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Ali AA. Pearls for Caring for the Boarding Psychiatric Patient in the Emergency Department. J Emerg Med 2024; 67:e42-e49. [PMID: 38816261 DOI: 10.1016/j.jemermed.2024.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 03/07/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Emergency department (ED) boarding of psychiatric patients is a national issue that continues to worsen at a disturbing rate. Implementing strategies in the ED to provide continuous care for patients can help secure patient safety. OBJECTIVE The objective of this review is to discuss the boarding of psychiatric patients and its implications. It will focus on executing best clinical practices in managing boarding psychiatric patients in the ED. It will not focus on the treatment of substance use disorders. DISCUSSION This article will address the pearls for management plans that can be implemented in the ED, alongside discussing pregnant and elderly patients. Risk factors, complications, and treatments for boarding psychiatric patients are discussed. CONCLUSIONS Patients with psychiatric disorders boarding in the ED need careful consideration of management plans to mitigate patient safety events.
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Affiliation(s)
- Afrah A Ali
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD.
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Smith JG, Anderson K, Clarke G, Crowe C, Goldsmith LP, Jarman H, Johnson S, Lomani J, McDaid D, Park AL, Turner K, Gillard S. The effect of psychiatric decision unit services on inpatient admissions and mental health presentations in emergency departments: an interrupted time series analysis from two cities and one rural area in England. Epidemiol Psychiatr Sci 2024; 33:e15. [PMID: 38512000 DOI: 10.1017/s2045796024000209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/22/2024] Open
Abstract
AIMS High-quality evidence is lacking for the impact on healthcare utilisation of short-stay alternatives to psychiatric inpatient services for people experiencing acute and/or complex mental health crises (known in England as psychiatric decision units [PDUs]). We assessed the extent to which changes in psychiatric hospital and emergency department (ED) activity were explained by implementation of PDUs in England using a quasi-experimental approach. METHODS We conducted an interrupted time series (ITS) analysis of weekly aggregated data pre- and post-PDU implementation in one rural and two urban sites using segmented regression, adjusting for temporal and seasonal trends. Primary outcomes were changes in the number of voluntary inpatient admissions to (acute) adult psychiatric wards and number of ED adult mental health-related attendances in the 24 months post-PDU implementation compared to that in the 24 months pre-PDU implementation. RESULTS The two PDUs (one urban and one rural) with longer (average) stays and high staff-to-patient ratios observed post-PDU decreases in the pattern of weekly voluntary psychiatric admissions relative to pre-PDU trend (Rural: -0.45%/week, 95% confidence interval [CI] = -0.78%, -0.12%; Urban: -0.49%/week, 95% CI = -0.73%, -0.25%); PDU implementation in each was associated with an estimated 35-38% reduction in total voluntary admissions in the post-PDU period. The (urban) PDU with the highest throughput, lowest staff-to-patient ratio and shortest average stay observed a 20% (-20.4%, CI = -29.7%, -10.0%) level reduction in mental health-related ED attendances post-PDU, although there was little impact on long-term trend. Pooled analyses across sites indicated a significant reduction in the number of voluntary admissions following PDU implementation (-16.6%, 95% CI = -23.9%, -8.5%) but no significant (long-term) trend change (-0.20%/week, 95% CI = -0.74%, 0.34%) and no short- (-2.8%, 95% CI = -19.3%, 17.0%) or long-term (0.08%/week, 95% CI = -0.13, 0.28%) effects on mental health-related ED attendances. Findings were largely unchanged in secondary (ITS) analyses that considered the introduction of other service initiatives in the study period. CONCLUSIONS The introduction of PDUs was associated with an immediate reduction of voluntary psychiatric inpatient admissions. The extent to which PDUs change long-term trends of voluntary psychiatric admissions or impact on psychiatric presentations at ED may be linked to their configuration. PDUs with a large capacity, short length of stay and low staff-to-patient ratio can positively impact ED mental health presentations, while PDUs with longer length of stay and higher staff-to-patient ratios have potential to reduce voluntary psychiatric admissions over an extended period. Taken as a whole, our analyses suggest that when establishing a PDU, consideration of the primary crisis-care need that underlies the creation of the unit is key.
