Patients accept screening for mental health and substance use disorders while ED clinicians support only if able to refer
American Journal of Emergency Medicine 38 (2020) 2727-2729
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Patients accept screening for mental health and Substance use disorders while ED clinicians support only if able to refer
(86%) expressed CARS would be useful for facilitating referrals. Some (28%) reported that if their ED visit was for MHSUD, they would have preferred in-person assessment. Many (71%) reported that com-
pleting the screener prompted reflection on their mental health.
While some reported preference for in-person assessment, 43% re-
Mental health and substance use disorder (MHSUD) visits to the emergency department (ED) are frequent and increasing [1-5]. The ED is often the first contact for patients with MHSUD [6], and provides an opportunity for screening, brief intervention, and referral to treat- ment [7]. Universal screening for MHSUD in the ED has proven contro- versial. The American College of Emergency Physicians (ACEP) has argued that MHSUD screening, particularly for suicidal ideation, should only occur if there are sufficient resources for screening and outpatient referrals [8]. However, patients who present to the ED for suicidal thoughts have increased suicide risk for 12 months after presentation [9], suggesting the importance of screening. Universal suicide screening is listed as a “best practice” by most suicide prevention organizations [10,11].
Given the importance of identification and early intervention for a range of MHSUD [12-18], it is worth asking not only whether universal screening for MHSUD in the ED setting is effective, but under what con- ditions is it feasible and acceptable to clinicians? The goal of our qualita- tive study was to assess patient and clinician views and barriers to and facilitators of implementation of a computerized MHSUD screener, the Computerized Assessment and Referral System (CARS), in an ED setting. We conducted qualitative interviews with ED patients (n = 7) present- ing for non-MHSUD reasons who completed CARS, ED physicians (n = 5) randomized to receive a CARS report, and ED nurses (n = 2) who worked with patients who had completed CARS. The study was con- ducted in an urban ED within a Level I Trauma Center that sees approx- imately 70,000 patients annually in a Southern U.S. state. We used Summative Template Analysis, a data abstraction procedure [19], to an- alyze data.
Patients were supportive of universal screening of MHSUD in the ED even when not relevant to their visit. Most expressed willingness to engage in screening if it could help identify others with undiag- nosed or untreated MHSUD. Most patients (71%) reported that identi- fying underlying MHSUD was an advantage of screening and most
1 Departments of Psychiatry and Surgery, University of Arkansas for Medical Sciences, Little Rock, AR; VA South Central Mental illness Research, Education, and Clinical Center (MIRECC), Central Arkansas Veterans Healthcare System, North Little Rock, AR.
2 Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR; VA Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR.
3 Department of Medicine, University of Minnesota Medical School, Minneapolis, MN.
4 Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR; Behavioral Health QUERI, Central Arkansas Veterans Healthcare System, North Little Rock, AR.
5 Departments of Emergency Medicine and Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR.
0735-6757/(C) 2020
ported it was easier to disclose MHSUD symptoms using CARS. One patient reported that completing CARS encouraged him to disclose his 25-year old trauma history for the first time to a trusted primary care physician.
ED clinicians supported a limited version of MHSUD screening. They believed screening could potentially be useful and might identify under- lying MHSUD, inform treatment in the ED, and facilitate referral. While none opposed MHSUD screening in the ED, they identified significant concerns regarding disruption of work flow, system strain, time burden, and the logistics of managing MHSUD in the ED.
57% of ED clinicians reported that MHSUD screening to facilitate referral was helpful for creating a more patient-centered, integrated health care experience. They reported this is dependent on the hospital’s ability to ensure access to appropriate referrals. Most ED clinicians felt there were not enough resources in their hospital sys- tem or community to provide adequate MHSUD referral options. They expressed hesitation in screening for problems for which they did not perceive adequate referral options. See Table 1 for ED clini- cians’ recommendations for implementation of MHSUD screening in the ED.
These results support ACEP’s position on universal MHSUD screening, namely that ED clinicians are more likely to support screening if sufficient resources exist for screening and referral. As in previous studies, patients were accepting of MHSUD screening, with most finding computerized methods acceptable. ED clinicians generally found computerized MHSUD to be acceptable and useful. Feasibility and acceptability of screening was largely dependent on how actionable the information was during the ED visit and on the ability to refer to outpatient care.
Given lack of referral options was the biggest barrier to universal screening in this study, EDs that intend to address MHSUD may want to consider integrating mental health professionals into the ED. This is more resource-intensive than a computerized self- administered screener, but is consistent with the recommendations of ED clinicians in the current study and studies in other critical care settings [20]. If mental health professionals provided brief in- terventions within the ED, this could alleviate physicians’ concerns of screening for problems that were subsequently not treated [21]. Institutions intending to implement MHSUD screening in their ED should consider utilizing Screening tools that can be tailored to the ED setting in terms of the questions asked (i.e., actionable in the ED) and how and when the information is disseminated to the care team. Future studies are needed to assess patient motivation to seek treatment after receiving positive MHSUD screener results and the extent to which appropriate referral sources is a barrier to seeking treatment.
