2020 Schedule

Wednesday, December 2

Time (EST)Session TitleSpeaker
6:00 pm – 7:00 pmMembership Meeting
7:00 pm – 8:00 pmClinical Controversy: Excited Delirium

In this live panel discussion, two emergency physicians with expertise in medication management for agitation will discuss the pros and cons of ketamine and the controversial diagnosis of Excited Delirium Syndrome.
Michael Wilson, MD

Les Zun, MD, MBA
Gary Vilke, MD

Thursday, December 3

Thursday Sessions Sponsored By:

Time (EST) Session TitleSpeakerTopic
10:00 am Opening RemarksLes Zun, MD, MBA
10:15 amWhither Emergency Psychiatry?

Emergency Psychiatry as a subspecialty has never been stronger. There are Emergency Psychiatry programs springing up both across the nation and internationally; several academic centers are now offering Emergency Psychiatry fellowships; and many young psychiatrists are now choosing Emergency Psychiatry as their career path. Emergency Psychiatry research is becoming highly published, and Emergency Psychiatry topics are currently ubiquitous in major academic and popular journals.
Yet despite all this, we are still seeing far too many locations where Emergency Psychiatry is still a virtually unknown concept. Psychiatric patients continue to board in emergency departments across the country, with clinicians longing for more inpatient beds as their only perceived solution, never even considering what emergency psychiatry interventions might help resolve. Patients with profound agitation and/or psychosis in many clinical settings regularly receive only physical restraints, forcible injections and heavy sedation as default standard treatments. Individuals with acute behavioral emergencies are too often excluded from traditional mental health programs and end up subdued by police and taken to jail or high-security locations, with little thought given to de-escalation attempts, alternate personnel, or expanded exclusionary criteria.
Scott Zeller, MDProfessional Issues
10:45 am988, ET3, NPSG 15, Virtualization and the Crisis Now Model

Like a physical health crisis, a mental health crisis can be devastating for individuals, families and communities. Too often, that experience is met with delay, detainment and even denial of service that can all add to a person’s trauma history. The National Action Alliance for Suicide Prevention Crisis Now model shows communities how to invest in a crisis response and continuum of services that works, in a partnership with hospitals and law enforcement where those entities attend to their core missions instead of being the de facto, patchwork response
Michael Allen, MD

David Covington, LPC, MBA
Professional Issues
11:15 amFellowship Training in Emergency Psychiatry: The Future of our Subspecialty

Emergency departments (EDs) are a critical setting for behavioral health treatment, yet quality emergency psychiatric care remains inconsistently available. Subspecialty fellowship training in emergency psychiatry represents the most transformative potential approach to improving psychiatric care in EDs and crisis centers.
In this panel presentation, we describe a new network of emergency psychiatry fellowship programs that are training the next generation of expert clinicians and leaders in the field.

These efforts will improve access to and the quality of mental health care for all patients regardless of treatment setting. Benefits of expanding fellowship training include improving patient outcomes, utilizing crisis mental health resources more efficiently, expanding access to quality care for underserved communities, fostering scholarship and research, and encouraging trainees from psychiatry, emergency medicine, and other fields to pursue a career in emergency psychiatry.

An introductory presentation and panel discussion will introduce audience members to fellowship training programs, including
• Historical efforts to build fellowships,
• Design and educational objectives of new training programs,
• Novel curriculum developments addressing the challenges of teaching emergency psychiatry,
• Efforts to achieve formal accreditation, and
• Financial sustainability.
Representatives from all of the country’s fellowship programs are included in this presentation. Finally, audience members learn how to support development of Fellowship programs at their own institutions.
Scott Simpson, MDProfessional Issues
11:30 amPanel DiscussionModerator: Seth PowsnerProfessional Issues
11:45 am

11:55 am
The Forgotten Collaborator: Suicide and Impacted Family Communication and Collaboration

Suicide is the 10th leading cause of death, resulting in approximately 44,000 deaths annually.
Patients presenting to the ED with self-harm or suicidal ideation are at high risk for suicide and death within the following year. With an alarming rate of 22% of those patients having accessed the ED one month before their death.
Suicidal or at-risk patients typically present at the ED accompanied by an impacted family member who cares for the patient during their most vulnerable moments and is quite simply the first responder when a patient is experiencing an acute crisis. However, due to the rapid-paced acute nature of ED care, impacted family members are often not recognized as indispensable resources. By failing to understand the critical role of the impacted family member, we inadvertently relegate them to being ‘The Forgotten Collaborator,’ the very person who is in the position to inform our understanding of the history and acute nature of the presenting suicidal crises.