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Affiliation(s)
- J G Smith
- Population Health Research Institute, St George's, University of London, London, UK
- Clinical Research Unit, South West London & St George's Mental Health Trust, Springfield University Hospital, London, UK
| | - K Anderson
- Department of Psychology, Middlesex University, London, UK
| | - G Clarke
- Improvement Analytics Unit, The Health Foundation, London, UK
| | - C Crowe
- Sunflowers Court Inpatient Unit, North East London NHS Foundation Trust, Goodmayes Hospital, Ilford, UK
| | - L P Goldsmith
- Population Health Research Institute, St George's, University of London, London, UK
| | - H Jarman
- Population Health Research Institute, St George's, University of London, London, UK
- Emergency Department, St George's University Hospitals NHS Foundation Trust, London, UK
| | - S Johnson
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
- Early Intervention Service, Camden and Islington NHS Foundation Trust, London, UK
| | - J Lomani
- NHS England and NHS Improvement, London, UK
| | - D McDaid
- Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science, London, UK
| | - A L Park
- Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science, London, UK
| | - K Turner
- Population Health Research Institute, St George's, University of London, London, UK
| | - S Gillard
- School of Health and Psychological Sciences, City, University of London, London, UK
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Gillard S, Anderson K, Clarke G, Crowe C, Goldsmith L, Jarman H, Johnson S, Lomani J, McDaid D, Pariza P, Park AL, Smith J, Turner K, Yoeli H. Evaluating mental health decision units in acute care pathways (DECISION): a quasi-experimental, qualitative and health economic evaluation. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-221. [PMID: 38149657 DOI: 10.3310/pbsm2274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
Background People experiencing mental health crises in the community often present to emergency departments and are admitted to a psychiatric hospital. Because of the demands on emergency department and inpatient care, psychiatric decision units have emerged to provide a more suitable environment for assessment and signposting to appropriate care. Objectives The study aimed to ascertain the structure and activities of psychiatric decision units in England and to provide an evidence base for their effectiveness, costs and benefits, and optimal configuration. Design This was a mixed-methods study comprising survey, systematic review, interrupted time series, synthetic control study, cohort study, qualitative interview study and health economic evaluation, using a critical interpretive synthesis approach. Setting The study took place in four mental health National Health Service trusts with psychiatric decision units, and six acute hospital National Health Service trusts where emergency departments referred to psychiatric decision units in each mental health trust. Participants Participants in the cohort study (n = 2110) were first-time referrals to psychiatric decision units for two 5-month periods from 1 October 2018 and 1 October 2019, respectively. Participants in the qualitative study were first-time referrals to psychiatric decision units recruited within 1 month of discharge (n = 39), members of psychiatric decision unit clinical teams (n = 15) and clinicians referring to psychiatric decision units (n = 19). Outcomes Primary mental health outcome in the interrupted time series and cohort study was informal psychiatric hospital admission, and in the synthetic control any psychiatric hospital admission; primary emergency department outcome in the interrupted time series and synthetic control was mental health attendance at emergency department. Data for the interrupted time series and cohort study were extracted from electronic patient record in mental health and acute trusts; data for the synthetic control study were obtained through NHS Digital from Hospital Episode Statistics admitted patient care for psychiatric admissions and Hospital Episode Statistics Accident and Emergency for emergency department attendances. The health economic evaluation used data from all studies. Relevant databases were searched for controlled or comparison group studies of hospital-based mental health assessments permitting overnight stays of a maximum of 1 week that measured adult acute psychiatric admissions and/or mental health presentations at emergency department. Selection, data extraction and quality rating of studies were double assessed. Narrative synthesis of included studies was undertaken and meta-analyses were performed where sufficient studies reported outcomes. Results Psychiatric decision units have the potential to reduce informal psychiatric admissions, mental health presentations and wait times at emergency department. Cost savings are largely marginal and do not offset the cost of units. First-time referrals to psychiatric decision units use more inpatient and community care and less emergency department-based liaison psychiatry in the months following the first visit. Psychiatric decision units work best when configured to reduce either informal psychiatric admissions (longer length of stay, higher staff-to-patient ratio, use of psychosocial interventions), resulting in improved quality of crisis care or demand on the emergency department (higher capacity, shorter length of stay). To function well, psychiatric decision units should be integrated into the crisis care pathway alongside a range of community-based support. Limitations The availability and quality of data imposed limitations on the reliability of some analyses. Future work Psychiatric decision units should not be commissioned with an expectation of short-term financial return on investment but, if appropriately configured, they can provide better quality of care for people in crisis who would not benefit from acute admission or reduce pressure on emergency department. Study registration The systematic review was registered on the International Prospective Register of Systematic Reviews as CRD42019151043. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/49/70) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 25. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Steve Gillard
- School of Health and Psychological Sciences, City, University of London, London, UK
| | - Katie Anderson
- School of Health and Psychological Sciences, City, University of London, London, UK
| | | | - Chloe Crowe
- Adult Acute Mental Health Services, North East London NHS Foundation Trust, London, UK
| | - Lucy Goldsmith
- Population Health Research Institute, St George's, University of London, London, UK
| | - Heather Jarman
- Emergency Department Clinical Research Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Sonia Johnson
- Division of Psychiatry, University College London, London, UK
| | - Jo Lomani
- School of Health and Psychological Sciences, City, University of London, London, UK
| | - David McDaid
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Paris Pariza
- Improvement Analytics Unit, Health Foundation, London, UK
| | - A-La Park
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Jared Smith
- Population Health Research Institute, St George's, University of London, London, UK
| | - Kati Turner
- Population Health Research Institute, St George's, University of London, London, UK
| | - Heather Yoeli
- School of Health and Psychological Sciences, City, University of London, London, UK
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Powell A, Clark P, Shah K. Hospital Development of a Hybrid Emergency Department-Inpatient Care Observation Unit. J Emerg Nurs 2023; 49:853-862. [PMID: 37656115 DOI: 10.1016/j.jen.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 06/27/2023] [Accepted: 07/07/2023] [Indexed: 09/02/2023]
Abstract
INTRODUCTION This project aimed to design and implement an emergency department-managed observation unit that improves inpatient bed and emergency department stretcher capacity, decreases observation patient length of stay, earns high patient satisfaction scores, and generates a positive fiscal impact on the organization. METHODS This quality improvement project followed a 1-group, pre- and postprogram implementation design. RESULTS In the first year of operations, 40% of the total observation patients treated in this hospital were managed in the new observation unit. Emergency department observation unit length of stay across all patient complaints was half of the average length of stay for observation patients located on hospital inpatient units. In most cases, the emergency department observation unit was in the top 25 percentile of hospital Press Ganey inpatient satisfaction categories. The hospital estimates a contribution margin of three-quarters of a million dollars in the first year. DISCUSSION This effective and efficient hybrid observation unit possessed specific aspects of inpatient and emergency department patient care models. Placing providers and nurses at the workstation for faster communication expedited care. Prioritizing all observation patient testing, transportation, phlebotomy, and intravenous (IV) services shortened disposition times. Emergency nurses transitioning to the observation unit were challenged to acquire inpatient care knowledge. Observation unit management struggled to maintain staffing while under an inpatient productivity model managed by the inpatient house supervisor. Reducing patient disposition time required clear communication between observation unit and inpatient staffing managers, between physician consultants and advanced practice nursing providers, and among nurses, patients, and providers. Observation units are 1 solution to decrease observation patient length of stay and improve emergency department capacity.