2728 Patients accept screening for mental health and substance use disorders while ED clinicians support only if able to refer
Table 1
Recommendations from ED clinicians for implementation of universal MHSUD screening in the ED.
Domain Recommendations
Appendix A. CARS Qualitative Interview Guide – Patient Version
During your visit to the ER, do you remember answering questions on a computer about your emotions, how you feel about things, or your mental health?
Orientation to screening tool
-
- Provide repeated, brief orientation to the purpose of MHSUD screening
- Designate Clinical champions to provide impromptu education as needed
- Educate on how to manage or discuss MHSUD with patients
[If yes]
How did you feel about completing those questions during a visit to the ER?
Timing – Screen as early as possible (e.g., triage or waiting room)
-
- Provide report as early in encounter as possible to maximize utility
What was it like to answer them on the computer?
[Was it hard/easy to do? Why?]
Assessment and report content
- Exclusively assess domains of MHSUD that are action- able within an ED
- Prioritize current suicide risk and MHSUD symptoms
- Keep screeners and reports as brief as possible
- Utilize verbal handoffs in addition to printed or elec- tronic reports
What is your opinion about the types of questions you were asked?
[Look for positive/negative/neutral opinions]
Intervention – Develop a defined protocol for responding to positive
screens
- Educate ED clinicians about available MHSUD referrals
- Employ mental health professionals to provide brief intervention during ED visit
- Base MHSUD referral protocol on existing ambulatory Referral processes
Financial support
Funds from the Emergency Medicine Foundation were utilized for this project.
Prior presentations
N/A.
SAM is the corresponding author and contributed to the data collec- tion along with ENW. SAM, ENW, SJL, and MPW contributed to the study concept and design. SAM, BEP, and ENW contributed to the data analy- sis. MPW contributed to acquisition of funding. All authors contributed to the writing of the article and critical revision.
Emergency Medicine Foundation.
Dr. McBain’s time was supported by the Department of Veterans Af- fairs Office of Academic Affiliations Advanced Fellowship Program in Mental Illness Research and Treatment; the Medical Research Service of the Central Arkansas Veterans Healthcare System; the Department of Veterans Affairs South Central Mental Illness Research, Education, and Clinical Center (MIRECC). Dr. Woodward is a fellow with the Imple- mentation Research Institute (IRI), at the George Warren Brown School of Social Work, Washington University in St. Louis; through an award from the National Institute of Mental Health (5R25MH08091607). Dr. Landes is supported by a Clinical and Translational Science Award (CTSA) program from the NIH National Center for Advancing Transla- tional Sciences (NCATS) awarded to the University of Arkansas for Med- ical Sciences, grant UL1TR003107. Dr. Wilson’s time was supported by the University of Arkansas for Medical Sciences Clinician Scientist pro- gram. Drs. Palmer, Landes, and Wilson received funding from the Emer- gency Medicine Foundation.
If you had went to the ER for an emotional concern, would you have wanted to answer those questions on the computer?
Do you think these types of questions should be asked of all people who visit an ER?
For example, they may have talked about mental health problems such as depression, they may have had you talk to another doctor who specializes in mental health, or made a referral to a service outside the hospital.
How did your answers to the questions effect the care you received?
a. Think of one or two questions that stood out to you. How did an- swering those effect you later, after the ER visit, if at all?
From your perspective, how do you think the information from these questions about people’s mental health should be used in the ER?
a. What about after they leave the ER? For example, would you want this to be used to help you get mental health services later?
Knowing we are trying to decide whether to keep using these ques- tions in the ER, and knowing our hospital wants to provide the best care to patients like yourself, are there additional comments you’d like to add?
Appendix B. CARS Qualitative Interview Guide – Clinician Version
Do you remember ever receiving results from a computerized mental health screener for any patients completed in the ED in the last 1-2 months?
Patients accept screening for mental health and substance use disorders while ED clinicians support only if able to refer 2729
What did you think about receiving those results before clinical en- counters in the ED?
Were they presented in a way that was easy to understand?
Types of MH diagnosis?
What would you need to conduct this regularly? E.g., People, train- ing, repeated cycles of quality improvement to make sure it fits the flow
Probe: How would mental health screening support this strategic plan?
Sacha A. McBain1,? Eva Woodward2
University of Arkansas for Medical Sciences, United States of America Central Arkansas VA Health Care System, United States of America
?Corresponding author at: University of Arkansas for Medical Sciences,
United States of America.
E-mail addresses: [email protected], [email protected].
Brooke E. Palmer3
University of Minnesota Medical School, United States of America
E-mail address: [email protected].
Sara J. Landes4 University of Arkansas for Medical Sciences, United States of America Central Arkansas VA Health Care System, United States of America
E-mail address: [email protected].
University of Arkansas for Medical Sciences, United States of America
E-mail address: [email protected].
https://doi.org/10.1016/j.ajem.2020.04.014
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