In the 2010 ‘Framework for Action on Interprofessional Education and Collaborative Practice’ the WHO identified a deeply entrenched silo centric healthcare system. As part of the recommended healthcare reform, the WHO identified interpersonal collaboration, learning, and communication as remedies to this fragmented healthcare system. Central to these reforms, the WHO advocates a collaborative care model inclusive of interprofessional collaborative practice and communication. In this model, patients and their family members are full partners essential in that collaborative communication.

Remaining barriers to care and collaborative communication is never more evident in the treatment, evaluation, and care of the patient who presents as suicidal when the accompanying impacted family member is not recognized.

We should treat our patients with overt or passive suicidal ideations or behaviors the same as we would a cardiac or cancer patient. In these instances, we recognize the impacted family members of these patients as the first responder, accurate historian, and essential component of discharge care and critical to our patients’ ongoing well-being.
Collaborative care taken together with family practice principles advises that we expand our practice to invite family member(s) into the conversation. What do they know? What do they see? What are their fears? How prepared are they to support the needs of the patient?
Family members are a primary source of ‘protective factors’ in implementing a safety/crisis discharge plan in the ongoing care of patients who struggle with both acute and chronic suicidal tendencies. Family members should never leave an ED feeling as if ‘it is their job to keep their loved one alive.’ Through collaborative communication and compassionate, coordinated care, we are in the unique position to help the family member strengthen their ability and confidence to provide safe care for their family member, our patient.
Collaboration with family members is our best defense for an effective discharge plan that will help mitigate return visits to the ED or, worse yet, a successful suicide attempt.

Kathleen Carter-Martinez, EdDClinical: Family Involvement
12:00 pmAppropriate Evaluation for Medical Mimickers

Kimberly Nordstrom, MDClinical: Toxicologic & Medical Mimickers
12:10 pmA Review and Case Presentation of Two Challenging Toxicological Emergencies: Tramadol Induced Serotonin Syndrome and Spiceophrenia

Tramadol is commonly prescribed for pain control because it presents a lower risk for addiction and respiratory depression compared to other opioids. However, tramadol’s serotonin and norepinephrine reuptake inhibitory effects result in a unique adverse effect profile. Two such adverse events are serotonin syndrome and seizures. The prevalence of tramadol-induced serotonin syndrome and seizures is modest in the general population, but if left untreated, the morbidity and mortality can be high; therefore, prompt recognition and management is essential.

Tramadol overdoses have been closely linked with serotonin syndrome and seizures. Between 2011 and 2017, tramadol overdoses increased in the United States, and as of August 2020, 6,800 isolated cases of tramadol overdoses have been reported to the Food and Drug Administration. Various risk factors such as medical comorbidities, use or abuse of supratherapeutic doses of tramadol, and concomitant administration of proconvulsant serotonergic cytochrome P-450 inhibitors increase the risk for serotonin toxicity and seizures. Emergency room psychiatrists must be aware of the potential for patients who overdose on tramadol to develop these life threatening adverse reactions. Serotonin syndrome and seizures can be effectively treated by administering benzodiazepines, providing supportive care, and discontinuing tramadol and other contributing agents.

Cyproheptadine should be administered in moderate to severe cases of serotonin syndrome.
The objective of this presentation is to summarize the literature on the pharmacology, epidemiology, risk factors, clinical presentations, and evidence-based management of tramadol-related seizures and serotonin syndrome.
Sameer Hassamal, MDClinical: Toxicologic & Medical Mimickers
12:30 pmPaging House MD: Diagnostic Dilemmas in Neuropsychiatry

I will present three cases in which a patient presented to the emergency department with psychiatric symptoms which were ultimately determined to be caused by non-psychiatric conditions.

In the first case, a 37 year-old female with no previous medical or psychiatric history presented to the emergency department with a three day history of intermittent confusion, agitation, paranoia, hypersexuality & insomnia. Her agitation and mood lability did not respond to various psychotropic medications, and she was found to have elevated NMDA receptor antibodies in her cerebrospinal fluid, confirming a diagnosis of NMDA receptor encephalitis.
In the second case, a 49 year-old male with a history of opioid & alcohol abuse presented to the emergency department with new onset confusion, disorganized behavior, requesting to get the bolts in his neck tightened. His mental status exam was notable only for severe disorganized thought process, prompting a more extensive neurologic evaluation. Neuroimaging was notable for meningeal enhancement, and his serum and cerebrospinal fluid were positive for cryptococcal antigen, confirming a diagnosis of cryptococcal meningitis.
In the third case, a 36 year-old female with a history of substance abuse and a previous diagnosis of bipolar disorder & PTSD was transferred from outlying hospital with a three day history of confusion & hallucinations. She was empirically treated with acyclovir with no improvement in her mental status. She underwent eight electroconvulsive therapy treatments with no success. A more extensive evaluation revealed that she had been chewing on urine cakes to manage her anxiety. Repeat neuroimaging showed toxic leukoencephalopathy from the cortex to brainstem, and it was determined that her presentation was secondary to paradichlorobenzene toxicity, or urine cake encephalopathy.
Megan Schabbing, MDClinical: Toxicologic & Medical Mimickers
12:50 pmPanel DiscussionClinical: Toxicologic & Medical Mimickers
1:00 pmViolence 301: How Antiracism and Diversity Help Us Manage Violence Risk