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Saidinejad M, Duffy S, Wallin D, Hoffmann JA, Joseph M, Uhlenbrock JS, Brown K, Waseem M, Snow SK, Andrew M, Kuo AA, Sulton C, Chun T, Lee LK. The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies. J Emerg Nurs 2023; 49:703-713. [PMID: 37581617 DOI: 10.1016/j.jen.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Abstract
Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.
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Saidinejad M, Duffy S, Wallin D, Hoffmann JA, Joseph M, Schieferle Uhlenbrock J, Brown K, Waseem M, Snow SK, Andrew M, Kuo AA, Sulton C, Chun T, Lee LK, Conners GP, Callahan J, Gross T, Joseph M, Lee L, Mack E, Marin J, Mazor S, Paul R, Timm N, Dietrich AM, Alade KH, Amato CS, Atanelov Z, Auerbach M, Barata IA, Benjamin LS, Berg KT, Brown K, Chang C, Chow J, Chumpitazi CE, Claudius IA, Easter J, Foster A, Fox SM, Gausche-Hill M, Gerardi MJ, Goodloe JM, Heniff M, Homme JJL, Ishimine PT, John SD, Joseph MM, Lam SHF, Lawson SL, Lee MO, Li J, Lin SD, Martini DI, Mellick LB, Mendez D, Petrack EM, Rice L, Rose EA, Ruttan T, Saidinejad M, Santillanes G, Simpson JN, Sivasankar SM, Slubowski D, Sorrentino A, Stoner MJ, Sulton CD, Valente JH, Vora S, Wall JJ, Wallin D, Walls TA, Waseem M, Woolridge DP, Brandt C, Kult KM, Milici JJ, Nelson NA, Redlo MA, Curtis Cooper MR, Redlo M, Kult K, Logee K, Bryant DE, Cooper MC, Cline K. The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies. Ann Emerg Med 2023; 82:e97-e105. [PMID: 37596031 DOI: 10.1016/j.annemergmed.2023.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/01/2023] [Indexed: 08/20/2023]
Abstract
Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.
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Saidinejad M, Duffy S, Wallin D, Hoffmann JA, Joseph MM, Uhlenbrock JS, Brown K, Waseem M, Snow S, Andrew M, Kuo AA, Sulton C, Chun T, Lee LK. The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies. Pediatrics 2023; 152:e2023063255. [PMID: 37584147 DOI: 10.1542/peds.2023-063255] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/23/2023] [Indexed: 08/17/2023] Open
Abstract
Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure; challenges with timely access to a mental health professional; the nature of a busy ED environment; and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affect patient care and ED operations. Strategies to improve care for MBH emergencies, including systems-level coordination of care, are therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.
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Affiliation(s)
- Mohsen Saidinejad
- Department of Clinical Emergency Medicine & Pediatrics, David Geffen School of Medicine at UCLA, Institute for Health Services and Outcomes Research, The Lundquist Institute for Biomedical Innovation at Harbor UCLA, and Department of Emergency Medicine, Harbor UCLA Medical Center, Los Angeles, California
| | - Susan Duffy
- Department of Emergency Medicine, Brown University School of Medicine, Providence, Rhode Island
| | - Dina Wallin
- Department of Emergency Medicine, University of California San Francisco, UCSF Benioff Children's Hospital, San Francisco, California
| | - Jennifer A Hoffmann
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Evanston, Illinois
| | - Madeline M Joseph
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, University of Florida Health Sciences Center, Jacksonville, Jacksonville, Florida
| | | | - Kathleen Brown
- Emergency Medicine and Trauma Center, Children's National Hospital, Washington, District of Columbia
| | - Muhammad Waseem
- Department of Emergency Medicine, Lincoln Medical Center, Bronx, New York
| | - Sally Snow
- Independent Consultant, Pediatric Emergency and Trauma Nursing
| | | | - Alice A Kuo
- Departments of Medicine and Pediatrics, University of California, Los Angeles, Los Angeles, California
| | - Carmen Sulton
- Departments of Pediatrics and Emergency Medicine, Emory University School of Medicine, CPG Sedation Services, Children's Healthcare of Atlanta, Egleston, Atlanta, Georgia
| | - Thomas Chun
- Division of Pediatric Emergency Medicine, Departments of Emergency Medicine and Pediatrics, Hasbro Children's Hospital, Warren Alpert Medical School of Medicine at Brown University, Providence, Rhode Island
| | - Lois K Lee
- Division of Emergency Medicine, Boston Children's Hospital, Department of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts
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Reinfeld S, Gill P, Cáceda R, Batra J. Integrating Psychiatric Services in the Emergency Room to Improve Patient Care by Using Quality Improvement Methods. J Nerv Ment Dis 2023; 211:550-553. [PMID: 37382997 DOI: 10.1097/nmd.0000000000001664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
ABSTRACT Prolonged length of stay in emergency departments (EDs) for patients with a psychiatric chief complaint is a widespread problem. Prolonged stays can lead to adverse outcomes and poor quality of care. We sought to improve quality of care for patients in the medical ED who needed psychiatric care. To identify the areas of weakness, we queried the ED staff via an online survey about the perception of the challenges working with our Comprehensive Psychiatric Emergency Program (CPEP), which is located adjacent to and works closely with the medical ED providing psychiatric consultation. We identified several action steps and used the Plan-Do-Study-Act methodology for implementation. We reported a reduction in time to complete consultations and improved communication between CPEP and the medical ED staff.
