The UT Health Living Room: Expanding the Psychiatric Crisis Continuum of Care

Traditional forms of psychiatric crisis treatment increasingly are being buttressed by services along the Psychiatric Crisis Continuum of Care, such as short-term crisis stabilization services and peer crisis services. The UT Health Living Room (LR) is an outpatient crisis counseling service that adds three promising elements to the Continuum: (1) it integrates outpatient treatment plans into crisis counseling, (2) provides care in a space and with staff who are familiar to patients, and (3) provides training in evidence-based crisis intervention. We examined two-year LR feasibility and outcome data. Mixed-method analyses used longitudinal clinic data and patient self-report measures. Results provide initial support for the feasibility, cost effectiveness and clinical effectiveness of the LR. Limitations include non-blinded ratings, limited experimental control, and simple cost-effectiveness methodology. The UT Living Room is feasible and offers novel elements to help patients in community clinics address emotional crises.

The significance of nonurgent psychiatric emergencies in an ED: a retrospective study

BACKGROUND

In emergency departments, patients with mental health conditions are a major concern and make up the third or fourth of the most common diagnosis seen during all consultations. Over the past two decades, there has been a noticeable rise in the number of cases, particularly due to an increase in nonurgent visits for somatic medical issues. The significance of nonurgent visits for psychiatric patients is yet to be determined. This study aims to uncover the significance and identify the characteristics of this group.

METHODS

A retrospective analysis of psychiatric emergency visits at an interdisciplinary emergency department of a German general hospital in 2015 was conducted. For this purpose, patient records were reviewed and evaluated. An analysis was conducted based on the German definition of psychiatric emergencies according to the German guidelines for emergency psychiatry.

RESULTS

A total of 21,124 emergency patients visited the evaluated Emergency Department. Of this number, 1,735 psychiatric patient records were evaluated, representing 8.21% of the total population. Nearly 30% of these patients did not meet any emergency criteria according to German guidelines. Significant differences were observed between previously treated patients and those presenting for the first time.

CONCLUSIONS

The high proportion of nonurgent psychiatric patients in the total volume of psychiatric emergency contacts indicates a possible control and information deficit within the emergency system. Just as prior research has emphasized the importance of investigating nonurgent somatic medical visits, it is equally imperative to delve into studies centered around psychiatric nonurgent presentations.

Effectiveness of a Self-Administered Computerized Mental Health Screening Tool in the Emergency Department

OBJECTIVE

The authors sought to determine the effectiveness of a self-administered computerized mental health screening tool in a general acute care emergency department (ED).

METHODS

Changes in patient care (diagnosis of a past-year psychiatric disorder, request for psychiatric consultation, psychiatric referral at discharge, or transfer to psychiatric facility) and patient ED return visits (3 months after discharge vs. 3 months before) were assessed among ED physicians (N=451) who received patients' computerized screening reports (N=207) and those who did not (N=244). All patients received copies of screening results.

RESULTS

The computerized mental health screening tool identified previously undiagnosed psychiatric problems. However, no statistically significant differences were found in physician care or patient ED return visits.

CONCLUSIONS

Computerized mental health screening did not result in further psychiatric diagnoses or treatment; it also did not significantly reduce patient ED return visits. Collaboration among EDs and mental health treatment agencies, organizations, and researchers is needed to facilitate appropriate treatment referrals and linkage.

Risk factors of involuntary referral by police to ER psychiatric services for patients with a severe mental illness: A GEE analysis

This study aimed to identify risk factors for involuntary referral by police to emergency room (ER) psychiatric services for community-based patients with a mental illness via a generalized estimating equation (GEE) analysis. The analysis was based on data from the Management Information System of Psychiatric Care (MISPC) system for patients with a severe mental illness in Taipei, Taiwan and registered referral records of the police. Data on 6378 patients aged ≥20 years were used in this study, including 164 patients who were involuntarily referred to the ER by the police and 6214 patients who were not during the period of January 1, 2018 to December 31, 2020. GEEs were utilized to explore possible risk factors of repeated involuntary referral to ER psychiatric services for patients with a severe mental illness. The logistic regressions indicated that patients defined as "severe" according to the Mental Health Act of Taiwan (crude odds ratio (OR): 3.840, 95 % confidence interval (CI): 2.407-6.126), with a disability (crude OR: 3.567, 95 % CI: 1.339-9.501), with two or more family members with a psychiatric disorder (crude OR: 1.598, 95 % CI: 1.002-2.548), with a history of a suicide attempt (crude OR: 25.582, 95 % CI: 17.608-37.167), and with a history of domestic violence (crude OR: 16.141, 95 % CI: 11.539-22.579) were positively associated with involuntary referral to ER psychiatric services. However, age (crude OR: 0.971, 95 % CI: 0.960-0.983) and the MISPC score (crude OR: 0.834, 95 % CI: 0.800-0.869) were inversely associated with involuntary referral to ER psychiatric services. After adjusting for demographics and potential confounders, we found that patients defined as "severe" (Exp (β): 3.236), with a disability (Exp (β): 3.715), with a history of a suicide attempt (Exp (β): 8.706), and with a history of domestic violence (Exp (β): 8.826), as well as age (Exp (β): 0.986) and the MISPC score (Exp (β): 0.902) remained significantly associated with repeated involuntary referral to ER psychiatric services. In conclusion, community-based mentally ill patients with a history of a suicide attempt, with a history of domestic violence, with a severe illness, and with a profound level of disability were highly associated with involuntary referral to ER psychiatric services. We suggest that community mental health case managers identify significant factors associated with involuntary referral to ER psychiatric services to accordingly arrange case management plans.

Contemporary Practices for Medical Evaluation of the Psychiatric Patient in the Emergency Department

Although emergency department (ED) visits for patients with mental illness are frequent, medical evaluation (i.e., "medical screening") of patients presenting with psychiatric complaints is inconsistent. This may largely be related to differing goals for medical screening, which often vary according to specialty. Although emergency physicians typically focus on stabilization of life-threatening diseases, psychiatrists tend to believe that care in the ED is more comprehensive, which often places the two fields at odds. The authors discuss the concept of medical screening, review the literature on this topic, and offer a clinically oriented update to the 2017 American Association for Emergency Psychiatry consensus guidelines on medical evaluation of the adult psychiatric patient in the ED.

Patterns of mortality risk among patients with substance use disorder: an opportunity for proactive patient safety?

BACKGROUND

Patients with substance use disorder (SUD) suffer from excess mortality compared to the overall population. This study aims to identify patterns in death rates among patients with SUD visiting a SUD emergency ward and to explore whether this knowledge can be used as input to identify patients at risk and increase patient safety.

METHODS

Hospital visit data to a SUD emergency ward were collected between 2010 and 2020 through medical records. Data included gender, age, SUD diagnosis, and the time of death. The Kruskal-Wallis rank sum test was used to test between ordinal variables, and risk ratio was used to quantify the difference in mortality risk. All statistical tests were two-sided, with a 95% confidence interval and a minimum significance level of 0.05.

RESULTS

The male patients in the study group had 1.41-1.59 higher mortality risk than the female patients. The study revealed an average death rate of 0.14 among all patients during the study period. Although patients with a diagnosed alcohol use disorder constituted 73.7% of the cohort, having an opioid use disorder or sedative hypnotics use disorder was associated with the highest death rates; 1.29-1.52 and 1.47-1.74 higher mortality risk than those without such diagnoses.

CONCLUSION

This study demonstrates that data from visits to SUD emergency wards can be used to identify mortality risk factors, such as gender, type of diagnosis, number of diagnoses, and number of visits to the SUD emergency ward. Knowledge about patterns of patient visits and mortality risk could be used to increase patient safety through a decision support tool integrated with the electronic medical records. An improved system for early detection of increased mortality risk offers an opportunity for an adaptive patient safety system.

