Factors associated with longer length of stay for mental health emergency department patients

Models to predict length of stay in the emergency department: a systematic literature review and appraisal

INTRODUCTION

Prolonged Length of Stay (LOS) in ED (Emergency Department) has been associated with poor clinical outcomes. Prediction of ED LOS may help optimize resource utilization, clinical management, and benchmarking. This study aims to systematically review models for predicting ED LOS and to assess the reporting and methodological quality about these models.

METHODS

The online database PubMed, Scopus, and Web of Science (10 Sep 2023) was searched for English language articles that reported prediction models of LOS in ED. Identified titles and abstracts were independently screened by two reviewers. All original papers describing either development (with or without internal validation) or external validation of a prediction model for LOS in ED were included.

RESULTS

Of 12,193 uniquely identified articles, 34 studies were included (29 describe the development of new models and five describe the validation of existing models). Different statistical and machine learning methods were applied to the papers. On the 39-point reporting score and 11-point methodological quality score, the highest reporting scores for development and validation studies were 39 and 8, respectively.

CONCLUSION

Various studies on prediction models for ED LOS were published but they are fairly heterogeneous and suffer from methodological and reporting issues. Model development studies were associated with a poor to a fair level of methodological quality in terms of the predictor selection approach, the sample size, reproducibility of the results, missing imputation technique, and avoiding dichotomizing continuous variables. Moreover, it is recommended that future investigators use the confirmed checklist to improve the quality of reporting.

Evaluation of different machine learning algorithms for predicting the length of stay in the emergency departments: a single-centre study

Background

Recently, crowding in emergency departments (EDs) has become a recognised critical factor impacting global public healthcare, resulting from both the rising supply/demand mismatch in medical services and the paucity of hospital beds available in inpatients units and EDs. The length of stay in the ED (ED-LOS) has been found to be a significant indicator of ED bottlenecks. The time a patient spends in the ED is quantified by measuring the ED-LOS, which can be influenced by inefficient care processes and results in increased mortality and health expenditure. Therefore, it is critical to understand the major factors influencing the ED-LOS through forecasting tools enabling early improvements.

Methods

The purpose of this work is to use a limited set of features impacting ED-LOS, both related to patient characteristics and to ED workflow, to predict it. Different factors were chosen (age, gender, triage level, time of admission, arrival mode) and analysed. Then, machine learning (ML) algorithms were employed to foresee ED-LOS. ML procedures were implemented taking into consideration a dataset of patients obtained from the ED database of the "San Giovanni di Dio e Ruggi d'Aragona" University Hospital (Salerno, Italy) from the period 2014-2019.

Results

For the years considered, 496,172 admissions were evaluated and 143,641 of them (28.9%) revealed a prolonged ED-LOS. Considering the complete data (48.1% female vs. 51.9% male), 51.7% patients with prolonged ED-LOS were male and 47.3% were female. Regarding the age groups, the patients that were most affected by prolonged ED-LOS were over 64 years. The evaluation metrics of Random Forest algorithm proved to be the best; indeed, it achieved the highest accuracy (74.8%), precision (72.8%), and recall (74.8%) in predicting ED-LOS.

Conclusions

Different variables, referring to patients' personal and clinical attributes and to the ED process, have a direct impact on the value of ED-LOS. The suggested prediction model has encouraging results; thus, it may be applied to anticipate and manage ED-LOS, preventing crowding and optimising effectiveness and efficiency of the ED.

Assessing the Effectiveness of an E-Coaching Intervention in Improving Family Support for Individuals with Mental Disorders: A Quasi-Experimental Approach

Background

The increasing number of mental disorders (MDs) requires government, social, and family attention. The purpose of this study was to determine the effectiveness of an e-coaching empowerment application in improving families' abilities to care for individuals with mental disorders (MDs).

Methods

A quasi-experimental design was used for this study. Totaling 122 individuals selected through purposive sampling from families with (MDs) in six selected community health centers that divided into two groups, intervention and regular mental healthcare. The data collected were analyzed using multiple linear regression. The independent variable was the provision of intervention using the e-coaching application with GROW (Goal, Reality, Option, Will) model, while the dependent variables were the family's ability to recognize problems, make decisions, take care of people with MDs, modify the environment, and utilize health facilities. Further, multivariate tests were used to evaluate the effect of e-coaching empowerment on families' ability to care for MDs.