Tarasoff may be one of the most famous legal cases in emergency psychiatry. While most often considered as a duty to warn case, it was also a case about cultural diversity in a system poorly equipped to recognize such matters. And, perhaps, Tarasoff’s tragic outcome was as much about a failure to recognize and manage systemic racism and implicit bias as it was about a failure to protect a target. This presentation will use Tarasoff as a launching point to explore the impact of racism, bias, and cognitive errors in the evaluation and management of violence risk in the psychiatric emergency setting.

This presentation will focus on three overlapping concepts which improve emergency psychiatric care of people at risk for violence:
Diverse teams improve clinical assessment. Highly diverse teams which represent the ethnic and cultural diversity of the populations served have a better chance to provide culturally effective care and objective decision making.
Threat management models reduce biased outcomes. Threat management integrates clinical and investigative practices to identify objective steps taken towards acts of violence. It has been demonstrated to reduce racially discriminatory disciplinary interventions in schools and shows promise as a tool in clinical medicine as well.
Diverse teams improve resilience. Emergency work is stressful. Cultivating resilience in clinical teams requires conscious promotion of diversity and anti-racism in those teams. Done properly, this improves the team and team members ability to respond to and recover from critical incidents.
Psychiatric emergency services sit at a crossroads between the mental health and criminal justice systems. They work with a population which is extremely vulnerable and which is often already subject to discrimination and the burdens of social determinants of health. It is hoped this presentation will help attendees improve their ability to use anti-racism to reduce the impact of systemic bias and racism on the patients they are charged with helping.

Jack Rozel, MD, MSLDiversity
1:45 pmBreak
2:00 pmScientific Session with Q&A
2:30 pm

2:50 pm
A Systems Approach to Workplace Violence and Management of Agitation

Emergency Departments (EDs) are seeing a rising number of visits for behavioral emergencies. As a result, providers and health workers face increasing safety threats from workplace violence while treating episodes of acute agitation. Unfortunately, the literature has shown that emergency providers are underequipped to manage agitation and prevent assaultive events despite reports of high violence exposure rates. Expert recommendations exist regarding verbal de-escalation and physical conditions when engaging this population, but implementation can be challenging in an innately chaotic work environment and during high patient census. Recent literature has called to light the use of a human factors systems approach to examine agitation management practices and interventions for workplace safety in the ED. This approach considers complex, high-pressure industries like healthcare as a set of interrelated elements in a work system, including worker(s), tasks, tools/technologies, physical environment, and organizational conditions to achieve desired safety outcomes.

In this presentation, a multi-institutional panel of violence prevention experts will provide a rigorous discussion of updated evidence and new research published by our team for the management of ED agitated patients. The session will start with an updated overview on workplace violence and agitation management in the ED, and how a human factors systems approach demonstrates the associated factors that overlay both issues. The panelists will then review recently published literature and local experiences at three institutions to implement systems-based interventions.
The panelists will draw from their own research, programmatic expertise, and clinical experience from three EDs with varied institutional attributes and patient demographics. Dr. Roppolo developed a novel multidisciplinary agitation protocol and electronic order set at Parkland Hospital in Dallas, TX. Dr. Wong used simulation technology for interprofessional training in team-based agitated patient care at Yale-New Haven Hospital in New Haven, CT. Drs. Vrablik and Lawrence performed focus groups for staff members and physicians who experienced workplace violence in the ED at the University of Washington Medical Center in Seattle, WA.

This session aims to shed light on a rising but understudied clinical issue and provide evidence-based strategies to improve safety for emergency providers while caring for this vulnerable patient population.