Factors predicting admission of psychiatric emergency contacts after presenting to the emergency department: results of a regression analysis

BACKGROUND

Psychiatric emergency patients have great relevance in the interdisciplinary emergency department. Emergency physicians in this setting often have to make decisions under time pressure based on incomplete information regarding the patient's further treatment. The aim of this study was to identify possible predictors associated with an increased likelihood of inpatient psychiatric admission.

METHODS

A retrospective cross-sectional study of all psychiatric emergency contacts in an interdisciplinary emergency department (ED) of a general hospital in a large German city was conducted for 2015. A binary regression analysis was performed to identify possible predictors.

RESULTS

In 2015, a total of 21421 patient contacts were reported in the emergency department, of which 1733 were psychiatric emergencies. Psychiatric emergency was the fourth most common cause presenting to the ED. The most common diagnosis given was mental and behavioral disorders due to the use of psychotropic substances (F1). Factors associated with an increased probability of inpatient psychiatric admission were previously known patients, patients under a legal care order (guardianship), and previous outpatient medical contact. No association for gender or age was found. Data demonstrated a negative relationship between a neurotic, stress-related and somatoform disorder diagnosis and admission.

CONCLUSIONS

The present study shows some significant characteristics associated with an increased likelihood of emergency admission. Independent of the health care system, the predictors found seem to be relevant with regard to the probability of admission, when compared internationally. To improve the treatment of patients in emergency units, these factors should be taken into account.

Musculoskeletal Pain Management and Patient Mental Health and Well-being

Orthopaedic trauma patients have high rates of psychiatric disorders, which put them at risk for worse outcomes after injury and surgery, including worse pain. Mental health conditions, such as depression and anxiety, can affect the perception of pain. Pain can also exacerbate or contribute to the development of mental illness after injury. Interventions to address both mental health and pain among orthopaedic trauma patients are critical. Balancing safety and comfort amid a drug overdose epidemic is challenging, and many clinicians do not feel comfortable addressing mental health or have the resources necessary. We reviewed the literature on the complex relationship between pain and mental health and presented examples of scalable and accessible interventions that can be implemented to promote the health and recovery of our patients. Interventions described include screening for depression in the orthopaedic trauma clinic and the emergency department or inpatient setting during injury and using a comprehensive and evidence-based multimodal pain management regimen that blends pharmacologic alternatives to opioids and physical and cognitive strategies to manage pain.

A quarter of century after: The changing ecology of psychiatric emergency services

INTRODUCTION

Previous studies demonstrated a trend of increasing common mental disorders among the Emergency Department (ED) visitors in Western countries. Little is known about the current conditions of the emergency psychiatric services in Asian countries. This study aims to survey the current epidemiology and the changing ecology of emergency psychiatry services in Taiwan.

METHODS

A total of 804 psychiatry consultations were initiated at the ED during the 1-year period from July 1, 2014 to June 30, 2015 in a medical center in northern Taiwan. Clinical data of gender, age, chief complaints, tentative diagnoses, dispositions, and ED staying hours were compared to a previous report in the same hospital in 1988.

RESULTS

Psychiatry consultation was initiated in 0.72% of all ED visits (804/111,923). Among these visits, females were 1.73 times of the males. The most common chief complaints were psychosis/mania (33.5%) and suicide/self-harm (33.2%), followed by homicide/violence (12.8%) and anxiety/depression (10.3%). Top tentative diagnoses were schizophrenia spectrum and other psychotic disorders (31.3%), trauma- and stressor-related disorders (17.5%), bipolar disorders (15.9%), and depressive disorders (14.2%). Compared to 1988, there are three major changes: (1) over-representation of female patients, (2) an increase of "neurosis" patients, and (3) an increase of suicide/self-harm as chief problem.

DISCUSSION

This study portrays the current epidemiology and changing ecology of psychiatric emergency in Taiwan. The increase of neurotic and suicide/self-harm patients requires more services and clinical training in managing common mental disorders and suicide in the ED.

Community trial evaluating the integration of Indigenous healing practices and a harm reduction approach with principles of seeking safety in an Indigenous residential treatment program in northern Ontario

OBJECTIVE

Our primary objective was to evaluate how the Indigenous Healing and Seeking Safety (IHSS) model impacted residential addiction treatment program completion rates. Our secondary objective was to evaluate health service use 6 months before and 6 months after residential treatment for clients who attended the program before and after implementing IHSS.

METHODS

We observed clients of the Benbowopka Residential Treatment before IHSS implementation (from April 2013 to March 31, 2016) and after IHSS implementation (from January 1, 2018 - March 31, 2020). The program data were linked to health administration data, including the Ontario Health Insurance Plan (OHIP) physician billing, the Registered Persons Database (RPDB), the National Ambulatory Care Reporting System (NACRS), and the Discharge Abstract Database (DAD). Chi-square tests were used to compare patient characteristics in the no-IHSS and IHSS groups. We used logistic regression to estimate the association between IHSS and treatment completion. We used generalized estimating equation (GEE) regression model to evaluate health service use (including primary care visits, ED visits overall and for substance use, hospitalizations and mental health visits), Results: There were 266 patients in the no-IHSS group and 136 in the IHSS group. After adjusting for individual characteristics, we observed that IHSS was associated with increased program completion rates (odds ratio = 1.95, 95% CI 1.02-3.70). There was no significant association between IHSS patients' health service use at time one or time two. Primary care visits time 1: aOR 0.55, 95%CI 0.72-1.13, time 2: aOR 1.13, 95%CI 0.79-1.23; ED visits overall time 1: aOR 0.91, 95%CI 0.67-1.23, time 2: aOR 1.06, 95%CI 0.75-1.50; ED visits for substance use time 1: aOR 0.81, 95%CI 0.47-1.39, time 2: aOR 0.79, 95%CI 0.37-1.54; Hospitalizations time 1: aOR 0.78, 95%CI 0.41-1.47, time 2: aOR 0.76, 95%CI 0.32-1.80; Mental health visits time 1: aOR 0.66, 95%CI 0.46-0.96, time 2: aOR 0.92 95%CI 0.7-1.40.

CONCLUSIONS

Our results indicate that IHSS positively influenced program completion but had no significant effect on health service use.

TRIAL REGISTRATION

This study was registered with clinicaltrials.gov (identifier number NCT04604574). First registration 10/27/2020.

Association Between Telepsychiatry Capability and Treatment of Patients With Mental Illness in the Emergency Department

OBJECTIVE

Because of limited access to psychiatrists, patients with acute mental illness in some emergency departments (EDs) may wait days for a consultation in the ED or as a medical-surgical admission. The study assessed whether telepsychiatry improves access to care and decreases ED wait times and hospital admissions.

METHODS

ED visits with a primary diagnosis of mental illness were identified from 2010-2018 Medicare claims. A total of 134 EDs across 22 states that implemented telepsychiatry between 2013 and 2016 were matched 1:1 with control EDs without telepsychiatry on several characteristics, including availability of in-person psychiatrist consultations. Outcomes included patients' likelihood of admission to a medical-surgical or psychiatric bed, mental illness spending, prolonged ED length of stay (LOS) (two or more midnights in the ED), 90-day mortality, and outpatient follow-up care. Using a difference-in-difference design, changes in outcomes between the 3 years before telepsychiatry adoption and the 2 years after were examined.

RESULTS

There were 172,708 ED mental illness visits across the 134 matched ED pairs in the study period. Telepsychiatry adoption was associated with increased admissions to a psychiatric bed (differential increase, 4.3 percentage points; p<0.001), decreased admissions to a medical-surgical bed (differential decrease, 2.0 percentage points; p<0.001), increased likelihood of a prolonged ED LOS (differential increase, 3.0 percentage points; p<0.001), and increased mental illness spending (differential increase, $292; p<0.01).

CONCLUSIONS

Telepsychiatry adoption was associated with a lower likelihood of admission to a medical-surgical bed but an increased likelihood of admission to a psychiatric bed and a prolonged ED LOS.

