Since 2020, incidences of mental illness have increased 25% worldwide, and in the United States there is only 1 mental health provider for every 340 people with a mental health condition. As such, the number of patients coming to emergency departments to treat mental health issues has skyrocketed. In the midst of this behavioral health emergencies epidemic, and against the backdrop of the uniquely high-intensity New York City environment, Dr. Angela Mills and Dr. Brenna Farmer– two emergency department leaders at NewYork-Presbyterian– are piloting new strategies to ensure that they coordinate top-quality care for this growing population of vulnerable patients.
On this episode of Advances in Care, we return to the high-intensity environment of New York City’s emergency departments with Dr. Angela Mills and Dr. Brenna Farmer. Host Erin Welsh hears from these leaders at NewYork-Presbyterian about how they are implementing innovative strategies to meet the challenges of the behavioral health emergencies epidemic.
Dr. Brenna Farmer, chief of emergency medicine at NewYork-Presbyterian Brooklyn Methodist, and Dr. Angela Mills, chief of emergency medicine at NewYork-Presbyterian and Columbia, bring us inside the emergency departments they lead to explain the challenges that their staff face in meeting the needs of severely decompensated patients. From disruptions in the flow of care, to potentially violent outbursts, their teams navigate these issues against the backdrop of an already complex operational environment.
Dr. Farmer tells us how she has implemented an innovative protocol called BERT– the Behavioral Health Response Team– in the Brooklyn Methodist Emergency Department, which is rolling out across the NewYork-Presbyterian system. BERT allows ED teams to better address behavioral health patients, leading to more robust support for staff, and quicker, more comprehensive patient care overall, including connecting them to much needed outpatient resources. Finally, Dr. Farmer and Dr. Mills share additional strategies they employ to support their own well-being– and that of their medical teams– as they face difficult cases, plus their personal reasons for working in this unique field.
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Dr. Angela M. Mills is a nationally recognized leader and expert in emergency medicine. She serves as the inaugural chair of the newly designated Department of Emergency Medicine at Columbia University Irving Medical Center and chief of Emergency Medicine Services at NewYork-Presbyterian.
Dr. Brenna M. Farmer is Chief of Emergency Medicine at NewYork-Presbyterian Brooklyn Methodist Hospital and vice chair for the Department of Emergency Medicine at Weill Cornell Medicine. She is also an assistant associate professor of clinical emergency medicine at Weill Cornell Medicine. Dr. Farmer is a nationally recognized medical toxicology expert and frequent keynote speaker on quality improvement, patient safety, and medication safety.
For more information visit nyp.org/Advances.
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Erin: It’s early morning in a New York City Emergency Department.
Dr. Angela Mills: Around 4:00AM to 6:00AM somewhere in there things might… you never wanna use the Q word quiet or S word slow...
Erin: That’s Dr. Angela Mills. chief of emergency medicine at NewYork-Presbyterian and Columbia, which encompasses four hospitals — Columbia University Irving Medical Center, Morgan Stanley Children's Hospital, Westchester Hospital, and Allen Hospital.
Dr. Angela Mills: … you are always hearing monitors beeping. There's constantly patients arriving by ambulance. But sometimes things uh aren't quite as, as crazy busy.
Dr. Angela Mills: But then when you're least expecting it, you know you’ll get paging system notifications that alert us all to the arrival of a sick patient.
Erin: An agitated young man struggles to escape the grip of two police officers who push him through the swinging doors. He has a gash on his head. And he’s lashing out with his arms and fists.
Dr. Brenna Farmer: Those really aggressive patients that are being escorted in by [00:01:00] police are the ones that we worry about the most.
Erin: That’s Weill Cornell Medicine physician Dr. Brenna Farmer, chief of emergency medicine at NewYork-Presbyterian Brooklyn Methodist hospital.
Dr. Brenna Farmer:: A lot of these patients have schizophrenia. They're not taking their medications that control their delusions or whatever the case may be. And so they're seeing the medical team, but they may be seeing monsters approaching them or something like that. And we need to start treatment.
Erin: Treating behaviorally decompensated, often aggressive patients is stressful, physically challenging, and disruptive. And it has become a familiar scenario for Dr. Farmer and Dr. Mills, and for physicians in emergency departments across the nation.
Dr. Brenna Farmer: New York City is definitely, just like the rest of the country, in the middle of a behavioral health emergencies epidemic.
