University of Colorado Hospital is in the early stages of a concerted effort to meet the behavioral health needs of its patients while protecting staff and providers.

The work, which includes teams from across the hospital (see box) centers on addressing the growing number of patients admitted to UCH with behavioral health issues – a broad umbrella that encompasses psychiatric problems, developmental disorders, dementia, traumatic brain injuries, substance use disorders, and more.

These issues are, in turn, frequently intertwined with medical conditions, said Sara Stowell, a social worker and process improvement consultant at UCH who helps lead the project. She estimates that as many as a third of the patients admitted to the hospital have a behavioral health component to their care. To complicate the issue, their disparate medical conditions mean they can be scattered throughout the house, making it even more difficult to deliver effective treatment.

The hospital recently completed a six-week pilot on the Oncology/BMT and Medicine Specialties units that aimed to provide support for staff and providers caring for patients with behavioral health issues. Stowell called it “an early intervention process,” designed to head off and de-escalate episodes that can lead to verbal and even physical abuse and drain resources from other patients on the units.

Memorial model

The pilot, which is modeled in part on a successful program launched at Memorial Hospital in Colorado Springs in 2011, relied on a team of behavioral health specialists in UCH’s Emergency Department. Providers on the pilot units who treated challenging patients could call the team and get advice and guidance on handling heated encounters. In the most serious situations, the team came to the unit to work with patients directly.

At Memorial Hospital, a response team consisting of a security staffer, psychiatric nurse, behavioral health technician, behavioral health evaluator, and house supervisor respond to “Code Gray” calls from dispatch for an “emergency staff assist” with a combative individual without an obvious weapon. Security first makes sure everyone is safe, and one of the team members takes the lead in verbally de-escalating the problem, said Billie Ratliff, manager of behavioral health for Memorial. Ratliff has assisted UCH leaders developing their program.

Ratliff said the team responds to 12 to 24 Code Grays each month, but rarely has to resort to physical restraints. “We talk to patients about what they need to be calm,” she said. Medications frequently help, but the team collaborates with providers on the unit to decide the most effective plan of care for the patient and the protection of staff.

Charles Peck, DO, handles all psychiatric consults ordered by attending physicians at Memorial. The behavioral health team also fields “pre-Code Gray calls,” talking staff through steps to take before a patient’s anger and frustration spin out of control.

The UCH team is sifting through and evaluating the results of their pilot, which focused primarily on helping staff in pre-Code Gray situations. The next steps have not been finalized, but the pilot laid bare the broad reach of the problem.

Far-reaching effects

Meeting the needs of behavioral health patients throughout the hospital will be a tall order. In the ED, for example, these patients routinely fill many of the beds in the Clinical Decision Unit (CDU), which was designed for providers to conduct short-term observation of patients with medical problems before making the call to admit them to an inpatient floor or discharge them.

“It has become clearer and clearer that the CDU is not being used as it was intended,” said Gina Napolitano, behavioral health manager in the ED. “The ED needs a separate observation unit for behavioral health patients. That would be helpful for the patients, our providers and the inpatient units.”

Keith Peterson, director of Community Relations for UCH, presented the case for a specialized unit to the hospital’s Board of Directors in mid-November. Memorial Hospital has addressed the need, Ratliff noted, with a secure 10-bed unit in the ED for patients with psychiatric issues.

The project also underscores the importance of balancing the needs of patients, staff and the hospital as a whole, said Jennifer Zwink, RN, director of Patient Services.

“We have to get patients the appropriate care from the time they enter our doors and understand their needs instead of waiting for situations to escalate,” Zwink said. But, she added, “equal weight” must be given to ensuring that staff are physically safe and not at heightened risk of compassion fatigue and burnout, the byproducts of emotionally draining situations.

Provider fall-out

The toll is real, said Jamie Nordhagen, RN, nurse manager for the Oncology/BMT Unit. She said the number of patients with severe behavioral health issues “waxes and wanes,” but at times there may be as many as six or seven on her unit during a shift. Many times, nurses who are highly skilled in managing a clinical problem like immunosuppression are challenged in trying to help patients struggling with depression, anxiety or anger issues.

“As oncology and BMT nurses, our focus is on our patients’ experience and we want to help,” Nordhagen said. “Doing that requires structure and boundaries. We need a plan of care for these patients, but staff safety is my utmost priority.”

