Emotion-based Assessment and Treatment of Patients with Repeat Unexplained ED Visits . 2010 Quality Award Winner 2010

1. Emotion-based Assessment and Treatment of Patients with Repeat Unexplained ED Visits.2010 Quality Award Winner2010 Accreditation Canada Leading Practice An Emergency Department and Centre for Emotions and Health Collaboration Contact: Allan Abbass 902473-2514, allan.abbass@dal.ca www.istdp.ca

2. Impact of Emotional factors in Capital Health Hospital Days Emergency use Medical Visits Tests + Procedures Excess Medications Poor Outcomes Disability Morbidity Mortality Physical Symptoms Physical Illnesses Low self care Self Injury Relationships Low Compliance Complaints Emotion Dysregulation

3. Great Overlap Between Common Problems Headache Confusion Irritable Bowel Dyspepsia Abdominal pain Bladder dysfunction Pelvic Pain Chemical Sensitivity Fibromyalgia Fatigue Hypertension Chest pain Psoriasis Dermatitis Conversion Pseudoneurological Phenomena Depression Anxiety Panic

4. Great Overlap Between Common Problems Headache Confusion Irritable Bowel Dyspepsia Abdominal pain Emotion Dysregulation Bladder dysfunction Pelvic Pain Chemical Sensitivity Fibromyalgia Fatigue Hypertension Chest pain Psoriasis Dermatitis Conversion Pseudoneurological Phenomena Depression Anxiety Panic

5. Unexplained Symptoms: Consecutive ReferralsNimnuan et al, 2001

6. Capital Health Excess Burden of Emotion-linked Medical Disorders Emergency use: ~15-20,000 visits/yr Hospital Days: ~13,000 days per year Medical Visits: 25-50% of all new consults Excess Tests + Procedures: ? Excess Medications: ~$150,000/yr in Hospital Suboptimal Outcomes: ? Cost Excess Side effects: ? Cost: many admissions Disability: ~$6,000,000/ year in Capital Health Mortality: a measurable excess in reviews Info from Emergency Database, Decision Support, Occupational Health and Pharmacy

7. Emergency Data Unexplained Chest Pain, Headache, Panic, Abdominal Pain account for 16% of all CDHA ED Visits each year 75% of all Chest Pain complaints come out with no diagnosis: 9000 visits 88% of all Abdominal Pain complaints come out with no diagnosis: 7000 visits    Wait Times

8. What is Intensive Short-term Dynamic Psychotherapy-ISTDP A method based on videotaped research to diagnose and address problems handling emotions Effective with broad range of physical and psychological problems Actively researched and taught in our Centre More information http://www.istdp.ca/whatis.htm

9. Voluntary Muscle Tension  Fibromyalgia, chest pain, abdominal pain, hyperventilation, panic attacks Involuntary Muscle Tension  Hypertension, IBS, Dyspepsia, Urinary symptoms, pelvic pain, migraine Physical Problems treatable with ISTDP

10. Cognitive-perceptual Disruption  dizziness, fainting, weakness, memory problems, accidents, injury, psychotic features Motor Conversion  Falling, loss of speech, spasm, weakness

11. How Effective is ISTDP 21 published outcome studies Effective with multiple medical conditions and physical symptom syndromes Marked drop in Dr and Hospital costs Majority stop psychiatric medications Around 85% of treated patients return to work from disabilities (several studies) Single session brings 25% symptom reduction on average Saves approximately 10 times what it costs each year through service use and disability reduction.

12. Medication Related Mixed office sample in BCAbbass, 2002

13. Health Care UtilizationAbbass, Am J Psychotherapy, 2002

14. ISTDP reduced Repeat Emergency Visits for Medically Unexplained Symptoms Abbass, Campbell et al, Can J Emerg Med, 2009, 2010a, 2010b Control ISTDP  Innovation Grant to staff ED with Diagnostic Clinicians

15. Implementation 2000-2009 Established long term relationship between CEH and ED Provided videotape based education sessions to the emergency staff Developed an information pamphlet for patients. Introduced rapid access referrals to the service where emergency patients were seen in less than 2 weeks when possible. Showed videotape of the emergency-referred cases we had seen. Provided literature to emergency physician and other staff. Provided a month of on-site consultation and liaison with emergency physicians.

16. Results Abbass, Campbell et al, 2009 3.8 sessions average Significant Improvement on symptom measure (BSI) High Patient Satisfaction ratings (~8/10) Marked increase in referral rates by more Emergency Doctors Major reduction in repeat Emergency Use (65-70% reduction) “Net Cost saving” of 500 per patient Funding received for 1.2 FTE Psychologists to staff the ED Named Canadian Leading Practice by Accreditation Canada 2010 Nova Scotia expected to roll this program out to other emergency departments

17. Results (cont’d) Simply understanding that emotional factors were responsible for symptoms was enough to reduce symptoms and ED use. Only 2 returned to ED, after assessment and during course of clinic. Almost all patients were suitable referrals for service. Only 2 or 3 did not fit the service. More complex patients needed coordinated Tx While all had multiple issues, at the core of the problem was some form of attachment trauma in early life. Nearly all were moderate resistant, highly resistant or fragile

18. Conclusions • The service is widely acceptable and well used • Patients benefit with reduced ED visits • Service use reduction can help to reduce wait times • This service matches meeting the patient at point of entry, and • Exemplifies patient-centred care at Capital Health

19. More information • Canadian Journal of Emergency Medicine 2009 article: http://www.istdp.ca/docs/CJEM_2009.pdf • Journal of Academy of Medical Psychology articles on Cost Effectiveness and Implementation http://www.istdp.ca/docs/Cost%20Saving%20ED%20Treatment.pdf http://www.istdp.ca/docs/Implementing%20ISTDP%20in%20the%20ED.pdf