient care paradox”, related under-reporting of WPV events, staff frustration and burnout, implicit bias contributing to disparity in outcomes including higher use of restraints among vulnerable population, etc. (iii) and finally, we will propose that instead of the traditional approach of competing staff and patient safety goals, we need to adopt a more unified, trauma-informed, systems-based approach that focuses on improving overall (Patient & Staff) safety during management and prevention of agitation and WPV events.

This presentation will be conducted by our expert panel. During the presentation our panelists will draw from their own research, programmatic expertise, and clinical experience to provide a rigorous discussion of latest evidence and new research on management of Agitation and workplace violence, present evidence on conflicting goals for patient and staff safety and propose a novel, trauma-informed, systems-based conceptual model that will help guide future research and serve as a roadmap to help provide focus and prioritization for future research in principles of management of agitation, workplace violence, and disparity mitigation in order to create a safe setting for patients and clinicians alike.

Learning Objectives:

Analyze the factors (e.g. structural, organizational, interpersonal) that influence agitation management practices and exposure to workplace violence.

Compare and contrast the evidence of overlap (and conflict) in patient and staff safety goals within current best practice guidelines for management of agitation and workplace violence and evaluate a novel perspective about agitation and workplace violence management (they are not two separate topics, but “two sides of the same coin”).

Implement a trauma-informed, systems-based approach to local institutional guidelines that will prioritize overlapping principles of management of agitation and workplace violence to mitigate bias, disparity and improve safety for patients and clinicians alike.

Political ideology and beliefs are rarely illegal and seldom relevant in psychiatric emergency care. Nonetheless, security and intelligence professionals are increasingly recognizing that ideologically motivated violence is a leading threat. From skirmishes at public protests, to threats against public health leaders and poll workers, to insurrection, incidents both isolated and expansive are increasingly coming under public scrutiny. And as law enforcement agencies do a better job of embracing multidisciplinary strategies like behavioral threat assessment and management, This presentation will provide a basic overview of what is known about ideologically motivated violence in the United States and provide practical guidance for PES clinicians in evaluating and understanding people at the intersection of violence risk and extreme ideological beliefs.

First, clinicians must be able to carefully navigate potentially fraught discussions about political ideology in clinical settings. There has long been an opprobrium about discussing politics in the workplace. Delving deeply into political beliefs in behavioral health settings is complex and perilous, with notable risk of transference and countertransference leading to disruptions in the therapeutic alliance. Practical guidance on navigating these turbulent waters will be offered.
Second, clinicians need to understand that the overlap between political extremism and violence risk is small and nuanced. Extremist ideology may be incidentally noted during an evaluation or the ideology may be expressly linked to violent threats or behavior as the primary cause for evaluation. While the adage to use individualized assessment and individualized treatment plans holds true for people with extremist beliefs there are specific considerations which will be discussed pertinent to evaluation of people which apply in the evaluation and management of violence risk.

Third, considerations related to clinical and administrative decision-making will be explored. Just as law enforcement is increasingly partnering with behavioral health and social services for threat management cases, so too do we need to reach out in the management of our high-risk cases. Identifying psychiatric illnesses and social stressors amenable to clinical interventions is critical. Peer supports for hate-based ideologies and for parents of people with extremist ideologies may be available in some regions. In some cases, people who are ambivalent about continued engagement with extremist organizations may respond well to CBT and RET even in the absence of other psychopathologies.
Case examples, critical terminology, and guidance for building both ad hoc and lasting productive partnerships between clinical services and law enforcement partners will be woven throughout the presentation.

Learning Objectives:

Assess risk factors for violence relevant for people with strong political and ideological beliefs.

Formulate strategies for consultation and documentation in high risk clinical cases.

Develop personal strategies to recognize and mitigate personal and organizational countertransference.

In Malaysia, Dutch botanist Pieter Korthals in 1831 first discovered Kratom or Mitragyna speciosia. Kratom is derived from the Nitragyna speciose korth, a tropical forest tree found in Malaysia, Thailand and Myanmar. The trees’ leaves contain psychoactive opioid compounds, that have been consumed for thousands of years. Kratom contains alkaloids that bind to opioid receptors, with an opioid drug structure.

Kratom can be ingested in various routes, traditionally chewed but also smoked or strained in teas. The leaves have a very bitter taste that can be masked by adding sugar or honey in juices or teas. As an alternative, lemon juice can be added to facilitate the extraction of the plant alkaloids.

Kratom induces euphoria, and in lower doses acts as a stimulant, increasing energy, alertness, while in higher doses it induces sedation. Kratom is purportedly used for anxiety, depression, inflammation, libido. Importantly, given opioid activity, it suppresses opioid withdrawal. With regular use, Kratom is associated with dependence and addiction.
Kratom’s pharmacological properties are similar to those of opioids but unlike opioids it is not a federally regulated substance. There are increasing number of case reports with Kratom intoxications and withdrawals that are challenging for the physicians. Kratom is not a very commonly known substance and is also difficult to detect as it does not cause positive findings in urine drug screens. The assessment relies on the history from the patient or specific immune-assay tests. The treatment can consist of symptomatic treatment with Clonidine but also with Suboxone. There are several cases reported of Kratom withdrawal.