Results

The results demonstrated a significant impact of e-coaching on the family's ability to care for individuals with MDs (p<0.01). Education also partially affected the family's ability to care for individuals with MDs (p<0.01). Additionally, age, gender, occupation, relationship with the individual MDs, and duration of care simultaneously did not significantly affect the family's ability to care for individuals with MDs (p<0.01). However, educationally background was significantly affect family ability in taking care for MD patients. Overall, e-coaching significantly improved the family's ability to recognize problems, make decisions, care for patients with MDs, modify the environment, and utilize health facilities.

Recommendations

The e-coaching empowerment application for families can assist healthcare workers in enhancing the family's ability to provide assistance for individuals with MDs at home. This application can improve mental health services in the broader location accessible via the internet and can be developed for other health fields. The application can be expanded into a simple game so that families can view their scores for their proficiency in each session to make it more entertaining.

Psychiatric Boarding Patterns Among Publicly Insured Youths Evaluated by Mobile Crisis Teams Before and During the COVID-19 Pandemic

Importance

Psychiatric boarding occurs when patients needing intensive psychiatric services who are already under clinical supervision experience delays in their admission to psychiatric facilities. Initial reports have suggested that the US had a psychiatric boarding crisis during the COVID-19 pandemic; however, little is known about the consequences of this crisis for publicly insured youths.

Objective

To estimate pandemic-associated changes in psychiatric boarding rates and discharge modalities for people aged 4 to 20 years who accessed psychiatric emergency services (PES) through a mobile crisis team (MCT) evaluation and were covered by Medicaid or health safety net programs.

Design, Setting, and Participants

This retrospective cross-sectional study used data from the MCT encounters of a multichannel PES program in Massachusetts. A total of 7625 MCT-initiated PES encounters with publicly insured youths who lived in Massachusetts between January 1, 2018, and August 31, 2021, were assessed.

Main Outcomes and Measures

Encounter-level outcomes (psychiatric boarding status, repeat visits, and discharge disposition) during a prepandemic period (January 1, 2018, to March 9, 2020) were compared with outcomes during a pandemic period (March 10, 2020, to August 31, 2021). Descriptive statistics and multivariate regression analysis were used.

Results

Among 7625 MCT-initiated PES encounters, the mean (SD) age of publicly insured youths was 13.6 (3.7) years; most youths identified as male (3656 [47.9%]), were of Black race (2725 [35.7%]) or Hispanic ethnicity (2708 [35.5%]), and spoke English (6941 [91.0%]). During the pandemic period, the mean monthly boarding encounter rate was 25.3 percentage points higher than the prepandemic period. After adjustment for covariates, the odds of an encounter resulting in boarding doubled during the pandemic (adjusted odds ratio [AOR], 2.03; 95% CI, 1.82-2.26; P < .001), and boarding youths were 64% less likely to be discharged to inpatient psychiatric care (AOR, 0.36; 95% CI, 0.31-0.43; P < .001). Publicly insured youths who boarded during the pandemic had significantly higher rates of 30-day readmissions (incidence rate ratio, 2.17; 95% CI, 1.88-2.50; P < .001). Boarding encounters during the pandemic were significantly less likely to end in discharge to inpatient psychiatric units (AOR, 0.36; 95% CI, 0.31-0.43; P < .001) or community-based acute treatment facilities (AOR, 0.70; 95% CI, 0.55-0.90; P = .005).

Conclusions and Relevance

In this cross-sectional study, publicly insured youths were more likely to experience psychiatric boarding during the COVID-19 pandemic and, if boarding, were less likely to transfer to a 24-hour level of care. These findings suggest that psychiatric service programs for youths were not prepared to support the levels of acuity and demand that emerged from the pandemic.

Prolonged length of stay and its associated factors at adult emergency department in amhara region comprehensive specialized hospitals, northwest Ethiopia

Background

Prolonged length of stay at the emergency department interferes with the main goal of emergency care and results in adverse patient outcomes like nosocomial infection, dissatisfaction, morbidity, and mortality. Despite this, little is known about the length of stay and the factors that influence it in Ethiopia’s emergency department.

Methods

An institution-based cross-sectional study was conducted on 495 patients admitted at Amhara region comprehensive specialized hospitals emergency department from May 14 to June 15/2022. A systematic random sampling was employed to select study participants. A pretested structured interview-based questionnaire was used to collect data by using Kobo toolbox software. SPSS version 25 was used for data analysis. Bi-variable logistic regression analysis was carried out to select variables with P-value < 0.25. The significance of association was interpreted using an Adjusted Odds Ratio with a 95% confidence interval. Variables with P-value < 0.05 in the multivariable logistic regression analysis were inferred to be significantly associated with length of stay.

