One day last winter, Pat Triplett received an urgent page: A patient who’d been on a medical unit for two weeks started lashing out at everyone in his path. By the time the Johns Hopkins psychiatrist arrived, it was too late to connect with the patient. Security staff members had already pinned him down. “It exacted a huge toll on the unit,” says Triplett, “and stuck in my mind as just what we are trying to avoid.”

That incident—and others—moved Triplett to fast-track a plan to screen all newly admitted inpatients—not just those headed for psychiatric units. The idea, he says, is for a psychiatrist, nurse practitioner and psychiatric social worker to assess medical unit patients for mental health concerns early on, “before they escalate.”

The need is dire, he adds. Roughly 38 percent of medical admissions to Johns Hopkins have psychiatric disorders such as depression, bipolar disorder or schizophrenia. Also, up to 20 percent of the hospital’s admissions are linked to opioids.

Now, however, with the debut of the Behavioral Intervention Team (BIT) in April 2016, at least one team member sees a patient, often within hours of admission to a medical unit. “Not everyone will need psychiatric assessment,” Triplett says, “but some will, and the sooner they’re identified, the quicker they will be treated.”

The Johns Hopkins BIT model is still a work in progress. Currently, the team covers three medical units—about 70 beds. By next spring, Triplett aims to roll out two more teams and a broader reach. He credits the model as the brainchild of former Johns Hopkins colleague Hochang “Ben” Lee, now at Yale New Haven Hospital, where it has proven successful.

Here’s how the approach works: Every weekday morning, one BIT member meets to review patient charts that medical-surgical staff members have prepared. Afterward, all three BIT members—each specialized in psychiatric evaluation—decide which patients will be seen and by whom.

Triage is tiered, says Triplett: Patients arriving after a suicide attempt, for example, are seen immediately; those co-burdened with schizophrenia and poor medical outcomes are also assessed more rapidly.

BIT nurse practitioner Maureen Lewis begins each visit by scanning the electronic medical record for any history of psychiatric illness or substance abuse. After introducing herself, she says, “We’re just checking in to see if you’re taking any antidepressants.” This surprises some patients, Lewis says, “but even the mildly troubled can benefit from the program and have been receptive to our efforts.” When necessary, she arranges transfers to inpatient psychiatry.

Signs of depression on medical units aren’t rare, often surfacing after a major medical event. But they can be subtle, says BIT psychiatric social worker Deborah “Sunny” Mendelson. She describes an elderly patient admitted with a massive stroke. “Everything was swirling around for him,” she recalls. Though he’d lost major abilities, “he felt especially vulnerable and sad about not seeing well enough to read the white board or adjust his bed. I told him that it takes a while for the brain for adapt, but you have the ability to communicate.” The conversation cheered the man, as did the vision consult she recommended, which led to new eyeglasses.

Often, Mendelson digs deeper. She asks how patients cope with new perceptions of themselves, particularly if they’ll need more surgery or have advanced cancer. Simply the chance to talk about their situations, she says, “can be liberating.”

But challenges abound. Many inpatients have a complex mix of medical and psychiatric problems, notes Triplett, such as those who develop delirium after joint replacement surgery. Or, new medication changes can make a huge difference in mood.

Complicating matters further are patients admitted for medical problems who also have chronic mental illness. Many of these patients have high rates of diabetes, obesity and smoking.

In its short existence, the program has won accolades for reducing psychiatric crises and length of stay. “We don’t have data yet,” says Triplett, “but if we can cut length of stay for patients getting psych consults by two-thirds of a day, as Yale has, it will have a huge financial impact.” The BIT program has also raised morale, especially among nurses. “Having the psych team on the unit or nearby,” says Triplett, “lets them focus fully on their medical nursing.”

But the biggest payoff for the Behavioral Intervention Team, says Triplett, has been how this approach improves patients’ peace of mind far sooner than later. 

 

- Pat Triplett