Ambrose Wong, MD, MSEdClinical: Agitation
3:00 pmThey Say It Can’t Be Taught: Eliciting Truer Feelings About Harm to Self and Others

Eliciting truer feelings about harm to self and others.
Despite being one of the most important tools in a clinician’s repertoire, the ability to think and feel one’s way into the experience of another person, particularly a defensive person in crisis, is generally thought to be a gift, not something that can be learned, or taught. However, we know from experience that this talent takes practice, only the nature of the practice has been a challenge to demonstrate. This presentation takes on that challenge. It builds on past lectures and writing and goes a step further, offering the audience a novel type of experiential learning, which gives participants the opportunity to practice in vitro the cognitive and affective skills involved in teasing out a patient’s truer feelings about harm to self and others.
Specifically, a case vignette of an abusive police officer in a suicidal crisis is constructed around a painting by Basquiat, which participants will view close up on their screens and analyze. The analogy between the mental work involved in understanding an artistic portrait and interviewing a patient is explored. Modern technology is also brought to bear. Adobe Photoshop is used to break down the complex facial image into components, amplifying subtle affect in much the same way that clinicians translate intuitive impressions into more conscious, fully formed perceptions. In the process, audience participants exercise their clinical ability to access guarded but crucial material of a patient’s inner world.
The key function of resistance is re-examined from the standpoint of the universal tension between the need to be understood and the fear of being understood. Complementary countertransference is appreciated as a key source of diagnostic insight. Analysis of the sample image graphically illustrates how resistance is defensive and protective in nature, and how greater respect for resistance paradoxically promotes greater openness. Sample facilitating comments in the heat of a true-to-life encounter are proposed. Doctor-patient engagement, risk assessment, and therapeutics of the clinical interview are enhanced. By becoming more aware of underlying hostility and reserve, timing and dose of the examination is fine-tuned, thereby minimizing iatrogenic agitation and increasing personal safety.
Finally, this talk reviews the elements of risk assessment and identifies how the concepts presented above fit into the standard scheme. Given the low levels of patient trust observed in ED and PES settings, we are accustomed to patients misrepresenting their degree of crisis with both minimizing and exaggerating. It is natural for the clinician to react by foreshortening the interview and relying more heavily on other kinds of data. The experiential learning offered in this presentation promises to refresh our interest in the clinical examination, and in the possibility of transforming virtual black boxes into real people. It reminds us of one of the greatest satisfactions of the work we do.
Jon Berlin, MD
Patient Engagement
3:30 pmHow Can We Be The Most Helpful? Practical Strategies for Critical Engagement

Individuals accessing crisis services experience a broad variation in length of stay, training and education of staff providing interventions, and quality of service. Regardless these factors, engaging the individual in treatment is the most important challenge facing crisis providers. In this session, learn the critical components of client engagement and the data connecting hope, effectiveness, and length of treatment.
Travis Atkinson, MS, LPCPatient Engagement
3:45 pmEngagement, Empathy, and the Evolution of Laws: Ethical approach to the Involuntary Patient in Crisis

Engagement, Empathy, and the Evolution of Laws: Ethical approach to the Involuntary Patient in Crisis
One of the most complicating factors surrounding emergency room work with psychiatric patients can be the frequent interactions with clients who are presenting involuntarily. Handling this longitudinally requires comfort with local laws, history of civil commitment, and the internal conflict that can arise when working with individuals not seeking out your services.
As such, this talk focuses on a brief overview of how involuntary laws evolved over the past 50 years to current state. Inherent in this is discussions pertaining to external stakeholders such as law enforcement, advocates, family members, support groups, and the courts. During all of the above, the main focus is on how these laws/rulings can be seen differently, depending on the scope/occupation of the viewer.
This conversation will not spend time on each individual state’s response to involuntary holds, but it will process the central themes that each physician must face in these cases. These include, but are not limited to: autonomous medical decision making vs. serving as an agent of the courts, balancing least restrictive treatment venues vs. court orders, and assisting in service recovery with patients/families vs. observing confidentiality and privacy rules.
We will then end by focusing on the provider themselves to make sure that their internal well being is being observed and assisted when having these cases arise. This will include suggestions in handling the initial interview as well as processing the differing affect this has on medical decision making and longitudinal risk management. Additional time will be given to the ideals of psychological first aid and trauma informed processes so that the physicians involved can see how these interventions will benefit not only the patient in the moment but also in their practice over time!
Tony Thrasher, DO, DFAPAPatient Engagement
4:00 pm Panel DiscussionPatient Engagement
4:15 pmAdjourn

Friday, December 4

Time (EST)Session TitleSpeakerTopic
10:00 amOpening RemarksLes Zun, MD, MBA
10:10 amA Multisite Study of Pediatric Suicide Attempts and Self Injurious Behavior During the COVID Pandemic