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Affiliation(s)
- Samuel Reinfeld
- Department of Psychiatry and Behavioral Health, Stony Brook University, Stony Brook, New York
| | - Poonamdeep Gill
- Department of Psychiatry and Behavioral Health, Stony Brook University, Stony Brook, New York
| | | | - Jaskanwar Batra
- Department of Psychiatry and Behavioral Health, Stony Brook University, Stony Brook, New York
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Goldsmith LP, Anderson K, Clarke G, Crowe C, Jarman H, Johnson S, Lomani J, McDaid D, Park AL, Smith JG, Gillard S. Service use preceding and following first referral for psychiatric emergency care at a short-stay crisis unit: A cohort study across three cities and one rural area in England. Int J Soc Psychiatry 2022:207640221142530. [PMID: 36527189 DOI: 10.1177/00207640221142530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Internationally, hospital-based short-stay crisis units have been introduced to provide a safe space for stabilisation and further assessment for those in psychiatric crisis. The units typically aim to reduce inpatient admissions and psychiatric presentations to emergency departments. AIMS To assess changes to service use following a service user's first visit to a unit, characterise the population accessing these units and examine equality of access to the units. METHODS A prospective cohort study design (ISCTRN registered; 53431343) compared service use for the 9 months preceding and following a first visit to a short-stay crisis unit at three cities and one rural area in England. Included individuals first visited a unit in the 6 months between 01/September/2020 and 28/February/2021. RESULTS The prospective cohort included 1189 individuals aged 36 years on average, significantly younger (by 5-13 years) than the population of local service users (<.001). Seventy percent were White British and most were without a psychiatric diagnosis (55%-82% across sites). The emergency department provided the largest single source of referrals to the unit (42%), followed by the Crisis and Home Treatment Team (20%). The use of most mental health services, including all types of admission and community mental health services was increased post discharge. Social-distancing measures due to the COVID-19 pandemic were in place for slightly over 50% of the follow-up period. Comparison to a pre-COVID cohort of 934 individuals suggested that the pandemic had no effect on the majority of service use variables. CONCLUSIONS Short-stay crisis units are typically accessed by a young population, including those who previously were unknown to mental health services, who proceed to access a broader range of mental health services following discharge.
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Affiliation(s)
| | | | | | - Chloe Crowe
- North East London NHS Foundation Trust, Goodmayes Hospital, Ilford, UK
| | - Heather Jarman
- Population Health Research Institute, St George's, University of London, UK.,St George's University Hospitals NHS Foundation Trust, London, UK
| | - Sonia Johnson
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London - Bloomsbury, UK
| | - Jo Lomani
- NHS England and NHS Improvement, London, UK
| | - David McDaid
- Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science, UK
| | - A-La Park
- Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science, UK
| | - Jared G Smith
- Population Health Research Institute, St George's, University of London, UK
| | - Steven Gillard
- School of Health and Psychological Sciences, City, University of London, London, UK
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Kim I, Bukhman AK, Chen PC, Shah SB, Schmelzer NA, Baymon DE, Sanchez LD, Baugh CW, Im DD. Psychiatric care in the emergency department: Converting boarding time to treatment time. Acad Emerg Med 2022; 29:1512-1514. [PMID: 36006174 DOI: 10.1111/acem.14586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 08/06/2022] [Accepted: 08/23/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Inkyu Kim
- Department of Emergency Medicine, Harvard Affiliated Emergency Medicine Residency, Mass General Brigham, Boston, Massachusetts, USA
| | - Alice K Bukhman
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Paul C Chen
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sejal B Shah
- Division of Medical Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Naomi A Schmelzer
- Division of Medical Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Da'Marcus E Baymon
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Leon D Sanchez
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Dana D Im
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Im DD, Scott KW, Venkatesh AK, Lobon LF, Kroll DS, Samuels EA, Wilson MP, Zeller S, Zun LS, Clifford KC, Zachrison KS. A Quality Measurement Framework for Emergency Department Care of Psychiatric Emergencies. Ann Emerg Med 2022; 81:592-605. [PMID: 36402629 DOI: 10.1016/j.annemergmed.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 09/10/2022] [Accepted: 09/14/2022] [Indexed: 11/19/2022]
Abstract
As a primary access point for crisis psychiatric care, the emergency department (ED) is uniquely positioned to improve the quality of care and outcomes for patients with psychiatric emergencies. Quality measurement is the first key step in understanding the gaps and variations in emergency psychiatric care to guide quality improvement initiatives. Our objective was to develop a quality measurement framework informed by a comprehensive review and gap analysis of quality measures for ED psychiatric care. We conducted a systematic literature review and convened an expert panel in emergency medicine, psychiatry, and quality improvement to consider if and how existing quality measures evaluate the delivery of emergency psychiatric care in the ED setting. The expert panel reviewed 48 measures, of which 5 were standardized, and 3 had active National Quality Forum endorsement. Drawing from the measure appraisal, we developed a quality measurement framework with specific structural, process, and outcome measures across the ED care continuum. This framework can help shape an emergency medicine roadmap for future clinical quality improvement initiatives, research, and advocacy work designed to improve outcomes for patients presenting with psychiatric emergencies.
