NUBE 2025

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.