A 7 Year Summary of Emergency Department Visits by Patients With Mental Health Disorders

OBJECTIVES

Emergency departments (EDs) have been increasingly utilized over time for psychiatric care. While multiple studies have assessed these trends in nationally representative data, few have evaluated these trends in state-level data. This investigation seeks to understand the mental health-related ED burden in North Carolina (NC) by describing trends in ED visits associated with a mental health diagnosis (MHD) over time.

METHODS

Using data from NC DETECT, this investigation describes trends in NC ED visits from January 1, 2008 through December 31, 2014 by presence of a MHD code. A visit was classified by the first listed MHD ICD-9-CM code in the surveillance record and MHD codes were grouped into related categories for analysis. Visits were summarized by MHD status and by MHD category.

RESULTS

Over 32 million ED visits were recorded from 2008 to 2014, of which 3,030,746 (9.4%) were MHD-related visits. The average age at presentation for MHD-related visits was 50 years (SD 23.5) and 63.9% of visits were from female patients. The proportion of ED visits with a MHD increased from 8.3 to 10.2% from 2008 to 2014. Annually and overall, the largest diagnostic category was stress/anxiety/depression. Hospital admissions resulting from MHD-related visits declined from 32.2 to 18.5% from 2008 to 2014 but remained consistently higher than the rate of admissions among non-MHD visits.

CONCLUSION

Similar to national trends, the proportion of ED visits associated with a MHD in NC has increased over time. This indicates a need for continued surveillance, both stateside and nationally, in order to inform future efforts to mitigate the growing ED burden.

Frequency, Prevalence, Interaction, and Gender Differences of Six Psychosocial Factors in Patients Presenting to a Psychiatric Emergency Service

INTRODUCTION

The psychiatric emergency service (PES) has become an increasingly utilized patient care approach over the past 50 years. Psychosocial factors play an important role in PES utilization and disposition of patients in this environment. PES utilization in our region has increased 450% in the past 18 years, while the population has changed <1%. Our objective was to determine the frequency and relationship between six psychosocial factors in our patients, in comparison to the general population.

METHODS

We completed a retrospective chart review of 160 patients selected at random who utilized the PES during 2009-2010. We looked for historical presence of a broken family, abuse or neglect, substance abuse, legal problems, violence, or incomplete education. We also looked at the relationship of these factors to race and gender.

RESULTS

75% had three or more of the factors measured. In our population, substance abuse and broken family were most prevalent. Females had significantly more abuse or neglect as compared to males, while male subjects had significantly more substance abuse and legal issues than females. The presence of a broken family was strongly associated with abuse or neglect, while violence was associated with incomplete education and legal issues. The prevalence of these factors in our patients was higher than the general population.

CONCLUSION

The average patient presenting to the PES has multiple major psychosocial problems at higher frequencies than the general population. Understanding the relationship between multiple psychosocial factors and increasing PES utilization can direct us towards addressing the problems causing the increase in PES presentation. A planned future prospective study will examine the incidence of these psychosocial factors in patients presenting to the PES as compared to the general population.

Impact of closure of the in-house psychiatric care unit on prehospital and emergency ward length of stay and disposition locations in patients who attempted suicide: A retrospective before-and-after cohort study at a community hospital in Japan

Suicide is an increasingly serious public health care concern worldwide. The impact of decreased in-house psychiatric resources on emergency care for suicidal patients has not been thoroughly examined. We evaluated the effects of closing an in-hospital psychiatric ward on the prehospital and emergency ward length of stay (LOS) and disposition location in patients who attempted suicide.This was a retrospective before-and-after study at a community emergency department (ED) in Japan. On March 31, 2014, the hospital closed its 50 psychiatric ward beds and outpatient consultation days were decreased from 5 to 2 days per week. Electronic health record data of suicidal patients who were brought to the ED were collected for 5 years before the decrease in in-hospital psychiatric services (April 1, 2009-March 31, 2014) and 5 years after the decrease (April 1, 2014-March 31, 2019). One-to-one propensity score matching was performed to compare prehospital and emergency ward LOS, and discharge location between the 2 groups.Of the 1083 eligible patients, 449 (41.5%) were brought to the ED after the closure of the psychiatric ward. Patients with older age, burns, and higher comorbidity index values, and those requiring endotracheal intubation, surgery, and emergency ward admission, were more likely to receive ED care after the psychiatric ward closure. In the propensity matched analysis with 418 pairs, the after-closure group showed a significant increase in median prehospital LOS (44.0 minutes vs 51.0 minutes, P < .001) and emergency ward LOS (3.0 days vs 4.0 days, P = .014) compared with the before-closure group. The rate of direct home return was significantly lower in the after-closure group compared with the before-closure group (87.1% vs 81.6%, odds ratio: 0.66; 95% confidence interval: 0.45-0.96).The prehospital and emergency ward LOS for patients who attempted suicide in the study site increased significantly after a decrease in hospital-based mental health services. Conversely, there was significant reduction in direct home discharge after the decrease in in-house psychiatric care. These results have important implications for future policy to address the increasing care needs of patients who attempt suicide.

Association between delivering live-born twins and acute psychiatric illness within 1 year of delivery

BACKGROUND

Having twins is associated with more depressive symptoms than having singletons. However, the association between having twins and psychiatric morbidity requiring emergency department visit or inpatient hospitalization is less well known.

OBJECTIVE

This study aimed to determine whether women have higher risk of having a psychiatric diagnosis at an emergency department visit or inpatient admission in the year after having twins vs singletons.

STUDY DESIGN

This retrospective cohort study used International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedure codes within the Florida State Inpatient Database and State Emergency Department Database, which have an encrypted identifier allowing nearly all inpatient and emergency department encounters statewide to be linked to the medical record. The first delivery of Florida residents at the age of 13 to 55 years from 2005 to 2014 was included, regardless of parity; women with International Classification of Diseases, Ninth Revision, Clinical Modification coding for psychiatric illness or substance misuse during pregnancy or for stillbirth or higher-order gestations were excluded. The exposure was an International Classification of Diseases, Ninth Revision, Clinical Modification code during delivery hospitalization of live-born twins. The primary outcome was an International Classification of Diseases, Ninth Revision, Clinical Modification code during an emergency department encounter or inpatient admission within 1 year of delivery for a psychiatric morbidity composite (suicide attempt, depression, anxiety, posttraumatic stress disorder, psychosis, acute stress reaction, or adjustment disorder). The secondary outcome was drug or alcohol use or dependence within 1 year of delivery. We compared outcomes after delivery of live-born twins with singletons using multivariable logistic regression adjusting for sociodemographic and medical factors. We tested for interactions between independent variables in the primary model and conducted sensitivity analyses stratifying women by insurance type and presence of severe intrapartum morbidity or medical comorbidities.

RESULTS

A total of 17,365 women who had live-born twins and 1,058,880 who had singletons were included. Within 1 year of birth, 1.6% of women delivering twins (n=270) and 1.6% of women delivering singletons (n=17,236) had an emergency department encounter or inpatient admission coded for psychiatric morbidity (adjusted odds ratio, 1.00; 95% confidence interval, 0.88-1.14). Coding for drug or alcohol use or dependence in an emergency department encounter or inpatient admission in the year after twin vs singleton delivery was also similar (n=96 [0.6%] vs n=6222 [0.6%]; adjusted odds ratio, 1.11; 95% confidence interval, 0.91-1.36). However, women with public health insurance were more likely to be coded for drug or alcohol use or dependence after twin than singleton delivery (n=75 [1.2%] vs n=4858 [1.0%]; adjusted odds ratio, 1.27; 95% confidence interval, 1.01-1.60). Women with ≥1 medical comorbidity, severe maternal morbidity, or low income also had an increased risk of psychiatric morbidity after twin delivery (comorbidities, n=7438 [42.8%]; adjusted odds ratio, 1.30; 95% confidence interval, 1.25-1.34; severe maternal morbidity, n=940 [5.4%]; adjusted odds ratio, 1.65; 95% confidence interval, 1.49-1.81; lowest income quartile, n=4409 [26.8%]; adjusted odds ratio, 1.31; 95% confidence interval, 1.23-1.40; second-lowest income quartile, n=4770 [29.0%]; adjusted odds ratio, 1.34; 95% confidence interval, 1.26-1.43).

