Sandy Herman, MD, MS, FACEP
Community Behavioral Health Medical Director
During the 2019 SA, I told the group that I would not have a panel discussion concerning behavioral health patients presenting to our shops, and often boarded much longer than other medical patients. However, circumstances made me feel we needed to do it again. In fact, the usual boarding for a psychiatric patient is three to four times longer than other patients. This has caused significant back up in our Emergency Departments. It was noted in 2012 that there was a sharp rise in the number of behavior health patients presenting to the ED. It is now estimated that 15-20% of those in our departments have some underlying BH issue. Since September, I have been the Community Behavioral Health Medical Director and have been charged with going to all of our Departments in Tennessee.
The TDMHSAS, TCEP, and the THA workgroup boarding report identified three areas for improvement. First was the need for early evaluation and treatment as quickly as possible. This requires the use of multiple techniques including pharmaceutical intervention and calming techniques. Second was the increase utilization of CSUs. Finally, there was a recommendation to place a physician as a liaison between the emergency departments and the mental health community. I was offered that position and accepted the mission of going to all of our EDs and presenting a plan to reduce boarding and improve the use of forms 6401 and the CON 6404.
During our discussion, Mike Dietrich, VP, THA and I presented new treatment protocols and guidelines surrounding the use of 6401 and 6404. There has been a great deal of confusion surrounding the rules and regulations for these documents. One key question was when does the 6404 expire and it was explained that it does not. It may be rescinded by a physician exam. I also stressed one of our main roles is to differentiate agitation due to delirium from acute psychotic events and deliver proper early intervention.
I explained that we have educated ourselves and became proficient treating coronary events, sepsis, pulmonary disease and other medical conditions. It is documented in our literature that we are not confident initiating treatment to the agitated patient possessing a psychiatric disorder. I emphasized the fact that we needed to develop skills in this area. We provided our State recommended protocols for all to use.
The last item we talked about was the SMART Medical Clearance/Stability tool. This allows the Emergency Provider to follow a set of questions to practice consistently while avoiding unnecessary laboratory evaluation. It is better for the patient and will also decrease boarding along with unnecessary testing. The tool has been approved and is set for roll out in the next 60 days.