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12
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Anderson K, Goldsmith LP, Lomani J, Ali Z, Clarke G, Crowe C, Jarman H, Johnson S, McDaid D, Pariza P, Park AL, Smith JA, Stovold E, Turner K, Gillard S. Short-stay crisis units for mental health patients on crisis care pathways: systematic review and meta-analysis. BJPsych Open 2022; 8:e144. [PMID: 35876075 PMCID: PMC9344431 DOI: 10.1192/bjo.2022.534] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Internationally, an increasing proportion of emergency department visits are mental health related. Concurrently, psychiatric wards are often occupied above capacity. Healthcare providers have introduced short-stay, hospital-based crisis units offering a therapeutic space for stabilisation, assessment and appropriate referral. Research lags behind roll-out, and a review of the evidence is urgently needed to inform policy and further introduction of similar units. AIMS This systematic review aims to evaluate the effectiveness of short-stay, hospital-based mental health crisis units. METHOD We searched EMBASE, Medline, CINAHL and PsycINFO up to March 2021. All designs incorporating a control or comparison group were eligible for inclusion, and all effect estimates with a comparison group were extracted and combined meta-analytically where appropriate. We assessed study risk of bias with Risk of Bias in Non-Randomized Studies - of Interventions and Risk of Bias in Randomized Trials. RESULTS Data from twelve studies across six countries (Australia, Belgium, Canada, The Netherlands, UK and USA) and 67 505 participants were included. Data indicated that units delivered benefits on many outcomes. Units could reduce psychiatric holds (42% after intervention compared with 49.8% before intervention; difference = 7.8%; P < 0.0001) and increase out-patient follow-up care (χ2 = 37.42, d.f. = 1; P < 0.001). Meta-analysis indicated a significant reduction in length of emergency department stay (by 164.24 min; 95% CI -261.24 to -67.23 min; P < 0.001) and number of in-patient admissions (odds ratio 0.55, 95% CI 0.43-0.68; P < 0.001). CONCLUSIONS Short-stay mental health crisis units are effective for reducing emergency department wait times and in-patient admissions. Further research should investigate the impact of units on patient experience, and clinical and social outcomes.
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Affiliation(s)
- Katie Anderson
- Division of Nursing, School of Health Sciences, City, University of London, UK
| | - Lucy P Goldsmith
- Division of Nursing, School of Health Sciences, City, University of London, UK
| | - Jo Lomani
- Division of Nursing, School of Health Sciences, City, University of London, UK
| | - Zena Ali
- Library Services, St George's, University of London, UK
| | | | - Chloe Crowe
- Sunflowers Court, North East London NHS Foundation Trust, UK
| | - Heather Jarman
- Emergency Care, St George's University Hospitals NHS Foundation Trust, London; and Population Health Research Institute, St George's, University of London, UK
| | - Sonia Johnson
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, UK
| | - David McDaid
- Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science, UK
| | - Paris Pariza
- Collabor8research, London, UK; and Division of Nursing, School of Health Sciences, City, University of London, UK
| | - A-La Park
- Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science, UK
| | - Jared A Smith
- Population Health Research Institute, St George's, University of London, UK
| | - Elizabeth Stovold
- Population Health Research Institute, St George's, University of London, UK
| | - Kati Turner
- Population Health Research Institute, St George's, University of London, UK
| | - Steve Gillard
- Division of Nursing, School of Health Sciences, City, University of London, UK
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Chung J, Sadeghzadeh K, Sibdari S. Psychiatric Hospitalization Associated with Emergency Department Visits. Issues Ment Health Nurs 2022; 43:552-559. [PMID: 35025714 DOI: 10.1080/01612840.2021.2013362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Psychiatric boarding in an emergency department (ED) has personal and social consequences that can increase healthcare expenditure through a variety of inter-related mechanisms. This study aimed to compare health outcomes (e.g., length of stays, the severity of illness) between patients who stayed in an emergency department and those who did not visit an emergency department before the hospitalization. With the National Inpatient Sample dataset in the United States, we compared psychiatric inpatient service utilization outcomes between those who had stated in an emergency department and those who had not. Results: Among those with ED visits, the in-hospital mortality was 0.80 times lower (95% CI: 0.79-0.81). The length of hospital stays and the total charges were not significantly different from those without ED visits. The integration of primary care with psychiatric inpatient services can improve the management of psychiatric prevention and treatment, with the reduction of ED visits. This study provides an essential value in reducing emergency visits as the plan for psychiatric inpatient utilization to achieve more cost-effective and adequate healthcare outcomes.
