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Taylor E. Close the Loop: Business Cases and Economic Evaluations. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2024; 17:263-268. [PMID: 38500453 DOI: 10.1177/19375867241236004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
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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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Hoffmann JA, Kshetrapal A, Pergjika A, Foster AA, Wnorowska JH, Johnson JK. A Qualitative Assessment of Barriers and Proposed Interventions to Improve Acute Agitation Management for Children With Mental and Behavioral Health Conditions in the Emergency Department. J Acad Consult Liaison Psychiatry 2024; 65:167-177. [PMID: 38070778 PMCID: PMC11032221 DOI: 10.1016/j.jaclp.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/11/2023] [Accepted: 12/04/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Mental health visits to the emergency department (ED) by children are rising in the United States, and acute agitation during these visits presents safety risks to patients and staff. OBJECTIVE We sought to assess barriers and strategies for providing high-quality care to children who experience acute agitation in the ED. METHODS We conducted semistructured interviews with 6 ED physicians, 6 ED nurses, 6 parents, and 6 adolescents at high risk for developing agitation. We asked participants about their experiences with acute agitation care in the ED, barriers and facilitators to providing high-quality care, and proposed interventions. Interviews were coded and analyzed thematically. RESULTS Participants discussed identifying risk factors for acute agitation, worrying about safety and the risk of injury, feeling moral distress, and shifting the culture toward patient-centered, trauma-informed care. Barriers and facilitators included using a standardized care pathway, identifying environmental barriers and allocating resources, partnering with the family and child, and communicating among team members. Nine interventions were proposed: opening a behavioral observation unit with dedicated staff and space, asking screening questions to identify risk of agitation, creating personalized care plans in the electronic health record, using a standardized agitation severity scale, implementing a behavioral response team, providing safe activities and environmental modifications, improving the handoff process, educating staff, and addressing bias and inequities. CONCLUSIONS Understanding barriers can inform solutions to improve care for children who experience acute agitation in the ED. The perspectives of families and patients should be considered when designing interventions to improve care.
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Affiliation(s)
- Jennifer A Hoffmann
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Anisha Kshetrapal
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Alba Pergjika
- Prtizker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Ashley A Foster
- Department of Emergency Medicine, University of California San Francisco, UCSF Benioff Children's Hospital, San Francisco, CA
| | | | - Julie K Johnson
- Department of Surgery, Northwestern Quality Improvement Research and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
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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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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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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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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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Alvarez Romero MG, Penthala C, Zeller SL, Wilson MP. The Impact of Coronavirus Disease 2019 on US Emergency Departments. Psychiatr Clin North Am 2022; 45:81-94. [PMID: 35219444 PMCID: PMC8580871 DOI: 10.1016/j.psc.2021.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Behavioral emergencies in the United States have been increasing, with some studies reporting a doubling in the number of people experiencing symptoms related to mental health conditions, although overall visits to US emergency departments (EDs) decreased during the coronavirus disease 2019 (COVID-19) pandemic. The uncertainty surrounding the COVID-19 pandemic caused many people to avoid health care facilities, including EDs, even if they may have otherwise sought emergency care, and was associated with increases in new behavioral health diagnoses. Measures to limit the spread of COVID-19 led to people limiting their in-person contact with others, likely exacerbating preexisting mental health issues.
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Affiliation(s)
- Manuel G Alvarez Romero
- Department of Emergency Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Slot #584, Little Rock, AR 72205, USA
| | - Chandra Penthala
- Department of Emergency Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Slot #584, Little Rock, AR 72205, USA
| | - Scott L Zeller
- Department of Psychiatry, University of California-Riverside, Riverside, CA, USA; Acute Psychiatry, Vituity, Emeryville, CA, USA.
| | - Michael P Wilson
- Department of Emergency Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Slot #584, Little Rock, AR 72205, USA; Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Slot #584, Little Rock, AR 72205, USA
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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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Zeller S, Thomas S. The Myriad Components of Creating a Comprehensive Patient Safety System. Jt Comm J Qual Patient Saf 2020; 47:S1553-7250(20)30272-5. [PMID: 33187932 DOI: 10.1016/j.jcjq.2020.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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