CONCLUSION

Overall, diagnostic codes for psychiatric illness or substance misuse in emergency department visits or hospital admissions in the year after twin vs singleton delivery are similar. However, women with who are low income or have public health insurance, comorbidities, or severe maternal morbidity are at an increased risk of postpartum psychiatric morbidity after twin vs singleton delivery.

Utility of Nonspecific Laboratory Testing for Psychiatric Patients Undergoing Medical Screening in a Military Emergency Department

INTRODUCTION

Psychiatric complaints account for a sizable and increasing portion of emergency department (ED) visits. Compared with other medical patients, these patients often require substantial resources because of limited specialized resources and prolonged boarding times, which can be detrimental to the safety and satisfaction of other patients. This can prompt early and indiscriminate laboratory testing to expedite early requests for admission consideration. Numerous emergency medicine literature and clinical policies already recommend against indiscriminate screening labs for these patients, yet many psychiatric services require these tests. This study further evidences the limited clinical utility and high associated costs of mandatory protocol screening labs for psychiatric patients evaluated in military EDs.

MATERIALS AND METHODS

A retrospective chart review of 441 active duty military patients and their families presenting to Madigan Army Medical Center's ED who received psychiatric diagnoses underwent analysis. A 3-physician review panel evaluated each identified patient case to confirm eligibility and determine whether or not laboratory studies led to a change in patient disposition that was not identified by history, review of systems, physical exam, and known past medical history. The review was approved by the hospital's institutional review board. Contemporary laboratory tests ordered in the evaluation of these patients included complete blood count with differential, complete metabolic panel, thyroid-stimulating hormone, serum ethanol, serum acetaminophen, serum salicylates, urine drug screening, urinalysis, urine human chorionic gonadotropin, and electrocardiograms.

RESULTS

Broad screening labs may have altered dispositions for 0.9% (4) of patients. In total, 93% (202) of admitted patients were dispositioned to a psychiatric service. Of the 15 patients admitted to a medical service, 10 involved overdoses or intoxication. One patient had anemia in addition to opioid use disorder as diagnoses and was dispositioned to a medicine service. One pediatric patient was admitted for observation only. The remaining patients had diagnoses based on physical exam and history requiring medical service admission. In total, 7 patients had unknown dispositions, of which 4 carried solely psychiatric diagnoses.

CONCLUSIONS

The cumulative reimbursement costs of broad testing in the studied population were estimated at $36,325.17 and rarely altered patient disposition. Further testing does not increase the incidence of disposition altering diagnoses and is associated with increased costs. When individual state laws and the clinical assessment by the responsible emergency physician are considered, future standardized ED lab screening evaluations of psychiatric patients in military EDs may be concentrated to breathalyzer alcohol level, urine drug screen, serum salicylates, serum acetaminophen, and urine human chorionic gonadotropin.

Evaluating the effectiveness of concurrent opioid agonist treatment and physician-based mental health services for patients with mental disorders in Ontario, Canada

Objective

The objective of this study was to evaluate the relationship between concurrent physician-based mental health services, all-cause mortality, and acute health service use for individuals enrolled in Opioid Agonist Treatment in Ontario, Canada.

Methods

A cohort study of patients enrolled in opioid agonist treatment in Ontario was conducted between January 1, 2011, and December 31, 2015, in Ontario with an inverse probability of treatment weights using the propensity score to estimate the effect of physician-based mental health services. Treatment groups were created based on opioid agonist treatment patients’ utilization of physician-based mental health services. Propensity score weighted odds ratios were calculated to assess the relationship between the treatment groups and the outcomes of interest. The outcomes included all-cause mortality using data from the Registered Persons Database, Emergency Department visits from the National Ambulatory Care Database, and hospitalizations using data from the Discharge Abstract Database. Encrypted patient identifiers were used to link across databases.

Results

A total of 48,679 individuals in OAT with mental disorders. Opioid agonist treatment alone was associated with reduced odds of all-cause mortality (odds ratio (OR) 0.4, 95% confidence interval (CI) 0.3–0.4). Patients who received mental health services from a psychiatrist and primary care physician while engaged in OAT, the estimated rate of ED visits per year was higher (OR = 1.3, 95% CI 1.2–1.4) and the rate of hospitalizations (OR = 0.5, 95% CI 0.4–0.6) than in the control group.

Conclusion

Our findings support the view that opioid agonist treatment and concurrent mental health services can improve clinical outcomes for complex patients, and is associated with enhanced use of acute care services.

[Analysis of the psychiatric emergency inpatients in an ER setting at a general hospital]

OBJECTIVES

Evaluation of psychiatric emergency contacts in an interdisciplinary emergency room.

METHODS

We conducted a retrospective examination of all psychiatric consultations of 2015.

RESULTS

The three most common emergency syndromes could be assigned in descending order to the F1 (32.2%), the F2 (25.9%) and the F3 diagnoses (21.2%). The admission rate was 58.9% and more than half of the patients came to the emergency room on foot (55.7%). Diagnosis-specific differences were found between first-time presenters and patients who had presented previously.

CONCLUSION

The psychiatric emergency has high relevance in the emergency room. The majority of the patients admitted to hospital meet the emergency criteria according to the guideline.

[Characterization of Ambulant Emergency Contacts in an Emergency Room at a General Hospital]

OBJECTIVE

Scientific interest in emergency psychiatric patients has increased significantly over the last two decades. Nevertheless, current knowledge of this group of patients in the setting of an interdisciplinary emergency department is surprisingly low.

METHODS

A retrospective examination of all ambulatory psychiatric emergency contacts in the emergency room of a regional hospital in 2015 took place.

RESULTS

Solely F4 diagnoses accounted for 48.1 % of all first-time patients. Female patients younger than 25 years used the ER twice as often as their male control-group. Almost half of all outpatients fulfilled no emergency criteria.

CONCLUSION

There are specific age and gender differences. The proportion of patients without any emergency criteria was surprisingly high. More scientific research is needed in order to scrutinize this possible inappropriate use of an ER by psychiatric patients.

Analysis of emergency department visits for all reasons by adults with depression in the United States

Background

We aimed to characterize Emergency Department (ED) utilization and outcomes of patients with depression seeking emergency care for all reasons.

Methods

Using 2014–2016 ED data from the National Hospital Ambulatory Medical Care Survey, we investigated demographics, ED resource utilization, clinical characteristics, and disposition of patients with depression versus those without depression.

Results

Approximately 10,626,184 (11.4%) out of 92,899,685 annual ED visits were by patients with depression. ED patients with depression were mostly non-Hispanic White (74.0%) and were less likely to be male than patients without depression (aOR: 0.62; [95%] CI: 0.57–0.68). ED patients with depression were more likely to be admitted to the hospital (aOR: 1.50; CI: 1.38–1.63) than patients without depression. Among ED patients with depression, males were more likely than females to be seeking emergency care for psychiatric reasons (OR: 2.45; 95% CI: 2.10–2.87)) and to present with overdose/poisoning (OR: 1.46; CI: 1.03–2.05).

Conclusions

We described the unique demographic, socioeconomic, and clinical characteristics of ED patients with depression, using the most comprehensive, nationally representative study to date. We revealed notable gender disparities in rates and reasons for admissions. The higher hospital and ICU admission rates of ED patients with depression suggests this population requires a higher level of emergency care, for reasons that remain poorly understood.

