Innovations: Upstream Crisis Intervention Unit

Upstream Crisis Intervention is the fourth phase of our Alternate Destination Program which began in 2010 when our ALS ambulances began transporting low acuity patients to neighborhood healthcare centers.  Phase two was the implementation tiered response system to send Basic Life Support (BLS) ambulances to calls that did not require the expertise of a paramedic currently trending over 1,000 calls per month. The third phase was the incorporation and eventual management of the Grady Health System (GHS) nurse advice call center.  911 calls triaged by our Priority Dispatch, Inc. emergency medical dispatch (EMD) program as low acuity complaints are sent to the advice nurses who provide more extensive evaluation, advice, schedule clinic appointments, and arrange non-emergency transportation. The nurse advice current demand for service is trending at 400 calls per month and the division has plans to expand staffing to meet the expanding call volume in 2014.  

Nationally, 9-1-1 Emergency Medical Services (EMS) systems are strained by serving large and increasing volumes of callers with the same or shrinking response resources due to the pressure for efficiency in an economically austere, public funding environment.  This has spawned considerable focus of published literature on a small, but influential group of frequent users who disproportionally request 9-1-1 EMS resources, for reasons researched to be mainly related to substance abuse, mental illness, homelessness, and some combination thereof.  

Excessive use of hospital-based emergency departments for medical screening and crisis intervention psychiatric services, as opposed to utilizing alternative outpatient care resources, has resulted in inefficient use of expensive, limited resources. This over use additionally contributes to secondary problems such as emergency department overcrowding, subsequent adverse wake effects such as staff and patient injuries by assault, and workforce attrition due to overwhelming workloads and fear of assaults. 

In 2012, Grady EMS encountered 5,807 patients with psychiatric problems based on the paramedic’s impression of anxiety, behavioral disorder, depression, and psychosis. Ten (10) percent of these psychiatric patients left the ED without treatment and ten (10) percent required admission resulting in average length of stay (AVOS) of thirty-three (33) hours.  Since ninety (90) percent of psychiatric patients encountered by Grady EMS are not admitted to an inpatient psychiatric service, the Grady EMS Upstream Crisis Intervention pilot was designed to target 9-1-1 calls for patients with complaints related to mental health and to provide mental health professional evaluations on-scene and referrals to definitive care resources other than the emergency department.  The goal of the program was to replicate the ED process of medical clearance upstream from the ED, at the community level.  The patients would benefit by medical clearance from the transport unit crew at point-of-patient contact, supported by on-line medical direction, then direct referral from the field to sources of definitive psychiatric outpatient or inpatient care.

Random samples of 156 GHS ED and Grady EMS charts were reviewed over a one month period in 2012 by the GHS finance department, revealing the following data:  the ED average loss per patient was -$401 and the EMS average loss per ambulance transport was- $109.  

Grady EMS partnered with GHS Behavioral Health, Morehouse School of Medicine Psychiatry, the Grady EMS Medical Director and Emory EMS fellows, the Mobile Crisis Team operated by Behavioral Health Link (BHL) which also operates the Georgia Crisis and Access Line (GCAL) to identify potential psychiatric case presentations, then solutions that identify the most appropriate care resources and transportation to this most appropriate facility.  

The mobile crisis unit, staffed with one paramedic and a licensed clinical social worker (LCSW), co-responded to 911 medical calls triaged as chief complaint 25 (psychiatric) in the National Academy of Emergency Medical Dispatch protocol system with a Grady EMS transport unit. This crisis team was empowered to offer the patients alternate (to the ED) dispositions and alternate destination transports, where and when appropriate, in conjunction with on-line medical direction.  The team was able to provide patients with same-day or next-day appointments, attempt to re-engage patients with their mental health providers, assist patients with psychiatric medication refill needs and referral follow-up options.  They also distributed referral cards to patients and their caregivers for contacting the 24-hour Georgia Crisis and Access Line (GCAL).

