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LONG BEACH, Calif. -- A hospital in Hawaii managed to dramatically reduce psychiatric admissions by taking over management of a statewide system wherein police officers must consult a professional mental health emergency worker prior to bringing people in for involuntary evaluations, psychiatric nurses told colleagues here.

In many cases, the individuals are diverted to community resources instead of the emergency department (ED).

The number of mental health visits to the Queen's Medical Center ED in Honolulu fell from nearly 1,800 per fiscal year from 2017-2019 to about 1,450 in 2020 and about 1,200 in 2021 after the program was instituted. This decline occurred even as mental health calls remained fairly steady, the nurses reported at the annual meeting of the American Psychiatric Nurses Association.

In addition, "we're seeing a 21% decline in mandatory psych evaluations and a 35% increase in voluntary admissions, as well as a 95% increase in family involvement," said Andrew Currivan, APRN-Rx, MSN.

According to Sondra Leiggi-Brandon, APRN-Rx, MSN, MPH, Hawaii law requires police officers to consult a professional mental health emergency worker before involuntarily transferring a person to a hospital for a psychiatric evaluation.

For the first 10 years of the program, she said, it was run by a psychologist. "He had no experience working in a hospital and no affiliation in the hospital. He could send patients, but didn't know what it was like to have an [ED] that was on divert." Nor did he understand what it was like, say, to receive five highly aggressive people in a row, said Leiggi-Brandon.

"We had to engage him and say these are some of the issues we face in the ED," she said. "It was really difficult for him to understand that."

Also, she said, only 20% of the incoming transfers were actually admitted. "There's a lot of room there to develop a process that maybe says we don't have to bring them to an ED."

So the Queen's Medical Center put in a bid for the contract to manage the system and won it, and a team led by psychiatric nurse practitioners took over the program in 2020. The system relies on a "really concrete algorithm" so there aren't any allegations that the hospital is trying to avoid taking its share of mental health patients, Leiggi-Brandon said. (Queen's sees 61% of mental health evaluations in the entire state.)

The focus is on sending patients where they belong, she said.

On one hand, "let's say somebody commits a petty crime, but there clearly is a mental health crisis. We can bring them into the ED rather than having them arrested. That way, we try to decriminalize mental health," said Leiggi-Brandon. "Or if it's someone who's on the edge of a bridge, trying to commit suicide: We automatically send those people right in."

But others need community resources instead of an evaluation, she said. "Sometimes it's about shelter or food, so we can send them to a crisis line. People who are depressed but have resources at home like family, we can refer them to crisis services. Some [of these cases] result in shelter assistance, some of them result in social-work consultations, or even community case management."

A HIPAA-compliant documentation system, meanwhile, allows the tracking of cases and lets ED physicians catch up on the history of the patients they see, Leiggi-Brandon said. "It also allows us to identify frequent utilizers so we can start working with the department of health to create some intervention plans for these people. There are individuals that have had 26 or more calls."

As for outcomes, the use of non-hospital mental-health facilities has jumped by 1,500%, the nurses said, and there's an 864% increase in use of crisis services.

"We want to make sure that we not only can help these individuals in crisis by the least traumatic means available, but also that we can tap them into resources," Currivan said. Many patients are victims of abuse, "and the last thing we want to do is roughhouse them or manhandle them, throw them in handcuffs, throw them in the back of a squad car, and then strap them down to a gurney in the emergency department."

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