Emergency psychiatric management of borderline personality disorder: Towards an articulation of modalities for personalised integrative care

Building on existing literature, the authors draw the landscape of psychiatric emergencies, and focus on borderline personality disorder, frequently encountered, and strongly linked to death by suicide. A review of knowledge in terms of diagnosis, prognosis, etiology, and treatment, as well as their own experiences, lead them to propose areas of progress that would secure the patient's care pathway. The evolution of society has led psychiatric emergency departments to play the role of a safety net and an entry point to the mental health system. Borderline personality disorder is one of the most common pathologies encountered in psychiatric emergencies. It represents a major concern, long characterized by an often dramatic evolution, and by the human and economic stress it generates. However, since the 1990s, knowledge of this disorder has been refined, and today there are various means of evaluation, good clinical practices and psychotherapeutic treatments, thanks to which significant and lasting improvement is possible. Recent studies highlight the crucial role of hospital caregivers, and the benefit of consolidating their skills by providing them with the knowledge and tools specific to this disorder. They also converge on the interest of setting up specific emergency treatment modalities, particularly highly structured, safe and empowering for the patient, in order to improve their effectiveness. The authors suggest that a case formulation model for persons with borderline personality disorder in emergency would make it possible to activate these two levers of progress, while improving collaboration between hospital and outpatient care. This would also address their main concern of optimizing the patient's therapeutic pathway and reinforcing adherence to treatment that could bring remission, and should be supported by data from empirical research.

Utilizing YouTube as platform for psychiatric emergency patient outreach in Chinese Americans

OBJECTIVE

Chinese Americans significantly underutilize mental health resources, which leads to delayed diagnosis, suboptimal management, and can be contributing to the large number of psychiatric emergencies seen in the ED. The goal of this study is to understand the role of using YouTube as a platform for psychiatric emergency outreach among Chinese Americans.

METHODS

We posted three videos about psychiatric emergencies in Cantonese on YouTube. We collected viewing data during a five-year period. The recorded parameters include watch time, number of views, average view duration, traffic source, search terms, and watch device type.

RESULTS

The videos generated 40,608 min of watch time and 5976 views, with an average view duration of 6.80 min. The top three traffic sources are YouTube suggested videos, direct YouTube search, and browse features. The three most used viewing devices are mobile phones (25,068 min of watch time, 3491 views, and 7.18 min of average view duration), computer/TV (9222 min of watch time, 1717 views, and 5.37 min of average view duration), and tablets (6318 min of watch time, 768 views, and 8.23 min of average view duration).

CONCLUSION

Majority of the viewers used mobile phones, and mobile phones and tablets had significantly longer average view durations as compared to computer/TV. YouTube and wireless devices may have potential as internet based psychiatric emergency outreach platform. This study calls for further research to explore the effectiveness of using social media and wireless devices for psychiatric emergency education prior to ED arrival, particularly in minority populations with cultural barriers to health care.

Screening Electrocardiograms in Cocaine-Positive Chest Pain-Free Psychiatric Patients Requiring Medical Screening

BACKGROUND

The current practice at a large urban academic emergency department (ED) is to obtain screening electrocardiograms (ECGs) as part of the medical screening on all psychiatric patients who test positive for cocaine.

OBJECTIVE

We sought to examine the impact of an ECG in the medical screening of chest pain-free psychiatric patients who test positive for cocaine.

METHODS

An institutional review board-approved retrospective chart review from January 2014 to December 2015 was performed on charts of adult ED patients requiring medical screening before transfer to a psychiatric facility. Patients who tested positive for cocaine on urine drug screens were included in this study. Patients with chest pain or those who did not have an ECG recorded were excluded. Outcomes evaluated included disposition and subsequent cardiac work-up.

RESULTS

One thousand nine hundred sixty-eight ED patients were identified who tested positive for cocaine on a urine toxicology screen, and 853 met the inclusion criteria. ECGs were normal in 812 patients (95% [95% confidence interval 93-96%]) and abnormal in 41 patients (5% [95% confidence interval 4-7%]). Of 41 patients with abnormal ECGs, 4 were admitted for cardiac work-up. Two patients had positive troponin values in the ED, 2 had cardiology consultations, and 3 had further cardiac stress testing, all of which were negative or nondiagnostic. No cardiac catheterizations were performed.

CONCLUSIONS

Most ED patients with recent cocaine use but without chest pain have a normal ECG. Of the minority with an abnormal ECG, no cases of acute myocardial ischemia or infarction were identified.

Suicide and all-cause mortality in a high-risk cohort: A latent class approach

OBJECTIVE

To use latent class analysis to group patients consulted to an emergency psychiatry consultation service and assess occurrence of suicide attempts and all-cause mortality across groups.

METHOD

Latent class analysis was used to classify individuals assessed by psychiatry in the emergency department of the two teaching hospitals in Winnipeg, Canada. A second latent class analysis was done on individuals presenting with a suicide attempt. Indicators variables included a variety of clinically assessed factors, such as presentation suicidality and occurrence of anxiety/depression/psychosis, and prior medical treatment. Two post-treatment indicators were used; suicide attempt hospitalizations and all-cause mortality within 12 months of assessment.

RESULTS

Latent class analysis identified 8 classes for all presentations (n = 5292) and 3 classes for the attempter subgroup (n = 730). Although there is considerable overlap in indicators among the classes certain indicators differentiated between the groups: suicide attempt presentation, prior psychiatric treatment, psychotropic medication polypharmacy, childhood abuse, and addictions. Although the presence of deaths and future attempts varied between the identified groups, there were no groups with a >10% proportion of individuals with either of these outcomes.

CONCLUSIONS

Potential exists for latent class-based assessments, but additional samples with better indicators are needed.

Prediction of Recurrent Emergency Department Visits in Patients With Mental Disorders

BACKGROUND

Patients with mental disorders are more likely to be frequent emergency department (ED) users than patients with somatic illnesses. There is little information about recurrent ED visitors (≥four ED visits/year) due to mental health problems in Switzerland. Therefore, our aim was to investigate the prevalence of recurrent ED visits due to mental disorders and to determine which mental disorders and risk factors were associated with recurrent ED visits.

METHODS

In a retrospective analysis, we investigated patients suffering from mental health problems between January and December 2015 who presented more than once in the ED of a tertiary care hospital. ED patients who sought out the ED due to mental disorders were grouped in a recurrent group with at least four ED visits per year or in a control group visiting the ED twice or three times within a year. The primary endpoint was to assess the prevalence of recurrent ED patients due to acute symptoms of mental disorders. As secondary endpoints, we investigated which mental disorders and risk factors were associated with recurrent ED visits.

RESULT

Of 33,335 primary ED visits, 642 ED visits (1.9%) were by 177 visitors suffering from acute mental health problems. Forty-five (25.4%) of these 177 patients were recurrent ED visitors; 132 (74.6%) visited the ED twice or three times (control). Patients with personality disorders had a four-times higher risk (p = 0.011) of being a recurrent ED visitor. Recurrent ED visitors with mental disorders had significantly more in-house admissions (p < 0.001), self-mutilations (p < 0.001), acute drug toxicity (p = 0.007) and were more often persons of single status (p = 0.045). Although recurrent ED visitors more often had an outpatient general physician or psychiatrist, they visited the ED more frequently within office hours (p < 0.001).

CONCLUSION

A quarter of frequent ED users with mental disorders are recurrent ED visitors and were more likely to suffer from personality disorders. Recurrent ED visits are associated with higher rates of self-mutilation, acute drug toxicity, and a greater number of in-house admissions.

National trends in mental health-related emergency department visits by children and adults, 2009-2015

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.

Association between stillbirth ≥23 weeks gestation and acute psychiatric illness within 1 year of delivery

BACKGROUND

Stillbirth has been associated with emotional and psychologic symptoms. The association between stillbirth and diagnosed postpartum psychiatric illness is less well-known.

OBJECTIVE

The purpose of this study was to determine whether women have a higher risk of experiencing clinician-diagnosed psychiatric morbidity in the year after stillbirth vs livebirth.