Erin: Since 2020, incidence of mental illness has increased 25% worldwide. In the United States, there is only 1 mental health provider for every 340 people with a mental health condition. So a rising number of patients are winding up in emergency [00:02:00] departments with complex mental health issues – from psychosis to substance use disorder.
Dr. Angela Mills: Whether it's housing insecurity, substance use disorders, mental illness. I mean, these are factors that we see in patients every day.
Erin: In a city like New York – frenetic, busy, and bursting at the seams – EDs have become the front lines for this consequential health – and social – crisis. Against an already complex backdrop, NewYork-Presbyterian’s Emergency Department leaders are pioneering new methods for meeting this latest challenge head-on.
I’m Erin Welsh, and this is Advances in Care, a podcast about groundbreaking developments in modern medicine.
Last episode, we looked at how NewYork-Presbyterian manages unique traumas in their diverse, high-volume emergency departments. Today, we return to the ED with Dr. Brenna Farmer and Dr. Angela Mills, to learn how they’re adapting the departments they each oversee, to address [00:03:00] the influx of behavioral health emergencies in New York City. Under their leadership, NewYork-Presbyterian is implementing collaborative strategies and protocols to provide care for an exploding population of vulnerable patients.
The emergency departments that Dr. Mills and Dr. Farmer run see hundreds of thousands of patients every year – over 750 patients every day across Dr. Mills campuses, and 250 a day at Brooklyn Methodist. In New York – where the unhoused population has tripled since 2022, and high opioid addiction and overdose incidents persist – this means serving a high volume of under-resourced patients.
Dr. Angela Mills: Obviously we're here for emergencies, right? Whether it's heart attack, strokes, things like that. But we're also here as a safety net for our society. And sometimes it's very hard for people to access medical care.
Erin: The COVID 19 pandemic was a catalyst for a surge [00:04:00] in mental health issues– nationwide– that has severely strained the emergency department's role as a healthcare safety net.
Dr. Angela Mills: Since the COVID pandemic, across the country and certainly in our EDs for sure, behavioral health visits are really soaring.
Erin: Stress, loneliness, economic instability – there were many compounding factors. In New York, before the pandemic, behavioral and mental health patients may have received care at an outpatient facility. But during lockdown many treatment centers across the city closed, and never reopened.
Dr. Angela Mills: There are significantly less outpatient resources available for patients. And the resources that are there are very much stretched.
Erin: Emergency departments are increasingly the first line of care for patients with mental health conditions, from substance use disorder to severe psychiatric illness. Over the last few years, Dr. Mills and Dr. Farmer have seen behavioral and mental health emergencies skyrocket – to a dozen or more cases per day.
These patients may [00:05:00] walk-in on their own, but many are brought by the police or EMS, as a response to a 9-1-1 call.
Dr. Brenna Farmer: The patients that come in by EMS may be patients that are more disenfranchised from their families or homeless or in the midst of such decompensation from the behavioral health concerns, that they've either caused a fight or got in a fight in public or noticed to be talking to themselves somewhere.
Dr. Angela Mills: … whether it's acute psychosis, you know, agitation, withdrawal… they might just be very intoxicated.
Erin: Caring for an increasing population of vulnerable patients– who may arrive in the ED with aggressive or disruptive behavior – adds a new level of complexity for emergency physicians.
Dr. Brenna Farmer: These patients are experiencing medical emergencies, they’re mental health emergencies, and they sometimes are in such crisis that they have aggressive behavior that puts both the team and the patient at risk.
Erin: As the pandemic wore on, a growing stream of [00:06:00] decompensated patients began to overwhelm the Brooklyn Methodist ED. Often, the same patients would come back numerous times in the same year – the ED was a reliable place they could land when experiencing a mental health incident. In a resource-strapped city grappling with COVID, it was also often the best place police could bring decompensating people after responding to a call.
While medical staff worked diligently to support patients in distress, they often had to manage complex situations, such as delusional, intoxicated, or severely agitated individuals, without the support of specialized resources or team-based interventions. If a patient lashed out or became violent, the physician would be caught in a difficult, often unsafe scenario.
Dr. Brenna Farmer: The patient may escalate even if you're trying to deescalate them because they're not getting the response that they want.
Erin: The demands were extraordinary, with staff often facing new and unpredictable situations alone.
On top of everything, decompensated [00:07:00] patients were creating bottlenecks. When a patient escalated, these disruptions would throw off the rhythm of the department, rattling staff and requiring ad hoc responses. It was distracting and time-consuming. Already busy shifts became even more challenging.