In March of 2020, our country faced an unprecedented health crisis with the rapid spread of COVID-19 and the resulting pandemic that continues to reverberate throughout our health systems. Although not as susceptible to the direct effects of COVID, pediatric patients have been considerably impacted by COVID and its downstream effects on health systems, schools, access to care, communities and society at large. Pediatric emergency care, and particularly pediatric mental healthcare within emergency care settings, has been significantly impacted by competing demands in this environment, access to mental health services in the community, potential delays in mental healthcare, and the chronic stress that exists for families in this environment.
We convened a study of six children’s hospitals in diverse geographic locations to better understand the impact of the COVID-19 pandemic on suicidal behavior and suicide attempts in the emergency room setting. We analyzed data from March to June of 2020 to capture the full scale of rise and subsequent decline in COVID cases as well as the reopening process. We compared this data to the same time frame in 2019 and 2018 to capture any associated changes seen during the COVID pandemic period. The data was collected from patients ages 10-18 either seen in a psychiatric emergency or pediatric emergency setting and focused on patients who engage in self-injurious behavior or a suicide attempt. Demographic factors, length of stay, need for intensive care, need for invasive procedures and care and associated diagnoses were all captured to describe this population, associated suicide attempts or other self- injurious behaviors and other sequelae related to hospital-based care.
We hypothesized that pediatric patients seen during the COVID pandemic would present with a greater proportion of suicide attempts and other self-injurious behavior compared to overall emergency care visits, that the presentations would be of a more clinical significant or severe nature, that there would be noted delays in accessing psychiatric care, and that patients would present at an earlier age given the added distress and lack of supports during the COVID pandemic.
Our presentation intends to review the intent of the study, study design, results of the study, as well as a discussion of our findings, the potential factors influencing our study findings and how this will impact emergency care for pediatric patients going forward as we continue to navigate psychiatric emergencies for youth with the COVID-19 pandemic.
Nasuh Malas, MD, MPHClinical: Perspectives on COVID
10:30 amRe-engineering the Comprehensive Psychiatric Emergency Program During the COVID-19 Epidemic

Starting in March of 2020, COVID began to surge in New York City. The Jacobi CPEP is located in the Bronx, an epicenter for the virus. Given that the virus was highly infectious with possible lethal outcomes, the Jacobi CPEP had to adapt in order to rapidly identify, isolate, and treat COVID positive acute psychiatric patients, while preventing the spread to non-infected patients and staff.

Initially, understanding the virus was challenging – new clinical presentations and sequelae were appearing, the mode of transmission was not established by the scientific community, and the level of infectivity was doubted by some. This led to conflicting ideas in our CPEP about wearing masks in the CPEP, when to don PPE, and who should be given access to PPE given its short supply. However, as our understanding evolved, on an individual, hospital-wide, corporate-wide and national level, so did our response to the virus.
In our talk, our goal is to provide insight into and understanding of the re-engineering of an existing CPEP system, specifically to address the needs of psychiatric patients with COVID-19 while prioritizing the safety of staff and the community as a whole. We address the multiple systemic components that required change in order to adapt to the evolving pandemic. These components include environmental factors; PPE supply; COVID testing; exposure risks to staff and patients; MD, clinician, and nursing and patient work-flow; medical management of COVID positive patients; and communication and interdisciplinary approach within the CPEP and with departmental and hospital-wide administration.

As we prepare for a potential resurgence of COVID cases, the lessons learned from our experience with the first wave proved invaluable. Potential areas of exploration and expansion include use of telepsychiatry, ready availability of support staff for our frontline workers, consideration of psychiatry presence in medical ED and rapid implementation of staggered staffing schedules.
John Navas, MDClinical: Perspectives on COVID
10:40 amEmergency Psychiatry Work Under the COVID-19 Pandemic

Working in the emergency psychiatric setting is challenging but extremely rewarding. It is fast paced and requires the ability to multitask and easily adapt. The COVID-19 pandemic brought challenges that we did not expect and pushed the unpredictability of the job to a different level.

Looking back at the last six months, during March of 2020 to August of 2020, compared with the same period in 2019, we are trying to analyze the impact the COVID-19 pandemic had on patients seeking help in the psychiatric emergency setting, healthcare provider’s response to the work challenges, and the overall flow in the emergency room.

We are comparing the number of patients seeking help in the psychiatric emergency department, the presenting problem, and the final disposition. We are seeking feedback from the healthcare workers designed to identify work related stressors new for the pandemic period.

Our free standing psychiatric emergency department was in communication with the medical emergency rooms in the community and followed the CDC recommendations.

Despite the challenges, our emergency room continued to operate 24/7 providing care for the patients in need. This was extremely important especially during the time when outpatient clinics closed and transitioned from in person visits to phone/telepsychiatry visits.

