Improving emergency care for people with developmental ...

Improving emergency care for people with developmental ...

Improving emergency care for people with developmental disabilities What does the research tell us? What does the research tell us about barriers experienced by clients, families and ED staff ?

2 1 in 2 adults with a DD will go to the ED 3 Epidemiology Ontario population study on ED and DD (Lunsky et. al)

Average # of visits among ED users = 3.0 vs 1.7 1.7 times more likely to be admitted ED visits can be VERY IMPACTFUL 4 Epidemiology Ontario population study on ED and DD 25% of 18-24 y.o DD patients >= 2 meds

50% >= 2 meds by age 35 5 Case Example 27 y.o. male w severe autism spectrum disorder. Non-verbal. Recent behaviour escalating to self-harm and harming caregivers after long stable period.

ED referred to Psychiatry. Psychiatry referred to Medicine. Guess how long patient stayed in the ED? Guess what the final diagnosis was? 6 DENTAL ABSCESS .After 4 days in the ED, and a range of PRNs to manage his behaviour.

Dental pain is one of the commonly missed diagnoses among adults with DD (see the clinical Tip Sheets), and is well-established precipitant of behaviour change. We all missed it. Research Findings Predictors of emergency visits in DD No crisis plan

Living with family Previous emerg visits Gaps in primary care 8 What do we hear from patients and families?

9 Lack of respect Rights Forced procedures Treated for a different complaint Consent Not given opportunity

Chemical and physical restraint Prior to alternative approaches Lunsky & Gracey, 2009 10 This lady said to me you come in here all the time and this and that She argued with me. I

was upset about it so I just left and went to another hospital 11 They said they couldnt keep her anymore so they sent her home The same day they sent her home,

she ran away... She has never taken the bus on her own but that day she took herself to another hospital. 12 It was a bit difficult because the more people came in with other problems,

the more anxious she got. Its not like a regular individual who could understand the wait. 13 They dont understand that it is hard to be cooperative when I am agitated.

14 What do we hear from Emergency Department staff? 15 How can I engage with this person?

We dont have that expertise. 16 We dont see a

lot, but when we do, they are time consuming and difficult Sometimes the same person comes 3 to 4 times in a row".

17 18 How are we going to help improve outcomes in our ED? How will we get there? Enhance Communication

With patients: Practical interview tips With eachother: Document DD in the chart Fill Knowledge Gaps Medical issues specific to DD clients; missed diagnoses Community resources for this population Fit these resources into our ED Context Recognize time and shift-work realities in the ED

Embed into electronic or existing infrastructure. 21 Identifying People with DD Enhance Recognition to improve ED response Goal: Barrier:

Discomfort with labelling Facilitator: Highlight benefits TO THE ED 22 Adapting Approaches

Use best evidence tools, strategies & techniques Goal: Integrating resources into ED best Barrier: practices & procedures. Understanding ED best practices and Facilitator: procedures and customizing accordingly (e.g. electronic prompts, visual aids, just-in-time).

23 Recognize the ABCs A All B Behaviour is

C Communication 24 Adapting Approaches We know how to do this we just have to

remember TO DO it. Slow down, sit down. Body language is important. Pick up on their verbal and non-verbal clues. See the clinical TIP SHEETS. Laying down the law. Not likely to help! 25 Educational Videos knowledge exchange videos The Frequent Visitor The Aggressive Patient The Difficult Blood draw 26

Discharge Planning Improve information given to patients and Goal: providers & reduce future repeat visits WORK FLOW, WORKFLOW, WORK FLOW !!! Barrier:

Ownership across the ED process & Facilitator: Minimizing additional work for staff 27 Patient Friendly Discharge Summary Complete this actively with

the patient involve them in the information to ensure their comprehension. 28 Example of electronic innovation (in EDIS) to auto-populate Dear Dr

letters for patients GP. Also translates into a Dear Patient version. 29 References Lunsky Y, Balogh R, Cairney J . Predictors of emergency department visits by persons with intellectual disability experiencing a psychiatric crisis. Psychiatr Serv. 2012 Mar;63(3):28790. Lunsky Y, Balogh R, Khodaverdian A, Elliott D, Jaskulski C, Morris S. A comparison of medical and psychobehavioral

emergency department visits made by adults with intellectual disabilities. Emerg Med Int. 2012 :427407. Lunsky Y, Elserafi J. Antipsychotic medication prescription patterns in adults with developmental disabilities who have experienced psychiatric crisis. Res Dev Disabil. 2012 JanFeb;33(1):32-8. Lunsky Y, Elserafi J. Life events and emergency department visits in response to crisis in individuals with intellectual disabilities. J Intellect Disabil Res. 2011 Jul;55(7):714-8. Lunsky Y, Gracey C. The reported experience of four women with intellectual disabilities receiving emergency psychiatric services in Canada: a qualitative study. J Intellect Disabil. 2009 Jun;13(2):87-98. Lunsky Y, Gracey C, Gelfand S.Emergency psychiatric services for individuals with intellectual disabilities: perspectives of hospital staff. Intellect Dev Disabil. 2008 Dec;46(6):446-55. Lunsky Y, Lin E, Balogh R, Klein-Geltink J, Bennie J, Wilton AS, Kurdyak P. Are adults with developmental disabilities more likely to visit EDs? Am J Emerg Med. 2011 May;29(4):463-5. Lunsky Y, Lin E, Balogh R, Klein-Geltink J, Wilton AS, Kurdyak P. Emergency department visits and use of outpatient physician services by adults with developmental disability and psychiatric disorder. Can J Psychiatry. 2012 Oct;57(10):601-7.

Lunsky Y, Paquette-Smith M, Weiss JA, Lee J. Predictors of emergency service use in adolescents and adults with autism spectrum disorder living with family. J Emerg Med J. 2015 Oct;32(10):787-92. Sullivan WF, Berg JM, Brrdley E, Cheetham T, Denton R, Heng J, Hennen B, Joyce D, Kelly M, Korossy M, Lunsky Y, McMillan S; Primary care of adults with developmental disabilities: Canadian consensus guidelines. Colloquium on Guidelines for the Primary Health Care of Adults with Developmental Disabilities. Can Fam Physician. 2011 May;57(5):541-53. Tint A, Lunsky Y. Individual, social and contextual factors associated with psychiatric care outcomes among patients with intellectual disabilities in the emergency department. J Intellect Disabil Res. 2015 Nov;59(11):999-1009.

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