Dr. Farmer saw an opportunity to pilot a new approach: what if emergency teams treated these difficult and unpredictable mental health cases just like they approached a complex trauma case, like a heart attack or stroke?
Though it may sound straightforward, this insight was transformative. Previously, behaviorally decompensated patients had not been viewed as ‘complex’ trauma cases. Dr. Farmer’s shift in thinking unlocked an impactful new approach.
Dr. Brenna Farmer: Just like any medical condition, mental health medical conditions like substance use disorders or depression, suicidality, et cetera, takes a lot of effort and a lot of teamwork to be able to take care of [00:08:00] those patients. And the coordination that has to go into place is the same type of coordination that you have to do for a trauma or a heart attack or a stroke, or any of the other types of problems that we see from medical conditions.
Erin: Dr. Farmer and her team designed and put into practice a new team-centered protocol: BERT -- the Behavioral Health Emergency Response Team. It's a multi-disciplinary, coordinated care team built and trained for behavioral and mental health decompensation.
Dr. Brenna Farmer: That is our patient team in the emergency department, our nursing team, our physician team, our techs. We include our security guards to help us with safety. We also include our psychiatry teams, just like we would include the cardiologist in a STEMI patient.
Erin: With BERT –
Dr. Brenna Farmer: Preemptively if we notice that a patient's already decompensated and maybe not as cooperative as we would like them to be, we call the BERT response team.
Erin: When they hear the page, everyone on the BERT team immediately assembles.
Dr. Brenna Farmer: People respond no matter what their role [00:09:00] is.
Erin: This proactive, all-hands approach is what makes BERT effective. Everyone from clerks to security guards, to nurses and physicians are working in lockstep to attend to the situation.
Dr. Brenna Farmer: That team then approaches the patient and tries to deescalate them with communication and verbal discussion about why they're there, what they're gonna try to do to help them.
If the patient is so ill from their psychiatric illness that they can't understand or comprehend what we're trying to tell them, then that's when we have to use the medication to help start treatment. And that's the coordinated effort with our nursing team and our physician team and our psychiatry team to get the medication to the patient.
Erin: Implementation of BERT has created critical support – doctors no longer face unpredictable, sometimes violent patients alone. This keeps operations running smoothly, so that one complex mental health case doesn’t derail a high-volume shift.
Dr. Brenna Farmer: We're getting meds to [00:10:00] the patients faster. Whether it’s if the patient's so decompensated that they need injection medicine, we're able to give that quicker. But we also have patients that calm down enough to say, yes, I'll take oral medications, and we're getting the oral medications to them faster as well.
Erin: Ultimately, the success of the BERT protocol has opened doors for improved follow-up care, which means fewer repeat patients come into the ED in crisis — a big win for Dr. Farmer and her team.
Dr. Brenna Farmer: We've had a number of patients that come in that were extremely violent, that once they get stabilized on medication and get good outpatient follow up and are able to meet those outpatient goals, they do tremendously well. And we're not seeing them come back to the emergency department with the behavioral health emergency or aggressive behavior.
Erin: As BERT has been piloted at Brooklyn Methodist, Dr. Mills has also taken an intentional, team-centered approach to caring for decompensated patients across the four EDs she oversees.
Dr. Angela Mills: We have [00:11:00] created dedicated spaces for our behavioral health patients and in those spaces in our EDs, we have more staff available, um including social work, security. So we have more, more resources in that space.
Erin: And when those team members arrive at the bedside, they know how to act. Because they’ve received extensive deescalation training.
Dr. Angela Mills: I think that that's, that's critical. 'cause certainly the way that we interact with a patient can sometimes easily flare them up more or could calm someone down. So the goal obviously is to deescalate and calm situations.
Erin: Detailed deescalation training is a key part of NewYork-Presbyterian’s system-wide approach to working with decompensated patients.
Dr. Brenna Farmer: Everybody in the hospital goes through deescalation training, it allows us to make sure that our body language, when we're approaching these patients, it's not aggressive or not threatening.
Erin: Deescalation training can sound straightforward, but these are high impact strategies. They’re the difference between being able to efficiently treat a patient, and a [00:12:00] situation spiraling into disorder. All staff must have deescalation skills – and the wherewithal to implement them in practice.
Dr. Brenna Farmer: Our hands are open and available so that the patients can see that we have nothing in our hands. We're standing slightly off to the side and not directly in front of the patient. It's all about body language and making sure that that patient doesn't feel increasingly threatened by the approach of our patient team to them.