Result

Out of 512 enrolled participants, 495 were participated with a response rate of 96.7%. The prevalence of prolonged length of stay in the adult emergency department was 46.5% (95%CI: 42.1, 51.1). Lack of insurance (AOR: 2.11; 95% CI: 1.22, 3.65), non-communicative presentation (AOR: 1.98; 95% CI: 1.07, 3.68), delayed consultation (AOR: 9.5; 95% CI: 5.00, 18.03), overcrowding (AOR: 4.98; 95% CI: 2.13, 11.68), and shift change experience (AOR: 3.67; 95% CI: 1.30, 10.37) were significantly associated with prolonged length of stay.

Conclusion

The result of this study is found to be high based on Ethiopian target emergency department patient length of stay. Lack of insurance, presentation without communication, delayed consultation, overcrowding, and shift change experience were significant factors for prolonged emergency department length of stay. Therefore, interventions like expansion of organizational setup are needed to decrease the length of stay to an acceptable level.

Descriptive analysis of emergency medical services 72-hour repeat patient encounters in a single, Urban Agency

INTRODUCTION

Emergency department unscheduled return visits within 72-h of discharge, called a "bounceback", have been used as a metric of quality of care. We hypothesize that specific demographics and dispositions may be associated with Emergency Medical Services (EMS) 72-h bouncebacks.

METHODS

For all patient encounters within one calendar year from a large, urban EMS agency, we recorded demographics (name, date of birth, race, gender), primary impression, disposition, and vital signs for EMS encounters. A bounceback was defined as a patient, identified by matching first name, last name and date of birth, with more than one EMS encounter within 72 h. We performed descriptive statistics for patients that did and did not have a subsequent bounceback using median (interquartile range) and Wilcoxon Rank Sum test for age and frequency (percent) and chi square test for gender, race and run disposition. For patients with a bounceback, we describe the frequency and percentage of EMS professional primary impressions on initial encounter.

RESULTS

98,043 encounters from January 1, 2021 to December 31, 2021, were analyzed. The median age was 50 years (IQR 32-65); 49.4% (46,147) were female and 50.7% (47,376) were White patients. 3951 encounters had a subsequent bounceback, and compared to those without bouncebacks, they were more often male patients (58.7% versus 50.2%, p < 0.001) and more commonly not transported (22.3% versus 15.5%, p < 0.001). A multivariable logistic regression model estimated the odds of bounceback were lower for females [OR 0.64 (95% CI 0.61-0.68)], Asian and Latino patients compared to White patients [OR 0.33 (95% CI 0.21-0.53) and 0.42 (95% CI 0.34-0.51)], respectively, no significant difference for Black patients compared to White patients, and higher for non-transported patients [OR 1.25 (95% CI 1.16-1.34)]. The The most common EMS primary impression for initial and subsequent encounters was mental health [576 (14.7%) and 944 (17.0%), respectively]. For subsequent encounters, the primary impression was cardiac arrest or death in 67 (1.2%) of cases.

CONCLUSION

Bouncebacks were common in this single year study of a high-volume urban EMS agency. Male and non-transported patients most often experienced bouncebacks. The most common primary impression for encounters with bounceback was mental health related. Out-of-hospital cardiac arrest occurred in 1 % of bounceback cases. Further study is necessary to understand the effect on patient-centered outcomes.

Factors related to the length of stay for major depressive disorder patients in China: A real-world retrospective study

Background

As numerous patients with depression have to be hospitalized because of various reasons, the demand far exceeds the limited bed count in the psychiatry department. Controlling the length of stay (LOS) of the patient is gradually being considered an effective method to alleviate this problem. Given the lack of statistical evidence of the LOS of patients with major depressive disorder (MDD) in China and the strain on the limited psychiatric resources, the purpose of our study was to investigate the LOS of patients with MDD among in-patient samples and to analyze related factors of the LOS in China by building a regression model.

Method

The data were exported from the electronic medical record system. A total of three categories of independent variables were enrolled in our study, namely, demographic, clinical, and biochemical. Univariate analysis and binominal regression analysis were applied comprehensively to find the factors related to the LOS among MDD samples. The discrimination accuracy of the model was evaluated by the receiver operating characteristic (ROC) analysis. ROC analysis indicated that the discrimination accuracy of our model was acceptable (AUC = 0.790, 95% CI = 0.714–0.865, P < 0.001).