STUDY DESIGN

This retrospective cohort study used International Classification of Diseases, 9th Revision, Clinical Modification diagnosis and procedure codes to identify participants, exposures, and outcomes within the Florida State Inpatient and State Emergency Department databases. The first delivery of female Florida residents aged 13-54 years old from 2005-2014 was included; women with International Classification of Diseases, 9th Revision, Clinical Modification coding for psychiatric illness or substance use during pregnancy were excluded. The exposure was an International Classification of Diseases, 9th Revision, Clinical Modification diagnosis code during delivery hospitalization of a stillbirth at ≥23 weeks gestation. The primary outcome was a primary or secondary International Classification of Diseases, 9th Revision, Clinical Modification diagnosis code during an Emergency Department encounter or inpatient admission within 1 year of delivery for a composite of psychiatric morbidity: suicide attempt, depression, anxiety, posttraumatic stress disorder, psychosis, acute stress reaction, or adjustment disorder. The secondary outcome was a substance use composite of drug or alcohol use or dependence. We compared outcomes after delivery of stillbirth vs livebirth using multivariable logistic regression, adjusting for maternal sociodemographic factors, medical comorbidities, and severe intrapartum morbidity. We also used Cox proportional hazard models and tested for violation of the proportional hazard assumption to identify the highest risk time within the year after stillbirth delivery for the primary outcome, adjusting for the same factors and morbidities as in the logistic regression model.

RESULTS

A total of 8292 women with stillborn singletons and 1,194,758 with liveborn singletons were included. Within 1 year of hospital discharge after stillbirth, 4.0% of the women (n=331) had an Emergency Department encounter or inpatient admission that was coded for psychiatric morbidity; the risk was nearly 2.5 times higher compared with livebirth (1.6%; n=19,746); adjusted odds ratio, 2.47; 95% confidence interval, 2.20- 2.77). Women also had higher risk of having an Emergency Department encounter or inpatient admission coded for drug or alcohol use or dependence in the year after delivery of stillbirth vs livebirth (124 [1.5%] vs 7033 [0.6%]; adjusted odds ratio, 2.41; 95% confidence interval, 1.99-2.90). Cox proportional hazard modeling suggested that the highest risk interval for postpartum psychiatric illness was within 4 months of stillbirth delivery (adjusted hazard ratio, 3.26; 95% confidence interval, 2.63-4.04), although the risk remained high during the 4-12 months after delivery (adjusted hazard ratio, 2.42; 95% confidence interval, 2.13-2.76).

CONCLUSION

Coding for psychiatric illness or substance misuse in Emergency Department visits or hospital admissions in the year after delivery of livebirths was not uncommon, corresponding to nearly 2 per 100 women. However, having a stillbirth was associated with increased risk of both psychiatric morbidity (corresponding to 1 per 25 women) and substance misuse (corresponding to 3 in 100 women), with the highest risk of postpartum psychiatric morbidity occurring from delivery until 4 months after delivery.

Association Between Severe Maternal Morbidity and Psychiatric Illness Within 1 Year of Hospital Discharge After Delivery

OBJECTIVE

To estimate whether severe maternal morbidity is associated with increased risk of psychiatric illness in the year after delivery hospital discharge.

METHODS

This retrospective cohort study used International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes within Florida's Healthcare Cost and Utilization Project's databases. The first liveborn singleton delivery from 2005 to 2015 was included; women with ICD-9-CM codes for psychiatric illness or substance use disorder during pregnancy were excluded. The exposure was ICD-9-CM codes during delivery hospitalization of severe maternal morbidity, as per the Centers for Disease Control and Prevention. The primary outcome was ICD-9-CM codes in emergency department encounter or inpatient admission within 1 year of hospital discharge of composite psychiatric morbidity (suicide attempt, depression, anxiety, posttraumatic stress disorder, psychosis, acute stress reaction, or adjustment disorder). The secondary outcome was a composite of ICD-9-CM codes for substance use disorder. We compared women with severe maternal morbidity with those without severe maternal morbidity using multivariable logistic regression adjusting for sociodemographic factors and medical comorbidities. Cox proportional hazard models identified the highest risk period after hospital discharge for the primary outcome.

RESULTS

A total of 15,510 women with severe maternal morbidity and 1,178,458 without severe maternal morbidity were included. Within 1 year of hospital discharge, 2.9% (n=452) of women with severe maternal morbidity had the primary outcome compared with 1.6% (n=19,279) of women without severe maternal morbidity, resulting in an adjusted odds ratio (aOR) 1.74 (95% CI 1.58-1.91). The highest risk interval was within 4 months of discharge (adjusted hazard ratio [adjusted HR] 2.53 [95% CI 2.05-3.12]). Most severe maternal morbidity conditions were associated with higher risk of postpartum psychiatric illness. Women with severe maternal morbidity had nearly twofold higher risk of postpartum substance use disorder (170 [1.1%] vs 6,861 [0.6%]; aOR 1.91 [95% CI 1.64-2.23]).

CONCLUSION

Though absolute numbers were modest, severe maternal morbidity was associated with increased risk of severe postpartum psychiatric morbidity and substance use disorder. The highest period of risk extended to 4 months after hospital discharge.

Disparities in Emergency Department Wait Time Among Patients with Mental Health and Substance-Related Disorders

This study examined disparities in emergency department (ED) wait time for patients with mental health and substance-related disorders (PwMHSDs), using data from the 2009-2011 National Hospital Ambulatory Medical Care Survey (NHAMCS). Wait time was defined as the time between arrival at ED and being seen by an ED provider. Results from multivariable regression models show racial disparities, with non-Hispanic Black PwMHSDs experiencing longer ED wait time, compared to non-Hispanic White PwMHSDs. A temporal decline in ED wait time was also observed over the study period. The findings of this study have implications for informing the development of policies tailored at facilitating the delivery of equitable emergency care services to all PwMHSDs.

Involuntary patient length-of-stay at a suburban emergency department

BACKGROUND

Patients who may be a danger to themselves or others often are placed on involuntary hold status in the Emergency Department (ED). Our primary objective was to determine if there are demographic and/or clinical variables of involuntary hold patients which were associated with an increased ED LOS.

METHODS

Records of ED patients evaluated while on involuntary hold from January 1, 2014 through November 30, 2015 at a suburban acute-care hospital ED were reviewed. Data collected included demographics information, LOS, suicidal or homicidal ideation, suicide attempt, blood alcohol concentration (BAC), urine drug test (UDT), psychiatric disorder, substance use, medical illness, violence in the ED, and hospital admission. Linear regression based on the log of LOS was used to identify factors associated with increased LOS.

RESULTS

Two-hundred and fifty-one patients were included in the study. ED LOS (median) was 6 h (1, 49). Linear regression analysis showed increased LOS was associated with BAC (p = 0.05), urine drug test (UDT) (p = 0.05) and UDT positive for barbiturates (p = 0.01). There was no significant difference in ED LOS with respect to age, gender, housing, psychiatric diagnosis, suicidal or homicidal ideation, suicide attempt, violence, medical diagnosis, or admission status.

CONCLUSIONS

Involuntary hold patients had an increased ED LOS associated with alcohol use, urine drug test screening, and barbiturate use. Protocol development to help stream-line ED evaluation of alcohol and drug use may improve ED LOS in this patient population.

Emergency psychiatric services in Roozbeh Hospital: A qualitative study of the staff's experiences

PURPOSE

This study aims to explore how psychiatric residents and nurses experience the conditions of psychiatric emergency services.

DESIGN AND METHODS

This qualitative study was carried out using content analysis. Data were collected through unstructured interviews conducted during three focus groups.

FINDINGS

The results of the focus groups were classified into the following five categories of issues influencing the staff's experiences: repetitive problems, long wait times, ambiguity, insecurity, and stability.

PRACTICE IMPLICATIONS

Improving the staff's communication skills and educating them on how to manage violence, establishing a well-functional system of triage, and optimizing bed management and discharge planning are among several potential strategies that might be considered to improve the quality of care in psychiatric emergency services.