Erin: Across NewYork-Presbyterian’s EDs, connecting at-risk patients with follow-up outpatient care options is also central to the institution’s mission.
Dr. Angela Mills: We have psychiatry available who’s able to see the patient, consult, et cetera. Trying to work with psychiatry closely and partner there and get patients to, you know, safe follow ups. Uh, bridging people to various clinics. Services that are, you know, very needed, especially when the outpatient services sometimes are a little bit lacking in this country.
Erin: Dr. Mills remembers one [00:13:00] aggressive patient who came into the ED repeatedly with substance use issues.
Dr. Angela Mills: He, you know, would present maybe with trauma while being intoxicated, you know, would come in with a head injury or, or get into an altercation, an assault or something with someone.
Erin: The team was persistent, offering options for follow-up care whenever he came in. Eventually, they got him set up with the outpatient services he needed. One day, Dr. Mills realized that she hadn’t seen him come through the ED in a while…
Dr. Angela Mills: He was able to get started on this medication assisted therapy with Buprenorphine, able to connect him to a bridge clinic and started attending there. And then we saw he was going there rather than coming to the emergency department and was able to get the care and the treatment that he needed as an outpatient.
Erin: This is the kind of outcome Dr. Mills – and Dr. Famer – strive for. It’s the work of the ED as a social safety net – treating emergencies, and helping patients access consistent care.
The BERT pilot program has been a huge success at Brooklyn Methodist.
Dr. Brenna Farmer: [00:14:00] The response has been tremendous. We do use it probably three or four times a day, if not more.
Erin: The next step will be to roll the BERT approach out across all emergency departments in the NewYork-Presbyterian system. It could even serve as a model for EDs around the country.
Dr. Brenna Farmer: It may look a little different depending on the resources in each emergency department, but we're using it as a way to standardize having a team approach to these patients.
Erin: Through innovative measures and collaboration, NewYork-Presbyterian is leading the way in modeling this coordinated approach.
That leadership will continue to be vital. Because the need for these protocols is urgent. Dr. Mills says that for staff in the emergency department, supportive, standardized operational approaches like BERT, could mean the difference between ED staff working in emergency medicine for another decade, or burning out.
Dr. Angela Mills: That raw humanity that we see in the emergency department… you know, unfortunately, the work that we do leaves marks, you know, leaves marks on [00:15:00] all of us. You know, we're human beings, right? And we get affected by things.
Erin: That's why establishing resources to support their teams has been critical. In the EDs at NewYork-Presbyterian, junior staff are often paired with more senior team members who they can go to for support after a traumatic case.
Dr. Angela Mills: We pair up people with a buddy, especially when they're brand new with us, to be able to debrief and talk about new cases and get feedback. You can spend some time together and I think really be able to connect and realize again, like, what's so wonderful about our place is all the people that we work with. And I think to me, that's the reason that I'm here. And, you know, the reason I work here is, is all of our people.
Erin: More than anything, Dr. Mills and Dr. Farmer know that the unique camaraderie among the exceptional people on their teams – from nurses and physicians to social workers and security staff – is the essential ingredient that keeps everyone coming back for their next shift in the ED, ready to meet head-on whatever, and whoever, the city [00:16:00] brings in that day.
Dr. Angela Mills: The team I work with is by far just tremendous and outstanding in so many ways. We have people who are really committed to our community, our patients, all of the service that we do. So, you know, being able to connect, get back to our purpose and our mission. Why are we here? Right? And, why do we go into this? And I think that's, um, a really important place to be.
Dr. Brenna Farmer: For me that means that I'm seeing patients that may not have the most resources, and I am doing my best to get them the resources that they need for their health. Whether that's taking care of their behavioral health concern or taking care of their trauma.
I am slowly making a difference in one patient's life one day at a time. Just adds to the reason that I feel like I'm supposed to be in emergency medicine.
Erin: Many thanks to Dr. Brenna Farmer and Dr. Angela Mills for taking us inside their emergency departments to share how they’re making [00:17:00] innovative changes to support patients and staff alike, especially in a time of overwhelming mental and behavioral health emergencies.
I'm Erin Welsh.
Advances in Care is a production of NewYork-Presbyterian Hospital. As a reminder, the views shared on this podcast solely reflect the expertise and experience of our guests. To listen to more episodes of Advances in Care, be sure to follow and subscribe on Apple Podcasts, Spotify, or wherever you get your podcasts. And to learn more about the latest medical innovations from the pioneering physicians at NewYork-Presbyterian, go to nyp.org/advances.
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