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Affiliation(s)
- Joohyun Chung
- College of Nursing, University of Massachusetts Amherst, Amherst, MA, USA
| | - Keivan Sadeghzadeh
- D'Amore-McKim School of Business, Northeastern University Boston, Boston, MA, USA
| | - Soheil Sibdari
- Charlton College of Business, University of Massachusetts Dartmouth, Dartmouth, MA, USA
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14
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Kim AK, Vakkalanka JP, Heukelom PV, Tate J, Lee S. Emergency psychiatric assessment, treatment, and healing (EmPATH) unit decreases hospital admission for patients presenting with suicidal ideation in rural America. Acad Emerg Med 2022; 29:142-149. [PMID: 34403550 PMCID: PMC8850530 DOI: 10.1111/acem.14374] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 08/12/2021] [Accepted: 08/14/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVES The objective was to evaluate the impact of an emergency psychiatric assessment, treatment, and healing (EmPATH) unit in the emergency department (ED) on hospital admissions, ED length of stay, and 30-day follow-up for patients presenting with suicidal ideation or attempt. METHODS This study was a before-and-after analysis of introducing the EmPATH unit within a Midwestern academic medical center on outcomes of adult patients (≥18 years) presenting with suicidal ideation or suicidal attempt. The primary outcome in this study was the change in proportion of inpatient psychiatric admission of suicidal patients presenting to the ED before and after implementation of the EmPATH unit. Secondary outcomes compared were changes in proportion of any admission, incomplete admission defined as discharge from the ED after admission request placed, outpatient follow-up, return ED visits within 30 days of admission, and ED boarding time. Association between the EmPATH unit implementation and categorical outcomes were determined using log-binomial regression to estimate relative risks (RRs) and 95% confidence intervals (CIs). Continuous outcomes were log-transformed and generalized estimating equations were used to examine as the mean difference by time period. RESULTS There were 962 patients presenting with suicidal ideation (n = 435 before EmPATH unit, n = 527 after EmPATH unit). Compared to the pre-EmPATH-unit period, there was a reduction in psychiatric admission (RR = 0.48, 95% CI = 0.40 to 0.56), any admission (RR = 0.65, 95% CI = 0.58 to 0.73), incomplete admission (RR = 0.22, 95% CI = 0.11 to 0.43), and 30-day return to the ED (RR = 0.74, 95% CI = 0.56 to 0.98). ED boarding time among admitted patients was reduced by approximately two-thirds both in admitted patients (RR = 0.34, 95% CI = 0.30 to 0.39) and among those with incomplete admissions (RR = 0.37, 95% CI = 0.23 to 0.61). There was a 60% increase in a 30-day follow-up care established at the time of discharge (RR = 1.60, 95% CI = 1.40 to 1.82). CONCLUSIONS The introduction of the EmPATH unit has improved management of patients presenting to the ED with suicidal attempts/ideation by reducing ED boarding and unnecessary admissions and establishing post-ED follow-up care.
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Affiliation(s)
- Allison K. Kim
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - J. Priyanka Vakkalanka
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA,Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Paul Van Heukelom
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Jodi Tate
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Sangil Lee
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA,Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
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15
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Kargin M, Aydin A. The experiences of Turkish psychiatric nurses with psychiatric emergencies in the clinics of Turkey's mental health and diseases hospital: A descriptive qualitative study. Perspect Psychiatr Care 2022; 58:39-46. [PMID: 34260750 DOI: 10.1111/ppc.12914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/08/2021] [Accepted: 06/19/2021] [Indexed: 11/29/2022] Open
Abstract
PURPOSE The aim of this study was to describe the experiences of Turkish nurses in the psychiatry clinics of Turkey's Mental Health and Diseases Hospital DESIGN AND METHODS: This descriptive qualitative study was conducted on 20 psychiatric nurses working at a psychiatric hospital. A semi-structured in-person interview technique was used for data collection. RESULTS Six themes were defined in this study. The majority of psychiatric nurses stated that they usually faced suicidal and aggressive cases and that they used security measures, restraint and isolation, medical treatment, and emergency codes as basic interventions. PRACTICE IMPLICATIONS Psychiatry is a field of clinical practice requiring case management skills to deal with various psychiatric presentations.
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Affiliation(s)
- Maral Kargin
- Nursing Department, Faculty of Health Sciences, Cyprus Science University, Kyrenia, Cyprus
| | - Adeviye Aydin
- Nursing Department, Faculty of Health Sciences, Sinop University, Sinop, Turkey
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16
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Kanjee Z, Beltran CP, Smith CC, Lewis J, Hall MM, Tibbles CD, Sullivan AM. "Friction by Definition": Conflict at Patient Handover Between Emergency and Internal Medicine Physicians at an Academic Medical Center. West J Emerg Med 2021; 22:1227-1239. [PMID: 34787545 PMCID: PMC8597691 DOI: 10.5811/westjem.2021.7.52762] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 07/23/2021] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Patient handoffs from emergency physicians (EP) to internal medicine (IM) physicians may be complicated by conflict with the potential for adverse outcomes. The objective of this study was to identify the specific types of, and contributors to, conflict between EPs and IM physicians in this context. METHODS We performed a qualitative focus group study using a constructivist grounded theory approach involving emergency medicine (EM) and IM residents and faculty at a large academic medical center. Focus groups assessed perspectives and experiences of EP/IM physician interactions related to patient handoffs. We interpreted data with the matrix analytic method. RESULTS From May to December 2019, 24 residents (IM = 11, EM = 13) and 11 faculty (IM = 6, EM = 5) from the two departments participated in eight focus groups and two interviews. Two key themes emerged: 1) disagreements about disposition (ie, whether a patient needed to be admitted, should go to an intensive care unit, or required additional testing before transfer to the floor); and 2) contextual factors (ie, the request to discuss an admission being a primer for conflict; lack of knowledge of the other person and their workflow; high clinical workload and volume; and different interdepartmental perspectives on the benefits of a rapid emergency department workflow). CONCLUSIONS Causes of conflict at patient handover between EPs and IM physicians are related primarily to disposition concerns and contextual factors. Using theoretical models of task, process, and relationship conflict, we suggest recommendations to improve the EM/IM interaction to potentially reduce conflict and advance patient care.