The pandemic brought many unexpected situations that were dealt with as they arrived. Looking back will help us better prepare for the following months and the challenges that might arrive in the near future.
The last few months taught us to be prepared for any circumstance, deal with unpredictable situations at any level, overcome any challenges and adapt to novel situations.
Gabriela Feier, MDClinical: Perspectives on COVID
10:50 amPanel DiscussionModerator: David Hoyer, MD Clinical: Perspectives on COVID
11:30 am

11:55 am
Readin’, Ritin’, and the Reduction of Risk: High Acuity Risk Documentation

Practicing current day medicine in emergency departments or psychiatric emergency centers means handling a high degree of acuity and corresponding risk. This talk will focus predominantly on how one documents these scenarios to best protect the provider in a medico-legal sense as well as noting the best treatment options in a patient centered manner.
The talk will have components that are quite engaging, basing them on a Top Ten “do not document this, but instead document this!”
By using real life examples and utilizing phrasing/scenarios that are very common, the audience can be engaged…..even in a virtual sense.
Unlike other talks that focus on the decisions/risk management scenario(s), this conversation will look primarily at how we describe these situations…..and how the language we use can then not only protect our work but also lead to markedly better hand-off communication with our colleagues.

Tony Thrasher, DO, DFAPAProfessional Issues: Risk Management
12:00 pmSo Many Suicide Scales: I Just Can’t Take It Anymore

Genetics, validated scales, neuroimaging. Research on suicide has increasingly expanded the tools that might uncover risk, yet the range of options is vast. By providing an overview of these options, this session is designed to help clinicians and administrators better integrate standardized suicide screening into practice. This session will specifically focus on the different scales available for assessing suicide: their length, training requirements for administration, statistical validity, and clinical utility as either triage screens, risk assessments as JACO sanctioned tools or measures of treatment response. Description of evolving technologies like genetics and neuroimaging will also be briefly discussed. A polling app such as polleverywhere will be used to keep the audience engaged and sample participants’ current use of available suicide screening tools.
Lara Chepenik, MD, PhDClinical: Scales and Tools for Suicide Assessment
12:20 pmViewing our patients through screens

Patients presenting to Emergency Services are screened for many things from infectious diseases, to domestic violence. The development and implementation of screening tools has become so routine we hardly blink when a new one is added. Some of the screening tools are validate, evidence based approaches and others are simple questions attempting to identify symptoms or illnesses. I will review some of the commonly used screening tools and the evidence behind them. I will also look at the challenges of using this information in clinical decisions and the various depictions these screens can paint. I will review some of the inherent dangers as well as the rewards in using screening tools.
David Pepper, MDClinical: Scales and Tools for Suicide Assessment
12:40 pmPanel DiscussionModerator: Jennifer Peltzer-JonesClinical: Scales and Tools for Suicide Assessment
1:00 pm Break
1:15 pmControversies in Medical Clearance

Les Zun, MD, MBAClinical: Medical Assessment
1:45 pmWhat is Necessary? Medical Clearance Algorithm for Psychiatric Patients in a Pediatric Emergency Department

The American College of Emergency Physicians recommends that medical clearance should be driven by physical exam, vital signs, medical history, and previous psychiatric diagnoses, and not protocolized laboratory testing. (Nazarian, 2017) On a national level, reduced testing in pediatric patients could represent up to $90 million in savings annually without reducing the ability to screen for emergency medical conditions. Patients received ancillary testing at an average cost of $1235, 94.3% of the patients had exams that were not concerning and had test results that were clinically insignificant. (Donofrio, 2015)

Methods: Our free standing children’s hospital has eliminated universal medical clearance labs for pediatric patients requiring psychiatric inpatient admissions. Urine pregnancy tests and urine drug tests on all admissions are still obtained, as these results could alter medication plans on the unit. In addition, a medical clearance algorithm was created to help emergency department physicians to help determine if a medical etiology requiring additional screening is present and possibly precipitating the psychiatric symptoms. Otherwise, if a patient has no concerning red flags, no routine laboratory testing is completed. In addition, a retrospective data analysis is currently being performed, to indicate whether negative medical safety events on the inpatient psychiatric unit have occurred since eliminating universal medical clearance labs.
Results: Since eliminating routine medical labs, our free standing children’s hospital has saved an estimated $1667 per patient. With the retrospective chart review, thus adverse medical events while on the medical unit are not significantly different than when routine medical labs were conducted.
Discussion: Since removing routine medical clearance labs, it is estimated to have saved our hospital over $1 million annually in unnecessary lab tests. Despite not doing these laboratory tests it has not lead to other financial costs later to the institution and has not produced any significant negative outcomes to the patient. The creation of the algorithm for non-psychiatric physicians, has made it easier for these physicians to understand the rational for additional medical testing.
Discussion: Since removing routine medical clearance labs, it is estimated to have saved our hospital over $1 million annually in unnecessary lab tests. Despite not doing these laboratory tests it has not lead to other financial costs later to the institution and has not produced any significant negative outcomes to the patient. The creation of the algorithm for non-psychiatric physicians, has made it easier for these physicians to understand the rational for additional medical testing.

