Mobile Crisis Outreach and Emergency Department Utilization: A Propensity Score-matched Analysis

Introduction

Mental health and substance use disorder (MHSUD) patients in the emergency department (ED) have been facing increasing lengths of stay due to a shortage of inpatient beds. Previous research indicates mobile crisis outreach (MCO) reduces long ED stays for MHSUD patients. Our objective was to assess the impact of MCO contact on future ED utilization.

Methods

We conducted a retrospective chart review of patients presenting to a large Midwest university ED with an MHSUD chief complaint from 2015–2018. We defined the exposure as those who had MCO contact and any MHSUD-related ED visit within 30 days of MCO contact. The MCO patients were 2:1 propensity score–matched by demographic data and comorbidities matched to patients with no MCO contact. Outcomes were all-cause and psychiatric-specific reasons for return to the ED within one year of the index ED visit. We report descriptive statistics and odds ratios (OR) to describe the difference between the two groups, and hazard ratios (HR) to estimate the risk of return ED visit.

Results

The final sample included 106 MCO and 196 non-MCO patients. The MCO patients were more likely to be homeless (OR 14.8; 95% confidence interval [CI],1.87, 117), less likely to have adequate family or social support (OR 0.51; 95% CI, 0.31, 0.84), and less likely to have a hospital bed requested for them in the index visit by ED providers (OR 0.50; 95% CI, 0.29, 0.88). For those who returned to the ED, the median time for all-cause return to the ED was 28 days (interquartile range [IQR]: 6–93 days) for the MCO patients and 88 days (IQR: 20–164 days) for non-MCO patients. The risk of all-cause return to the ED was greater among MCO patients (67%) compared to non-MCO patients (49%) (adjusted HR: 1.66; 95% CI, 1.22, 2.27).

Conclusion

The MCO patients had less family and social support; however, they were less likely to require hospitalization for each visit, likely due to MCO involvement. Patients with MCO contact presented to the ED more frequently than non-MCO patients, which implies a strong linkage between the ED and MCO in our community. An effective referral to community service from the ED and MCO and collaboration could be the next step to improve healthcare utilization.

Telemedicine is associated with rapid transfer and fewer involuntary holds among patients presenting with suicidal ideation in rural hospitals: a propensity matched cohort study

OBJECTIVE

The purpose of this study was to evaluate the impact of telemedicine in clinical management and patient outcomes of patients presenting to rural critical access hospital emergency departments (EDs) with suicidal ideation or attempt.

METHODS

Retrospective propensity-matched cohort study of patients treated for suicidal attempt and ideation in 13 rural critical access hospital EDs participating in a telemedicine network. Patients for whom telemedicine was used were matched 1:1 to those who did not have telemedicine as an exposure (n=139 TM+, n=139 TM-) using optimal matching of propensity scores based on administrative data. Our primary outcome was ED length-of-stay (LOS), and secondary outcomes included admission proportion, use of chemical or physical restraint, 30 day ED return, involuntary detention orders, treatment/follow-up plan and 6-month mortality. Analyses for multivariable models were conducted using conditional linear and logistic regression clustered on matched pairs with purposeful selection of covariates.

RESULTS

Mean ED LOS was not associated with telemedicine consultation among all patients, but was associated with a 29.3% decrease in transferred patients (95% CI 11.1 to 47.5). The adjusted odds of hospital admission (either local or through transfer) was 2.35 (95% CI 1.10 to 5.00) times greater among TM+ patients compared with TM- patients. Involuntary hold placement was lower in those exposed to telemedicine (adjusted odds ratio (aOR): 0.48; 95% CI 0.23 to 0.97). We did not observe significant differences in other outcomes.

CONCLUSION

The role of telemedicine in influencing access, quality and efficiency of care in underserved rural hospitals is critically important as these networks become more prevalent in rural healthcare environments.

Safety of reassessment-and-release practice for mental health patients boarded in the emergency department

OBJECTIVES

Among emergency department (ED) mental health and substance abuse (MHSA) patients, we sought to compare mortality and healthcare utilization by ED discharge disposition and inpatient bed request status.

METHODS

A retrospective cohort study of 492 patients was conducted at a single University ED. We reviewed three groups of MHSA patients including ED patients that were admitted, ED patients with a bed request that were discharged from the ED, and ED patients with no bed request that were discharged from the ED. We identified main outcomes as ED return visit, re-hospitalization and mortality within 12months based on chart review and reference from the National Death Index.

RESULTS

The average age of patients presenting was 30.5 (SD16.4) years and 251 (51.0%) were female patients. Of these patients, 216 (43.9%) presented with mood disorder and 93 (18.9%) with self-harm. The most common reason for discharge from the ED after an admission request was placed was from stabilization of the patient (n=138). An ED revisit within 12months was significantly higher among patients discharged who had a bed request in place prior to departure (54.0%, p<0.001), than those discharged from the ED (40.9%) or admitted to inpatient care (30.5%). The rate of suicide attempt and death did not show statistical significance (p=0.55 and p=0.88).

CONCLUSION

MHSA patients who were discharged from ED after bed requests were placed were at greater risk for return visits to the ED. This implicates that these patients require outpatient planning to prevent further avoidable healthcare utilization.

Prevalence of xerostomia in an adolescent inpatient psychiatric clinic: a preliminary study

OBJECTIVE

Adolescents with psychiatric conditions may be at risk for xerostomia. In this preliminary study, we estimated xerostomia prevalence in adolescents ages 9 to 17 years from an inpatient psychiatric clinic (N = 25) and examined whether: (1) gender and age were associated with xerostomia and (2) xerostomia was associated with self-reported cavities.

METHODS

We used a modified 11-item Xerostomia Index to identify xerostomia (no/yes) and asked if adolescents ever had or currently have cavities (no/yes).

RESULTS

The mean age was 14 years (SD = 2.3) and 72% were male. Sixty percent reported xerostomia (SD = 50). There were no significant associations between xerostomia and gender (p = 0.99) or age (p = 0.66), or between xerostomia and past (p = 0.26) or current cavities (p = 0.11). Larger proportions of adolescents with xerostomia reported previous and current cavities.

CONCLUSIONS

Sixty percent of adolescents from an inpatient psychiatric clinic reported having xerostomia, which may lead to increased caries risk over time. Additional research should examine the prevalence and consequences of xerostomia in high-risk adolescents.

Lip biting in a pediatric dental patient after dental local anesthesia: a case report

Self-inflicted lip trauma is a potential complication of dental treatment involving local anesthesia of the inferior alveolar nerve, particularly among children. Children presenting with this self-limiting condition are often times misdiagnosed as having a localized bacterial infection. In some extreme cases, children have been unnecessarily hospitalized and treated with systemic antibiotics or surgical interventions. This case report describes a child who bit his lip after a dental appointment and was subsequently hospitalized for monitoring. Pediatric nurses are in a unique position to help parents and primary care physicians properly diagnose and manage this benign condition palliatively.