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Affiliation(s)
- Zahir Kanjee
- Beth Israel Deaconess Medical Center, Hospital Medicine Program, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Christine P Beltran
- Beth Israel Deaconess Medical Center, Carl J. Shapiro Institute for Education and Research, Boston, Massachusetts
| | - C Christopher Smith
- Beth Israel Deaconess Medical Center, Hospital Medicine Program, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Internal Medicine Residency Program, Boston, Massachusetts
| | - Jason Lewis
- Harvard Medical School, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Matthew M Hall
- Providence Regional Medical Center, Department of Emergency Medicine, Everett, Washington.,Washington State University, Pullman, Washington
| | - Carrie D Tibbles
- Harvard Medical School, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Carl J. Shapiro Institute for Education and Research, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Emergency Medicine Residency Program, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Office of Graduate Medical Education, Boston, Massachusetts
| | - Amy M Sullivan
- Harvard Medical School, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Carl J. Shapiro Institute for Education and Research, Boston, Massachusetts
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17
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Parwani V, Goldenberg M, Venkatesh A. Emergency Department Psychiatric Observation Units: Good Care and Good Money? Acad Emerg Med 2021; 28:141-143. [PMID: 33140472 DOI: 10.1111/acem.14167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Vivek Parwani
- Department of Emergency Medicine Yale University School of Medicine GuilfordCTUSA
| | - Matthew Goldenberg
- Department of Psychiatry Yale University School of Medicine New Haven CTUSA
| | - Arjun Venkatesh
- Department of Emergency Medicine Yale University School of Medicine GuilfordCTUSA
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18
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Stamy C, Shane DM, Kannedy L, Van Heukelom P, Mohr NM, Tate J, Montross K, Lee S. Economic Evaluation of the Emergency Department After Implementation of an Emergency Psychiatric Assessment, Treatment, and Healing Unit. Acad Emerg Med 2021; 28:82-91. [PMID: 32869891 DOI: 10.1111/acem.14118] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/04/2020] [Accepted: 08/21/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We sought to evaluate the impact of an emergency psychiatric assessment, treatment, and healing (EmPATH) unit on emergency department (ED) revenue, psychiatric boarding time, and length of stay (LOS). METHODS We conducted a before-and-after economic evaluation of a single academic midwestern ED (60,000 annual visits) for all adult (≥18 years) patients before (December 2017-May 2018) and after (December 2018-May 2019) opening an EmPATH unit. These are outpatient hospital-based programs that provide emergent treatment and stabilization for mental health emergencies from ED patients. The Holt-Winters method was used to forecast pre-EmPATH expected ED levels of patients leaving without being seen, leaving against medical advice, eloping, or being transferred using 3 years of ED visits. ED revenues were calculated by finding the difference of pre-EmPATH expected and post-EmPATH observed values and multiplying by the revenue per visit. ED boarding time and LOS were obtained from the hospital's electronic medical record. RESULTS There were 23,231 and 23,336 ED visits evaluated during the pre- and post-EmPATH unit periods. The ED generated an estimated additional $404,954 in the 6 months and $861,065 annually after the implementation of the EmPATH unit. The median (interquartile range [IQR]) psychiatric boarding time decreased from 212 (119-536) minutes to 152 (86-307) minutes (mean difference = 189 minutes, 95% confidence interval [CI] = 150 to 228 minutes) and median (IQR) LOS decreased from 351 (204-631) minutes to 334 (212-517) minutes (mean difference = 114 minutes, 95% CI = 87 to 143 minutes). CONCLUSION The EmPATH unit had a positive impact on ED revenue and decreased ED boarding time and LOS for psychiatric patients.
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Affiliation(s)
- Chris Stamy
- From the Department of Emergency MedicineUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
| | - Dan M. Shane
- the Department of Health Management and PolicyUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
| | - Levi Kannedy
- From the Department of Emergency MedicineUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
| | - Paul Van Heukelom
- From the Department of Emergency MedicineUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
| | - Nicholas M. Mohr
- From the Department of Emergency MedicineUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
- the Division of Critical Care Department of AnesthesiaUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
| | - Jodi Tate
- and the Department of Psychiatry University of Iowa Carver College of Medicine Iowa City IAUSA
| | - Kelsey Montross
- and the Department of Psychiatry University of Iowa Carver College of Medicine Iowa City IAUSA
| | - Sangil Lee
- From the Department of Emergency MedicineUniversity of Iowa Carver College of Medicine Iowa CityIAUSA
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19
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Impact of changes in community psychiatric service provision on mental health presentations to the emergency department. Ir J Med Sci 2020; 190:1195-1200. [PMID: 33222076 PMCID: PMC7680212 DOI: 10.1007/s11845-020-02442-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 11/18/2020] [Indexed: 11/18/2022]
Abstract
Background The reconfiguration of many Irish stand-alone psychiatric units has led to many patients in acute mental health need now being assessed in emergency departments (EDs). This has implications for ED resources and raises questions about appropriate assessment location for this group. Aims This report aims to examine the impact of removal of a direct community access point for patients in acute mental health need on ED presentations in a Dublin hospital. Methods We examined data on ED referrals to psychiatry over 5 years: 12 months before the service change, and four subsequent 12-month periods. We compared numbers referred, mode of referral, average ED length of stay, proportion with no physical issue requiring psychiatric assessment only, and numbers who did not wait for psychiatry assessment. Results In the year directly after the service change, referrals to psychiatry from ED increased by 200%, remaining at this level for the subsequent 3 years. Of these, 32.5% were referred by a GP—more than a threefold increase in numbers from the previous year, with both numbers remaining similarly elevated over subsequent years. In the year after the service change, 52.1% of total ED to psychiatry presented solely for mental health reasons—nearly a fourfold increase in cases from the previous year, and remained high. Conclusions Removing a direct community access point for this group resulted in a substantial increase in ED presentations, many of which did not have physical needs. This study has implications for future policy to address the needs of this group, especially in light of the pandemic.