Conclusion: Universal laboratory testing is not necessary for pediatric patients requiring psychiatric inpatient hospitalizations. In addition to not increasing poor medical outcomes it has saved the hospital a significant amount of money. The medical clearance algorithm has provided comfortability for emergency physicians for understanding the need for further testing when necessary.
Meghan Schott, DO, FAPAClinical: Pediatrics/Medical Assessment
2:00Panel DiscussionClinical: Medical Assessment (Including Pediatrics)
2:10 pmInternational Psychiatry: Saudi Arabia

After six years treating Muslims in Saudi Arabia, I still make mistakes. Don’t touch her hand, even though it’s injured. Announce yourself before opening the curtain, grandma needs to cover her face. Take that stethoscope off of her though she’s here for a cough.

How can you best meet a conservative patient and family, not offend them and still make the assessment you need? It starts with entering their world view and then proceeding with care. Evil eye and Jin spirits may be complicating things. The man will explain the situation, answer your questions, and consult with the patient if necessary. If she’s not married she can not be pregnant. If she is pregnant, prepare to use the ultrasound to assess her labor risk since a pelvic exam is out of the question.

Is trying to follow all these traditions stressing you out? Some Saudi youth are brought in for that very reason, especially if they’ve studied in the West.

Let’s spend a few minutes reflecting on this beautiful culture, and sharing tips and insights to navigate successfully when they need our help.
Vincent Dodge, MDInternational Perspectives
2:20 pmInternational Psychiatry: Mexico

Mental Healthcare in Mexico is almost completely restricted to Psychiatric Hospitals. This is opposed to WHO recommendations about primary mental healthcare services, which should be privided and well coordinated both in First Level of care (Community) and Second Level of care (General Hospitals). A quite serious lack of procedures of Mental Health and Addictions is commonly seen in Mexican General Hospitals (MGH) offer of health care, even in the largest and most specialized ones.
We designed a National, pioneer program of four stages of mental health and addiction implementation procedures in MGH: 1) Arrangement, 2) Training Implementations, 3) Administrative Implementations and 4) Infrastructure Implementations. Educational and Administrative Implementations are focused in four main aspects of Mental Health: 1) Triage, 2) Agitation, 3) Suicide Prevention, and 4) Acute Addiction Management (“TASA”).
These four main “TASA” topics are projected to be formally trained and administratively implemented as standardized procedures, in order to measure educational, activity and quality indicators before and after implementation. We are also looking to afterwards develop techological software or apps of each TASA training and administrative implementation, in order to enhance reproducibility and eficiency of these interventions.
By now, we have implemented the first educational interventions and formally trained the TASA topics to the Emergency Department healthcare workers (Emergency Residents, Nurses, Psychologist and emergency staff from the “Hospital General de Mexico Eduardo Liceaga”, the largest General Hospital of the Country. We would like to share these first outcomes and to explore the strenghts and challenges of this program.
Alejandro Molina-Lopez, MD, PhDInternational Perspectives
2:30 pmInternational Psychiatry: Romania

Middle aged women presenting with sudden onset of acute psychosis became a very frequent and intriguing subject for psychiatrist, due to wide spectrum of symptoms, various trigger factors, challenging treatment and uncertain prognosis. Later-onset psycho­sis is more common in women than in men for reasons that are still not well understood.
Considering midlife medical and psychological triggers ,we are trying to highlight and compare different medical management approaches for psychosis in Europe and United States.
Managing acute psychotic disorders in an emergency department can be very demanding. We will first discuss the treatment plans for the patients, neuroimaging, blood tests, physical examinations, psychological examinations and applied scales, psychological stress impacting the brain via stress hormones, medications and their common side effects, the specifics of cases and common causes that can lead to later-onset psychosis.
Women in a psychotic state presenting with such symptoms as
perceptual disturbances, delusions, hallucinations and agressive behaviour may need sedation or physical restrains. This methods will be further discussed in our presentation.
Uncertain prognosis, treatment non-compliance and poor follow-up can lead to insufficient information for the healthcare provider. We would like to bring to light different methods that can increase fallow-up and treatment compliance, especially for patient population that may have very little insight into mental illness.
There is still much work to be done in terms of optimizing treatment and medical management for middle aged women with late-onset psychosis, therefore, we have many reasons to continue to explore this field so we can continue to improve it. Despite extensive research on symptomatology and neurofunctional and anatomical changes that occur in these patients, there is still room for diagnostic improvement. Cross cultural aspects and observations about this topic can highlight the positive outcomes by comparing the medical approaches so more awareness can be brought to this sector.
Andreea Rothstein, MDInternational Perspectives
2:40 pmPanel DiscussionModerator: Junji TakeshitaInternational Perspectives
3:00 pmSetting the Stage for Excellence in the Treatment and Stabilization of Behavioral Health Emergencies

