Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole and joining me today is Dr. Andrew New. He's an Assistant Professor of Psychiatry and Behavioral Sciences at Northwestern Medicine, and he's the Director of ED Psychiatry at Northwestern Memorial Hospital. He's here to highlight behavioral health team integration in the emergency department for us today.

Melanie Cole, MS: Dr. New, thank you so much for joining us. I'd like you to start by telling us a little bit about your position at Northwestern Medicine.

Andrew New, MD: Hi, yes. Thank you so much for having me. So, I got brought on to work here in the ED as a primary psychiatrist. A lot of hospitals don't have psychiatrists dedicated to the ER. But Northwestern's really dedicating a lot of time and effort towards this space. And so, I got brought on with the intention of really focusing on the clinical process for the patients as well as the education for the residents who are part of a very large academic institution. And so, we have learners of all different levels. And so, how can we integrate them into our patient care so that they both get a great experience for the patient and for the learner as well.

The other thing that I'm working on too is that I was brought on to be a part of administrative changes, kind of long term. A lot of doctors often are just engaged in the clinical care, but I find myself really wanting to improve the process of care and the facilities around that. And so, I also have, like, this wonderful administrative role I get to try and take part in.

Melanie Cole, MS: Well, thank you so much for telling us about that. Now, what is the prevalence of mental health emergencies and/or mental health needs when a person is admitted to the ER? Why the need for this type of program?

Andrew New, MD: So, sadly, over time or recently with the COVID, different things going on in the nation, there's been a spike in mental health emergencies. Previously, a long time ago, there was an aversion to seeking out mental health care, but a lot of those barriers have been broken down, and a lot of people are starting to seek out care. Sadly, due to the lack of available people in the outpatient setting and access to care, the predominance of people go to the ER first. When they can't get an appointment for six to eight weeks, they're coming to the ER to see if are they okay in the moment.

Melanie Cole, MS: Now, tell us a little bit about this program that you've developed and the team of psychiatrists that you're establishing in the emergency department. How is this all working?

Andrew New, MD: Yeah. So previously, they had a psychiatrist here in the ER, but it was kind of like the team was working in more, I would call like a relay race fashion. The ER would medically clear the patient, they would consult for the psychiatrist team to come. Once all the labs are back and everything was medically cleared, the psychiatrist would then take part in evaluating of the patient. And then after that, once they decided what would happen, the patient would either be sent to another facility, admitted to our hospital or discharged with recommendations for outpatient followup and different levels of care if they needed it.

What I've changed is that rather than it being a relay race, we're all going to start working as a team in conjunction together. So, kind of from the moment the patient hits the door, the ER team, once they know that the patient is psychiatrically in need of services, they consult us then. We no longer wait for the patient to be "medically cleared" to see how we can help our ED colleagues. And so by kind of getting to the patient sooner, it can really help in a lot of different ways.

To get this all done, it basically requires us to kind of work in teams. So previously, we were only doing this pager system back and forth. But now, we're doing lots of direct verbal face to face communication with the ED doctors. And we're trying to have ourselves stationed in the milieu with the patients and with the doctors. So that way, we're not some consultant from far away they have to call, but rather somebody there on site that can help for anything they need.

Melanie Cole, MS: What a comprehensive approach. Now, tell us a little bit about the benefits of having this behavioral health team work in tandem with the ED staff. How are you all working together?

Andrew New, MD: So, part of it is that it's not just doctors, and it's not just nurses. It's also the techs, it's the security guards, it's the students. And so, getting people to realize that the way we approach patients and how we ask questions can be therapeutic in nature. It can also be not therapeutic sometimes. And so working with our colleagues to kind of better, like how we approach these patients, what questions we ask, can greatly improve the experience that the patient has. One of the big things is that some of our staff doesn't get mental health training always. And so, one of the things I'm trying to actively work on is how can we get mental health training both for the security guards, the nurses, and the techs, not just to help treat patients, but to help for themselves. A lot of the things that we deal with are high acuity and very strenuous to our own emotional states. And so, we want to make sure that we're also engaging in like the well-being of our co-workers. And so, we're trying to integrate with both the security staff and the nursing staff to provide services to them to help debrief after situations in which bad things have happened and it might be impactful to them.