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21
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Goldsmith LP, Smith JG, Clarke G, Anderson K, Lomani J, Turner K, Gillard S. What is the impact of psychiatric decision units on mental health crisis care pathways? Protocol for an interrupted time series analysis with a synthetic control study. BMC Psychiatry 2020; 20:185. [PMID: 32326915 PMCID: PMC7178744 DOI: 10.1186/s12888-020-02581-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 04/02/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The UK mental health system is stretched to breaking point. Individuals presenting with mental health problems wait longer at the ED than those presenting with physical concerns and finding a bed when needed is difficult - 91% of psychiatric wards are operating at above the recommended occupancy rate. To address the pressure, a new type of facility - psychiatric decision units (also known as mental health decision units) - have been introduced in some areas. These are short-stay facilities, available upon referral, targeted to help individuals who may be able to avoid an inpatient admission or lengthy ED visit. To advance knowledge about the effectiveness of this service for this purpose, we will examine the effect of the service on the mental health crisis care pathway over a 4-year time period; the 2 years proceeding and following the introduction of the service. We use aggregate service level data of key indicators of the performance of this pathway. METHODS Data from four mental health Trusts in England will be analysed using an interrupted time series (ITS) design with the primary outcomes of the rate of (i) ED psychiatric presentations and (ii) voluntary admissions to mental health wards. This will be supplemented with a synthetic control study with the same primary outcomes, in which a comparable control group is generated for each outcome using a donor pool of suitable National Health Service Trusts in England. The methods are well suited to an evaluation of an intervention at a service delivery level targeting population-level health outcome and the randomisation or 'trialability' of the intervention is limited. The synthetic control study controls for national trends over time, increasing our confidence in the results. The study has been designed and will be carried out with the involvement of service users and carers. DISCUSSION This will be the first formal evaluation of psychiatric decision units in England. The analysis will provide estimates of the effect of the decision units on a number of important service use indicators, providing much-needed information for those designing service pathways. TRIAL REGISTRATION primary registry: isrctn.com Identifying number: ISRCTN77588384 Link: Date of registration in primary registry: 27/02/2020. PRIMARY SPONSOR St George's, University of London, Cramner Road, Tooting, SW17 ORE. Primary contact: Joe Montebello.
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Affiliation(s)
- L P Goldsmith
- Population Health Research Institute, St George's, University of London, Cramner Road, Tooting, London, SW17 0RE, UK.
| | - J G Smith
- Population Health Research Institute, St George's, University of London, Cramner Road, Tooting, London, SW17 0RE, UK
| | - G Clarke
- The Health Foundation, 8 Salisbury Square, London, UK
| | - K Anderson
- Population Health Research Institute, St George's, University of London, Cramner Road, Tooting, London, SW17 0RE, UK
| | - J Lomani
- Population Health Research Institute, St George's, University of London, Cramner Road, Tooting, London, SW17 0RE, UK
| | - K Turner
- Population Health Research Institute, St George's, University of London, Cramner Road, Tooting, London, SW17 0RE, UK
| | - S Gillard
- Population Health Research Institute, St George's, University of London, Cramner Road, Tooting, London, SW17 0RE, UK
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22
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Santillanes G, Axeen S, Lam CN, Menchine M. National trends in mental health-related emergency department visits by children and adults, 2009-2015. Am J Emerg Med 2019; 38:2536-2544. [PMID: 31902702 DOI: 10.1016/j.ajem.2019.12.035] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES Examine trends in mental health-related emergency department (ED) visits, changes in disposition and length of stay (LOS), describe disposition by age and estimate proportion of ED treatment hours dedicated to mental health-related visits. METHODS Retrospective analysis of ED encounters in the National Hospital Ambulatory Medical Care Visit Survey with a mental health primary, secondary or tertiary discharge diagnosis from 2009 to 2015. We report survey-weighted estimates of the number and proportion of ED visits that were mental health-related and disposition by age and survey year. We estimate the proportion of ED treatment hours dedicated to mental health-related visits. We analyze trends in disposition and LOS for mental health and non-mental health-related visits using multivariate regression analysis. RESULTS Mental health-related ED visits increased by 56.4% for pediatric patients and 40.8% for adults, accounting for over 10% of ED visits by 15-64 year-olds and nearly 9% by 10-14 year-olds in 2015. Mental health-related visit disposition of admission or transfer declined from 29.8% to 20.4% (p < .001); predicted median ED LOS for admissions or transfers increased from 6.5 to 9.0 hours while median LOS for discharges was stable at 4.4 hours. During the study period, mental health-related visits accounted for 5.0% (95% CI 4.6-5.3) of all pediatric and 11.1% (95% CI 11.0-11.3) of adult ED treatment hours. CONCLUSIONS Mental health-related visits account for an increasing proportion of ED visits and a considerable proportion of treatment hours. A decreasing proportion of mental health-related visits resulted in inpatient disposition and ED LOS increased for admissions and transfers.
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Affiliation(s)
- Genevieve Santillanes
- Department of Emergency Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Sarah Axeen
- Department of Emergency Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA.
| | - Chun Nok Lam
- Department of Emergency Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Michael Menchine
- Department of Emergency Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
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