The unit (7170) co-responded to active psychiatric dispatches wherein a Grady EMS ambulance crew was going to physically and chemically restrain patients.  The on-scene crew, having been notified of the 7170 response, attempts to delay the restraint process until the crisis team arrives.  This team utilizes its specialized skills in verbal de-escalation to manage the patient without imposing restraints.  This crisis team also has the ability to execute a mandatory hold (1013) prior to restraint for better legal and safety protections.  Additionally, the 1013 execution significantly reduced scene times.  

When a psychiatric patient is disorganized in thinking or behavior and does not meet criteria for an EMS patient refusal according to the Fulton County Clinical Care Guidelines (FCCCG) but the patient is sufficiently aware  to verbally refuse and/or physically resist the transport, disposition of these cases becomes challenging and time-consuming.  They often involve restraint by law enforcement, on-line Medical Direction input, and Grady EMS Supervisor response to the scene.  

The Grady EMS Emergency Communications Center finalized an MOU with the GCAL Call Center, in a subsequent development of the program, to allow us to directly transfer specific low-acuity psychiatric triaged calls (NAEMD 25-omega) to GCAL.  This corresponds to our Grady EMS Emergency Communications Center relationships to the Nurse Advice and Georgia Poison Center services.  The ambulance dispatch or response is cancelled upon GCAL call center acceptance of the call.  GCAL clinicians can provide phone care, scheduling of referral appointments, or dispatch of their mobile crisis team. As of October 2013, Grady EMS transferred 129 calls which successfully avoided a secondary ambulance or our crisis unit response.    

Under Grady EMS’ Alternate Destination Program, the crisis team transported patients to in-patient psychiatric or substance abuse facilities after bed acceptance was verified through the BHL Mobile Crisis process and approval was received from the Grady EMS Medical Director or EMS Fellow.

As of April 29, 2013, the crisis unit changed its response model from a co-response to the sole unit based on the EMD code and crisis unit’s geographic proximity to the call. 

The Grady EMS Quality Assurance Officers identified patients who had requested EMS resources with high frequency, had a history of mental illness, and possessed a physical address. When not responding to active dispatches for psychiatric patients, the crisis unit phoned these patients to schedule an appointment or made unscheduled home visits.  The crisis team met with patients and/or their caregivers to discuss options for care, assure medication compliance, provide GCAL cards, and track appointment compliance.  The unit provided the non-emergency transportation phone number if they are unable to obtain private transportation to their mental health appointment.  

On 08/04/2013, the crisis unit doubled staffing to operate 80-hours per week from 0900-0100.  Based on data review, the evening shift was able to complete a higher number of calls possibly due to the ease of driving throughout the city and the day shift unit focusing on high utilizers.

Outputs:

From January 14 through October 31, 2013, the crisis unit responded to 836 calls, transported 37 patients to in-patient psychiatric or substance abuse facilities, completed 221 non-transport refusals, arrived and was cancelled on 138 calls, transported 307 patients in the mobile crisis unit to the ED which availed other more appropriate patients of an ambulance response, contacted or attempted to contact 70 high EMS users as described above, and completed 11 home visits.  The consistency of the crisis team interventions and frequent interactions with patients decreased repetitive users and allowed for the crisis team to offer complimentary services to assist this group of patients while achieving operational efficiencies for EMS.

Outcomes: 

The success of this program is not only measured in non-transports or dispositions to alternate destinations but also in the community service provided as an integral component of the safety net health system to patients who suffer from mental illness and its frequently accompanied violent encounters.  The crisis intervention team has assumed a critical role in deploying mental health social worker expertise to de-escalate agitated and potentially violent patients

Michael Colman, MPA, NRP, Director of EMS Operations at Grady Health Systems

Glenda Wrenn, MD MSHP, Associate Project Director Satcher Health Leadership Institute Integrated Care Initiative, Morehouse School of Medicine

Arthur H. Yancey, II, MD, MPH, FACEP, Associate Professor Department of Emergency Medicine Emory University School of Medicine and Grady EMS Medical Director.