Melanie Cole, MS: That's amazing because we really are seeing this mental health epidemic, Dr. New. And it's not only the general population, as you say. And after COVID, our healthcare workers really were experiencing burnout like never before. So, that is really an amazing aspect to what you're doing, is to work on the employees as well to help everybody. Now, how does this model benefit the patients, both in terms of those who are eventually discharged from the emergency department, but also to those who are admitted to the psychiatry unit for a higher level of care? How does that work?

Andrew New, MD: Yeah. So, one is by trying to see patients as soon as we're aware, it helps decrease wait times. I know personally I've gone to the ER for things and sitting there waiting can be so exhausting. It can be hours sometimes before somebody might be able to help you. So being able to decrease the time before they actually get a face to face with the psychiatrist is wonderful for them. We also then get to explain the process and what's going to happen afterwards. So, it helps decrease that fear and anxiety of the what ifs and what might happen, what might go forward. We get to kind of help resolve that a little bit sooner for the patients.

The next thing is, is that instead of being a consultant that just makes recommendations to the ER providers, we're actually helping co-manage the patients. And so, we're willing to start treatment while they're in the ER. And so, there's a lot of patients that could benefit from medications immediately. That way when they're getting to an inpatient unit, they're actually a little bit less acute so they're feeling a little bit better already and it can decrease their length of stays once they're on the inpatient units. Similarly, by starting treatment in the ER, there's certain people that we can theoretically keep for one to two days that might improve and never need an admission. And so that way, we can also help decrease the strain on some of our resources that we have. When it comes to those people leaving the hospital, by starting some treatment inside, we can also gauge are they having any side effects to this. And we can feel a little bit more comfortable about prescribing a medication and then having followup with an outpatient doctor, rather than not giving them medications when they leave the ER.

Melanie Cole, MS: That's really a brilliant model of care, Dr. New. Dive into your interest for us in medical education and how residents learn in this environment, because what you are doing is such important work and to continue this with residents because, as we know now, psychiatry is really something that is more important than ever to help the general community. So, explain a little bit about how the education works with your residents.

Andrew New, MD: We have resident psychiatrists. They're varying levels. I mean, it's all the levels actually. There's interns who are brand new. There's second year psychiatrist residents who have done this a little bit, .And then, there's fourth years that are coming back to learn specific skills, and also to learn how to help teach this.

For the residents, we teach them both how to evaluate these patients, how to manage the acuity of the moments. But by being such an acute environment, we also get a chance to help them learn how to de escalate the most acute patients, and can we use verbal de-escalation skills rather than going to medications. By having them learn that, it can really help the future of their career kind of going forward.

By having high-acuity patients, they also get to see in real life, in the moment, these pathologies that sometimes we only get to read about in books. We have such a wide variety too that each day is so different that they really get to learn a wide gamut of pathologies and levels of acuity. And the way patients come to us can be from police, family members, EMS, walk-in. And so, they also learn to take into account where the patient might be coming from. And so, that way they learn when they leave, how can we best help that process.

As far as the different learners, since there's so much going on, and it could be social history, medication management, suicide assessments, there's also something for everybody to learn. The nursing students can learn here. We have pre-med interns, pre-medical students, that come and shadow us sometimes. We have medical students that shadow us. We have nursing students, mid-level provider students. Everybody gets to learn from this. And one of the biggest things is that regardless of who we're seeing, the way you talk to somebody and how you ask questions can be therapeutic in and of its own right. And even if these people don't go on to become psychiatrists, I hope that at least they can learn a better way to talk to patients and how to best help people who are in a crisis.

Melanie Cole, MS: That's such important work that you're doing, Dr. New. Thank you so much for joining us. Do you have any final thoughts that you'd like to leave other providers with about behavioral health team integration in the emergency department? And if they are looking to start something like this within their own institution, what do you feel is so important that they know?

Andrew New, MD: I think the biggest thing is that courtesy outweighs efficiency. Even though you think that by creating a really efficient process, you're going to make things better in the end, a process that's actually more courteous, both to patients and to other providers, usually takes care of a lot of issues on the front end and solves so many other things and provides, I feel like, a more wonderful patient care experience and a work experience. And so when designing processes, think about being courteous first, rather than efficient.

Melanie Cole, MS: Thank you, Dr. New, for joining us and to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/psychiatry to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. Thanks so much for joining us today.