Kratom is gaining increasingly popularity and about 40 million Americans are current using Kratom recreationally. However, there are currently very limited clinical studies available that demonstrate safety and efficacy in humans. The FDA has not approved Kratom for any medical use, and publishes warnings regarding its toxicity. Available information is mostly based on reports from users or animal models. Case reports involving the use of Kratom are concerning and alarming. The use of Kratom is associated with increasing numbers of ER visits, calls to poison control centers and even deaths related to multiple causes.

This presentation is based on a systematic review of literature of the current available data on Kratom and will be providing physician and clinician education about Kratom as a substance.

Utilized sources were Pubmed, Ovid, Medline, PsychInfo, EMBASE.

Learning objectives:

Kratom use- Clinical presentations, toxicity, risks.

Pharmacology of Kratom.

Kratom use- Diagnosis and Treatment

Precipitated opioid withdrawal is an abrupt onset of severe withdrawal symptoms after administration of full or partial mu antagonists.  This clinical case series and skill building workshop will elucidate options for management of precipitated opioid withdrawal in the emergency department.  Precipitated withdrawal can lead to symptoms from piloerection, nausea, vomiting and diarrhea to delirium and critical illness.  This series will look at 3 different patient scenarios to help guide clinicians in providing critical care for patients in acute precipitated withdrawal.  The fear of this complication and challenges managing precipitated withdrawal can be a barrier for some providers in starting buprenorphine.  Education around how to manage precipitated withdrawal can assist clinicians in increasing their comfort with buprenorphine initiation.

The patient scenarios involve precipitated opioid withdrawal with naloxone and buprenorphine administration in the ED and in the community. Clinicians will have increasing comfort in assessing patients Clinical Opioid Withdrawal Score (COWS) as well as immediate management of withdrawal symptoms.

Patient #1 has initiated buprenorphine through a home start and is presenting to the ED with worsening symptoms of withdrawal.

Patient #2 received naloxone by EMS in the field after unintentional opioid overdose and presents to ED with signs of precipitated withdrawal.

Patient #3 was started on buprenorphine in the ED and has rising COWS despite maximizing buprenorphine dosing.

This presentation will discuss using multimodal agents including buprenorphine (IV, SL and patches), benzodiazepines, ketamine, anti-dopaminergic agents and full agonist opioids for management of opioid withdrawal symptoms. The clinical scenarios, patient characteristics, risk factors for precipitated withdrawal and patient outcomes as well as follow up care will be discussed. Clinicians can utilize these skills to improve care for patients and gain confidence in starting medication assisted treatment in the emergency department.

Learning Objectives:

Recognizing precipitated opioid withdrawal.

Treating precipitated opioid withdrawal with multimodal agents.

Increasing confidence to initiate buprenorphine treatment for opioid withdrawal safely in the ED.

Cannabis and cannabis derivates are enjoying wide popularity in the U.S. While many developments came to a hold during the Covid-19 pandemic, the legalization of cannabis further progressed along with an expanding market for Delta-THC.

Cannabis is federally a schedule 1 substance but hemp derivates are exempt from this law through the 2018 Farm Bill. The substances classified as hemp derivates include the Delta-THC and CBD. Due to this legal loophole, they are easily accessible and sold at local convenience stores, gas stations or online. The sales of Delta-THC in the last 2 years have exceeded over 2 billion dollars.

The most used Delta-THC are Delta-8-, 9- and 10-THC. Delta-THC’s effects are similar to marijuana as they induce euphoria, feeling stoned and can cause anxiety and psychosis. The effects on cognitive alertness differ as Delta-8 -and 9-THC are sedating while Delta-10-THC is rather activating. Altered sense of time as well as short-term memory deficits and poor concentration are associated with any of the Delta-THC. In addition, cardiovascular effects including tachycardia and hypertension have been reported.

Legally, the THC content of these substances is supposed to be less than 0.3% THC. The majority of Delta-THC do not undergo any laboratory testing prior to marketing. Conducted tests of products have shown discrepancies with worrisome results with deviations from the claimed content on the label by up to 150%.

There is no standardized method established to synthesize Delta-THC. Chemically, the Delta-THC are molecularly close relatives. First, manufacturers must extract CBD from hemp and then convert it to psychoactive cannabinoids. For this chemical synthesis process, unsafe household chemicals are frequently used. Those potentially leave residual substances in the Delta-THC, so that the substance can contain toxic solvents, for example acetone, heavy metals, or lead. These toxic byproducts can lead to harm in the user and potentially cause lung damage if smoked or vaped.
Along with the increasing popularity of Delta-THC, there are also increasing cases of toxicity being reported. During the time between January 2021 and February 2022, the DFA (U.S. Food and Drug Administration) reported over 2,300 calls to national poison control centers. Every third person who called poison control required a medical evaluation in a hospital setting, while one person required an inpatient admission. Due to these safety concerns, seventeen states have banned the sales of Delta-8-THC while seven others have restrictions in place.

This presentation is a systematic review of literature discussing the available data on Delta-THC for psychiatric and medical use. Utilized sources were Pubmed, Ovid, Medline, PsychInfo, EMBASE.

Learning Objectives:

Policy of Delta-THC, Legal aspects.

Effects of Delta THC use.

Toxicity of Delta THC.