Behavioral Health (BH) related Emergency Department (ED) visits are estimated to account for 10-20% of ED visits in the United States. Despite the escalating BH crisis, only a small percentage of EDs in the United States offer dedicated BH treatment units and/or care models. Emergency providers, nurses and interdisciplinary team members have developed expertise and efficient processes to provide high quality care to a wide array of medical and traumatic emergencies. Despite this, individuals presenting to the ED for an acute BH emergency may not always receive the same efficient processes and exceptional care standards afforded to other medical or traumatic presentations. Some treatments and interventions routinely provided in general EDs are unnecessary, may not be based on current evidence, and may even worsen outcomes for individuals with BH emergencies (e.g., noisy or crowded care areas).
This session will provide a strategic overview and panel discussion of a longitudinal quality improvement initiative focused on achieving excellence the Emergency Medicine approach to acute treatment and stabilization of BH emergencies within a large, integrated health system in the Midwest. Emergency Medicine physicians and executive leaders observed a gap in their existing EDs ability to effectively treat, manage and stabilize individuals presenting with a BH crisis. This disparity prompted advocacy and an imperative for change to the delivery of emergency care for BH population within the system and community.
This panel will discuss methods used to effectively gain health system and community support to implement a novel, evidence-based model of care for the treatment and stabilization of acute BH emergencies. This work required transformative leadership and a strategic, stepwise approach to set the stage for abandoning long standing practice patterns for new model of care that integrated excellence and compassion with rapid treatment and stabilization of individuals with BH emergencies.
Priority Milestones Addressed:
1. Assessment and evaluation of the hospital systems ED BH population and performance metrics.
2. Development of an engaged team including key stakeholders and interdisciplinary representation from the intervention site, internal and external EDs within the region, psychiatric care facilities, community mental health agencies, behavioral health consultants and the probate courts of local counties.
3. Selection and adoption of research based standardized screening, evaluation, and treatment tools to create uniform medical clearance processes.
4. Executive level health system support to allocate capital and operational resources for a dedicated, emergency department behavioral health observation unit at the system’s urban, flagship site.
5. Establishment of a project team to design and implement an Emergency BH Observation Unit.
6. Robust initial and ongoing clinician development plan to assure the emergency team had the knowledge and skills to provide high-quality care to diverse BH populations. Including pathways to address co-existing substance use disorders as well as protocols to prevent alcohol withdrawal for discharged patients.
7. Evaluation of outcomes to quantify clinical, health system and community benefit, hospital return on investment, and to promote continuous process improvement.
8. Expansion of best-practice Emergency BH Observation Unit concepts to regional hospitals across the system.
Phillip Stawski, MDProfessional Issues: Selling Ideas to Your Administration
3:15 pmHow to Make a Community Partner Program for the Care of Homelessness and Substance Use Disorders

Front-line providers often feel powerless to change medical systems in which patients experiencing homelessness and substance use disorders receive revolving-door care that does not get at the underlying problems. By creating a “Community Partnership Program” a medical center can leverage the services of pre-existing community resources to streamline referrals and support patients in residential rehab facilities.
Community Partnership Programs can be beneficial for all parties involved. Patients receiving care through our program at UCSF have experienced a decrease in ED visits as well as a 50% decrease in the number of inpatient admissions, hospital days, and ICU days. Of the 134 patients that received community treatment in 2019, 28% are on track for long-term residency. Helping patients lead healthier lives has also helped stretch the value of our healthcare dollar. Our program is predicted to result in $1.9 million in avoided direct cost for the Medical Center this year.
In this lecture, I will present a brief “how-to” guide for front-line providers and administrators who would like to create their own community-partnership program at their home institution.
James Hardy, MDProfessional Issues: Selling Ideas to Your Administration
3:30 pmThe ABCs and 123s of Creating a Multi-Site Emergency Department Telepsychiatry Service Line

The Henry Ford Health System, located in central and southeast Michigan, has 9 emergency departments which collectively manage more than 400,000 visits per year. In the summer of 2019, leaders from Emergency Medicine and Behavioral Health Services made a commitment to redesign the delivery of psychiatric services in all 9 sites to create a more cohesive service line. By the first week of April 2020, despite being in the midst of a pandemic, all 9 sites were actively using telepsychiatry. This talk will focus on 3 major areas: (1) how the quality improvement argument for utilizing telepsychiatry informed the business case for it; (2) the multiple operational obstacles faced in getting the service up and running; and (3) the creation and monitoring of metrics to determine the success of the new strategy.
Jennifer Peltzer-Jones, PsyD, RNProfessional Issues: Selling Ideas to Your Administration
3:45 pmPanel DiscussionModerator: Scott ZellerProfessional Issues: Selling Ideas to Your Administration
4:00 pmConference Adjourns