Trends in Psychiatric Emergency Department Visits Among Youth and Young Adults in the US

BACKGROUND

Visits to the emergency department (ED) for psychiatric purposes are an indicator of chronic and acute unmet mental health needs. In the current study, we examined if psychiatric ED visits among individuals 6 to 24 years of age are increasing nationwide.

METHODS

ED data came from the 2011-2015 National Hospital Ambulatory Medical Care Survey, a national survey of ED visits across the United States. Psychiatric ED visits were identified by using the International Classification of Diseases, Ninth Revision and reason-for-visit codes. Survey-weighted logistic regression analyses were employed to examine trends in as well as correlates of psychiatric ED visits. Data from the US Census Bureau were used to examine population rates.

RESULTS

Between 2011 and 2015, there was a 28% overall increase (from 31.3 to 40.2) in psychiatric ED visits per 1000 youth in the United States. The largest increases in psychiatric ED visits per 1000 US youth were observed among adolescents (54%) and African American (53%) and Hispanic patients (91%). A large increase in suicide-related visits (by 2.5-fold) was observed among adolescents (4.6-11.7 visits per 1000 US youth). Although psychiatric ED visits were long (51% were ≥3 hours in length), few (16%) patients were seen by a mental health professional during their visit.

CONCLUSIONS

Visits to the ED for psychiatric purposes among youth are rising across the United States. Psychiatric expertise and effective mental health treatment options, particular those used to address the rising suicide epidemic among adolescents, are needed in the ED.

Characteristics and dispositional determinants of psychiatric emergencies in a University Hospital in Beirut

Mental health problems are common in Lebanon, and so are psychiatric emergencies. In order to show the characteristics of psychiatric emergencies in Lebanon along with their dispositional determinants, we conducted this retrospective, single-center, chart-review study of patients who presented to the Emergency Department between July 1, 2016 until December 31, 2016 and required an official psychiatrist consultation. Our sample included 195 patients of all age groups. The most common diagnosis was depression (75 patients) followed by anxiety (61 patients). 107 patients (54.8%) required admission for adequate treatment; however only 72 (67.3%) of those were actually admitted, and the rest (32.7%) left the hospital against medical advice. Increased hospital admission was associated with being a female (OR = 3.042), having family history of psychiatric disease (OR = 2.040) and having suicidal ideations (OR = 12.949). In a country that has inadequate health coverage, financial coverage can also be a determining factor in whether or not patients get the admission they need.

Characteristics and Trends of Emergency Department Visits in the United States (2010-2014)

BACKGROUND

It is important that policy makers, health administrators, and emergency physicians have up-to-date statistics on the most common diagnoses of patients seen in the emergency department (ED).

OBJECTIVES

We sought to describe the changes that occurred in ED visits from 2010 through 2014 and to describe the frequency of different ED diagnoses.

METHODS

This is a retrospective analysis of ED visit data from the National Emergency Department Sample from 2010 through 2014. Visits were stratified by age, sex, insurance status, disposition, diagnosis, and diagnostic category. We calculated the total annual ED visits and the ED visit rates by diagnoses and diagnostic categories.

RESULTS

Between 2010 and 2014, the number of U.S. ED visits increased from 128.9 million to 137.8 million. The rate of ED Visits per 1000 persons increased from 416.92 (95% confidence interval [CI] 399.47-434.37) in 2010 to 432.51 (95% CI 411.51-453.61) in 2014 (p = 0.0136). ED visits grew twice as quickly (1.7%) as the overall population (0.7%). The most common reason for an ED visit was abdominal pain (11.75% [95% CI 11.61-11.89]). This was followed by mental health problems (4.45% [95% CI 4.19-4.72]).

CONCLUSION

The number of ED visits in the United States continues to increase faster than the rate of population growth. Abdominal problems and mental health issues, including substance abuse, were the most common reasons for an ED visit in 2014.

Association between ambient PM2.5 and emergency department visits for psychiatric emergency diseases

Background

Whether or not short-term exposure to particulate matter <2.5 μm in diameter (PM_2.5) increases the risk of psychiatric emergency diseases is unclear.

Methods

The study was performed in a metropolis from January 2015 to December 2016. The exposure was PM_2.5, and the confounders were weather (temperature and humidity) and other pollutants (PM₁₀, SO₂, CO, O₃, and NO₂). The outcomes were emergency department (ED) visits with psychiatric disease codes (F00-F99 in ICD10 codes). General additive models were used for the statistical analysis to calculate the adjusted relative risks (ARRs) and 95% confidence intervals (95% CIs) for the daily number of ED visits with a lag of 1 to 3 days following a 10 μg/m³ increase in PM_2.5.

Results

During the study period, a total of 67,561 ED visits for psychiatric diseases were identified and tested for association with PM_2.5. Daily ED visits for all psychiatric diseases were not associated with PM_2.5 in the model that was not adjusted for other pollutants. The ARR (95% CI) in the model adjusted for SO₂ was 1.011 (1.002–1.021) by 10 μg/m³ of PM_2.5 on Lag 1 for all psychiatric diseases (F00-F99). The ARR (95% CI) in the model adjusted for O₃ was 1.015 (1.003–1.029) by 10 μg/m³ of PM_2.5 on Lag 1 for F40-F49 (Neurotic, stress-related and somatoform disorders).

Conclusion

An increase in PM_2.5 showed a significant association with an increase in ED visits for all psychiatric diseases (F00-F99) and for neurotic, stress-related and somatoform disorders (F40-F49) on lag day 1.

Substance Use, Homelessness, Mental Illness and Medicaid Coverage: A Set-up for High Emergency Department Utilization

Introduction

Frequent users of emergency departments (ED) account for 21–28% of all ED visits nationwide. The objective of our study was to identify characteristics unique to patients with psychiatric illness who are frequent ED users for mental health care. Understanding unique features of this population could lead to better care and lower healthcare costs.

Methods

This retrospective analysis of adult ED visits for mental healthcare from all acute care hospitals in California from 2009–2014 used patient-level data from California’s Office of Statewide Health Planning and Development. We calculated patient demographic and visit characteristics for patients with a primary diagnosis of a mental health disorder as a percentage of total adult ED visits. Frequent ED users were defined as patients with more than four visits in a 12-month period. We calculated adjusted rate ratios (aRR) to assess the association between classification as an ED frequent user and patient age, sex, payer, homelessness, and substance use disorder.

Results

In the study period, 846,867 ED visits for mental healthcare occurred including 238,892 (28.2%) visits by frequent users. Patients with a primary mental health diagnosis and a co-occurring substance use diagnosis in the prior 12 months (77% vs. 37%, aRR [4.02], 95% confidence interval [CI] [3.92–4.12]), homelessness (2.9% vs 1.1%, odds ratio [1.35], 95% [CI] [1.27–1.43]) were more likely to be frequent users. Those covered by Medicare (aRR [3.37], 95% CI [3.20–3.55]) or the state’s Medicaid program Medi-Cal (aRR [3.10], 95% CI [2.94–3.25]) were also more likely to be frequent users compared with those with private insurance coverage.

Conclusion

Patients with substance use disorders, homelessness and public healthcare coverage are more likely to be frequent users of EDs for mental illness. Substance use and housing needs are important factors to address in this population.

Emergency Department Telepsychiatry Service Model for a Rural Regional Health System: The First Steps

BACKGROUND

Emergency departments (EDs) have recognized an increasing number of patients presenting with mental health (MH) concerns. This trend imposes greater demands upon EDs already operating at capacity. Many ED providers do not feel they are optimally prepared to provide the necessary MH care. One consideration in response to this dilemma is to use advanced telemedicine technology for psychiatric consultation.

INTRODUCTION

We examined a rural- and community-based health system operating 21 EDs, none of which has direct access to psychiatric consultation. Dedicated beds to MH range from zero (in EDs with only 3 beds) to 6 (in an ED with 38 beds).