The challenge is not only to protect staff but also to retain them, added Gary Kushner, interim executive director for the Center for Dependency, Addiction and Rehabilitation (CeDAR) at UCH and a member of the executive steering committee working on the behavioral health project.

“We’re trying to find ways to mitigate the stress associated with inpatient staff who are dealing with patients with behavioral health issues,” Kushner said. He noted that the challenges have probably contributed to higher turnover rates for new grad nurses than the hospital would like.

Blurred lines

There is a steep cost, both short- and long-term, to leaving behavioral health issues unaddressed. For example, patients who threaten or commit harm to themselves and others require “sitters” from AlliedBarton, the security contractor for UCHealth. Sitters cost the hospital about $560,000 in fiscal year 2016, which ended June 30, 2016, said Jamie Le-Lazar, director of Resource Office and Capacity at UCH.

In addition, patients with unmet behavioral health needs are likely to stay in the hospital longer and return to the hospital more frequently. Zwink noted, for example, that it’s not uncommon for IV drug users to suffer from endocarditis, or inflammation of the valves or lining of the heart. Medical providers can treat the problem with antibiotics, but without help for the addiction issue, patients are likely to return to the hospital for the same reason.

“We can’t draw a line in the sand in treating these problems,” Zwink said.

With sufficient resources, the pilot project model could begin to erase those lines and replace them with paths to wellness, Kushner said. In addition to de-escalating tensions, Napolitano’s team could help to connect patients and families with clinical services in the hospital, including medications and psychiatric consultations, and resources in the community, he said.

Epic challenges

Among other hurdles, Napolitano noted, is that the Epic electronic health record wasn’t designed for behavioral health providers. It’s difficult to pull data on important elements of patient care, such as diagnoses, lengths of stay, mental health holds, their return rates, and what happened after discharge – whether or not patients got community-based mental health services, for example.

Work is underway, Napolitano said, on a “behavioral health dashboard” in Epic that would display this kind of information for providers, but it will be a long process.

Without that data, building the case for additional staffing and resources for behavioral health will be challenging. While hospital leadership generally acknowledges the need to address the problem, it’s not possible simply to “assume more FTEs alone will fix the problem,” Stowell said. Rather, she maintained, “reallocation and realignment of already existing behavioral resources has to be considered, “especially when Napolitano’s staff is stretched thin as it is covering the behavioral health needs of patients in the ED alone.

“We’re trying to figure out how to collaborate across disciplines and build a more streamlined and efficient process before we ask for more resources,” Stowell said. An important part of that, she added, is helping staff and providers learn strategies for responding proactively to aggressive patients while setting boundaries for the behaviors they will tolerate.

Tools of the trade

Educating staff about the nuances of behavioral health care is vital for medical providers, most of whom have little or no experience in it, said Ratliff, who routinely offers Crisis Prevention Institute training at Memorial. The goal: arm providers with tools, such as scripting, to manage “challenging patient and visitor behavior” and defuse anger, she said.

“It can be hard for nurses to set stern boundaries with patients,” Ratliff said. “We give them permission not to take abuse.”

A cohesive team like the one at Memorial could also help identify and address relatively straightforward patient stressors like not being able to smoke, Nordhagen said. Other helping hands include the University of Colorado College of Nursing, which is involved in grant work to improve care for patients with addictions. In addition, the School of Medicine’s Psychiatry Department is working to improve nursing education in behavioral health care and perhaps set up clinical rotations for nursing students, Nordhagen said.

“There is a gap in nursing education,” Stowell acknowledged. But she added that the shortfall is unsustainable and that behavioral health training through ULearn – “Mental Health 101,” as she dubbed it – will have to be part of the onboarding process for health care providers.

There is much ground to make up, Stowell added. “This is probably a three- to five-year journey,” she said, “but we’re in it for the long game. We have to find a long-term solution that makes sense and has positive financial repercussions for the hospital.”

It takes a village

A “rapid improvement event” last spring brought together representatives from many areas of UCH and the university. All have a stake in improving behavioral health services for patients admitted to the ED and the inpatient units.

The participants:

• Case Management
• Psychiatry
• Spiritual Care
• Family Medicine Inpatient Services
• ED Behavioral Health team
• ED providers, RNs, and staff
• Inpatient Providers, RNs, and staff
• Addiction Medicine
• Professional Risk Management
• Professional Resources
• CU College of Nursing
• CeDAR