MATERIALS AND METHODS

We conducted a needs assessment of this health system. This included a survey of emergency room providers with a 67% response rate and site visits to directly observe patient flow and communication with ED staff. A visioning workshop provided input from ED staff. Data were also obtained, which reflected ED admissions for the year 2015.

RESULTS

The data provide a summary of provider concerns, a summary of MH presentations and diagnosis, and age groupings. The data also provide a time when most MH concerns present to the ED.

DISCUSSION

Based upon these results, a proposed model for delivering comprehensive regional emergency telepsychiatry and behavioral health services is proposed.

CONCLUSIONS

Emergency telepsychiatry services may be a tenable solution for addressing the shortage of psychiatric consultation to EDs in light of increasing demand for MH treatment in the ED.

Clinical profiles and temporal patterns of psychiatric emergency room visitors in Sweden

AIMS

To describe persons visiting the psychiatric emergency room (PER) in Sweden and to compare persons who frequently (PFV) and infrequently (PIFV) visit PERs in terms of group size, age, gender, PER location inside versus outside the home municipality, diagnosis (ICD 10), temporal patterns of visits and hospital admissions.

METHODS

This register study included all visits to PERs in one Swedish county over 3 years, 2013-2015 (N = 67,031 visits). The study employed descriptive statistics as well as Chi-square tests combined with Bonferroni correction to compare PFV with PIFV.

RESULTS

Of the total of 27,282 visitors, 2201 (8.1%) were identified as PFV (five or more visits within 12 months) and they accounted for 38.1% of the total visits. The study found differences between PFV and PIFV in gender, diagnostic profile, hospital admissions and temporal patterns. Differences were also detected with regard to distance between PERs and home municipalities. However, no age-related differences were found between the two groups.

CONCLUSIONS

PFV and PIFV have different clinical profiles and temporal patterns. These results may be important when planning, developing and evaluating interventions targeting the needs of each group, which is in accordance with a person-centred approach. Such an approach might eventually result in fewer visits to PERs.

Temporal Trends in Mental Health Service Utilization across Outpatient and Acute Care Sectors: A Population-Based Study from 2006 to 2014

OBJECTIVE

Although evidence suggests that treatment seeking for mental illness has increased over time, little is known about how the health system is meeting the increasing demand for services. We examined trends in physician-based mental health service use across multiple sectors.

METHOD

In this population-based study, we used linked health-administrative databases to measure annual rates of mental health-related outpatient physician visits to family physicians and psychiatrists, emergency department visits, and hospitalizations in adults aged 16+ from 2006 to 2014. We examined absolute and relative changes in visit rates, number of patients, and frequency of visits per patient, and assessed temporal trends using linear regressions.

RESULTS

Among approximately 11 million Ontario adults, age- and sex-standardized rates of mental health-related outpatient physician visits declined from 604.8 to 565.5 per 1000 population over the study period ( P_trend = 0.04). Over time, the rate of visits to family physicians/general practitioners remained stable ( P_trend = 0.12); the number of individuals served decreased, but the number of visits per patient increased. The rate of visits to psychiatrists declined ( P_trend < 0.001); the number of individuals served increased, but the number of visits per patient decreased. Concurrently, visit rates to emergency departments and hospitals increased (16.1 to 19.7, P_trend < 0.001 and 5.6 to 6.0, P_trend = 0.01, per 1000 population, respectively). Increases in acute care service use were greatest for anxiety and addictions.

CONCLUSIONS

The increasing acute care service use coupled with the reduction in outpatient visits suggest, overall, an increase in demand for mental health care that is not being met in ambulatory care settings.

Validation of a 3-Item Screening Tool for Geriatric Depression in the Observation Unit of an Emergency Department

Introduction

The purpose of this study was to validate a new 3-item Emergency Department Depression Screening Instrument (ED-DSI) in screening for depression in elderly patients presenting to the emergency department (ED).

Methods

All Cantonese-speaking ED patients 65 years or older staying in the observation ward were included. Patients with a known diagnosis of dementia or depression and those with severe hearing problems were excluded. The doctor-in-charge would administer the 3-item ED-DSI which was adapted from the Geriatric Depression Scale (GDS). The research nurse who was blind to the answers of the initial screening then administered the 15-item GDS to the same patient. The 15-item GDS, which had been validated previously in the local population, was used as the reference standard.

Results

One hundred patients of whom 70 were female, were recruited. The mean age of the group was 75 years with a range from 65 to > 96 years. Using a cut-off score of 2, the new 3-item ED-DSI was shown to be as effective as the 15-item GDS (using a cut-off score of 8) in identifying depressed subjects. The sensitivity and specificity of the instrument were 90% and 74%, respectively.

Conclusions

The new 3-item ED-DSI for depression correlated well with the 15-item Geriatric Depression Scale. It can be used for screening of depression in elderly patients in a busy emergency department.

Highlight in Telepsychiatry and Behavioral Health Emergencies

Carolinas HealthCare System is one of the largest freestanding psychiatric emergency departments in the country. It has grown from a small community mental health center in the 1930s, to one of the largest providers of emergency mental health services in the country. It offers services in person and via telepsychiatry to other emergency departments and primary care clinics. It decreased emergency room wait times and revolutionized where and how patients get their care. This has been the work of several groups from many disciplines. The transition from community mental health center to large-scale mental health emergency department has been a model for the rest of the country.

Factors Associated With the Likelihood of Hospitalization Following Emergency Department Visits for Behavioral Health Conditions

OBJECTIVES

Behavioral health-related emergency department (ED) visits have been linked with ED overcrowding, an increased demand on limited resources, and a longer length of stay (LOS) due in part to patients being admitted to the hospital but waiting for an inpatient bed. This study examines factors associated with the likelihood of hospital admission for ED patients with behavioral health conditions at 16 hospital-based EDs in a large urban area in the southern United States.

METHODS

Using Andersen's Behavioral Model of Health Service Use for guidance, the study examined the relationship between predisposing (characteristics of the individual, i.e., age, sex, race/ethnicity), enabling (system or structural factors affecting healthcare access), and need (clinical) factors and the likelihood of hospitalization following ED visits for behavioral health conditions (n = 28,716 ED visits). In the adjusted analysis, a logistic fixed-effects model with blockwise entry was used to estimate the relative importance of predisposing, enabling, and need variables added separately as blocks while controlling for variation in unobserved hospital-specific practices across hospitals and time in years.

RESULTS

Significant predisposing factors associated with an increased likelihood of hospitalization following an ED visit included increasing age, while African American race was associated with a lower likelihood of hospitalization. Among enabling factors, arrival by emergency transport and a longer ED LOS were associated with a greater likelihood of hospitalization while being uninsured and the availability of community-based behavioral health services within 5 miles of the ED were associated with lower odds. Among need factors, having a discharge diagnosis of schizophrenia/psychotic spectrum disorder, an affective disorder, a personality disorder, dementia, or an impulse control disorder as well as secondary diagnoses of suicidal ideation and/or suicidal behavior increased the likelihood of hospitalization following an ED visit.

CONCLUSION

The block of enabling factors was the strongest predictor of hospitalization following an ED visit compared to predisposing and need factors. Our findings also provide evidence of disparities in hospitalization of the uninsured and racial and ethnic minority patients with ED visits for behavioral health conditions. Thus, improved access to community-based behavioral health services and an increased capacity for inpatient psychiatric hospitals for treating indigent patients may be needed to improve the efficiency of ED services in our region for patients with behavioral health conditions. Among need factors, a discharge diagnosis of schizophrenia/psychotic spectrum disorder, an affective disorder, a personality disorder, an impulse control disorder, or dementia as well as secondary diagnoses of suicidal ideation and/or suicidal behavior increased the likelihood of hospitalization following an ED visit, also suggesting an opportunity for improving the efficiency of ED care through the provision of psychiatric services to stabilize and treat patients with serious mental illness.