Result

A total of 254 patients were finally brought into analysis after filtering. Regression analysis indicated that abnormal LDL was the only risk factor of long LOS (OR = 3.352, 95% CI = 1.087–10.337, P = 0.035) among all the kinds of variables. Notably, in the statistically irrelevant factors of the LOS, the category of anti-depressant drugs [serotonin–norepinephrine reuptake inhibitor (SNRI) or selective serotonin reuptake inhibitor (SSRI)] prescribed to patients with MDD was not associated statistically with the LOS, which was against our initial hypothesis that the LOS of patients with MDD treated with SNRI would vary from that of the patients treated with SSRI.

Conclusion

Up to our knowledge, our research is the first study to show the potential factors related to the LOS from various domains, especially biochemical indexes, and the effect of drugs, among clinical patients with MDD in China. Our results could provide a theoretical reference for efficient psychiatry hospitalization management and prioritization of allocating medical resources. Future studies are required for updating independent variables which are potentially related to the LOS and verifying existing results in a larger sample.

Patient and Provider Perspectives on Emergency Department Care Experiences among People with Mental Health Concerns

Emergency departments (EDs) are an important source of care for people with mental health (MH) concerns. It can be challenging to treat MH in EDs, and there is little research capturing both patient and provider perspectives of these experiences. We sought to summarize the evidence on ED care experiences for people with MH concerns in North America, from both patient and provider perspectives. Medline and EMBASE were searched using PRISMA guidelines to identify primary studies. Two reviewers conducted a qualitative assessment of included papers and inductive thematic analysis to identify common emerging themes from patient and provider perspectives. Seventeen papers were included. Thematic analysis revealed barriers and facilitators to optimal ED care, which were organized into three themes each with sub-themes: (1) interpersonal factors, including communication, patient–staff interactions, and attitudes and behaviours; (2) environmental factors, including accommodations, wait times, and restraint use; and (3) system-level factors, including discharge planning, resources and policies, and knowledge and expertise. People with MH concerns and ED healthcare providers (HCPs) share converging perspectives on improving ED connections with community resources and diverging perspectives on the interplay between system-level and interpersonal factors. Examining both perspectives simultaneously can inform improvements in ED care for people with MH concerns.

The impact of Timothy's Law on hospitalization among patients with mental health conditions in New York State

Background

Timothy's law to reduce mental health care disparities was enacted in January 2007 in New York state (NY). According to Timothy's law, "if a patient is suffering from a Biologically Based Mental Illness, or is a Child with Serious Emotional Disturbances, the Inpatient mental health benefit will be the same as for any other illness". An assessment of its impact on inpatient mental health care is lacking. We provide a rigorous study of this policy intervention’s effect over the first year of its implementation.

Methods

We used a quasi-experimental design to combine the difference-in-difference method and propensity score weighting. Data are from inpatient records in NY and California (CA) (as a control) between January 2006 to December 2006 (the pre-enactment year in NY) and January to December 2007 (the enactment year) for non-Medicare/Medicaid patients hospitalized in both years with specific illnesses covered by Timothy's Law. Change in length of stay from 2006 to 2007 was measured for each patient, and the differences observed in NY and California were compared to each other (Difference-in-Difference), with differences in the characteristics of patients in NY and California addressed through Propensity Score Weighting (PSW).

Results

Before Timothy's Law was enacted (2006), length of stay (LOS) in NY was 16.3 days on average, and length of stay per hospitalization (LOSPH) was 11.72 days on average for the 1237 patients under study in 2006. In 2007, LOS increased by 4.91 days in NY (95% CI (2.89, 7.01)) compared with similar patients in California, and LOSPH by 3.25 days (95% CI (1.96, 4.57)). Among patients with serious mental illness diagnoses, LOS in NY increased by 7.07 days (95% CI (4.15, 10.17)), and LOSPH by 4.04 days (95% CI (1.93, 6.03)) compared to California.

Conclusions

Our study strongly suggests that, within the time frame of just a single year, Timothy's Law significantly increased inpatient mental healthcare utilization in NY. Our study raises the possibility that similar laws in other locations could have similar effects.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-022-00535-w.

Psychiatric patients at the emergency department: factors associated with length of stay and likelihood of hospitalization

Emergency department (ED) care for psychiatric patients is currently understudied despite being highly utilized. Therefore, we aimed to analyze psychiatric patients' length of stay (LOS) and LOS-related factors at the ED and to investigate and quantify the likelihood of being hospitalized after an emergency psychiatric evaluation. Charts of 408 individuals who sought help at the ED were retrospectively assessed to identify patients' sociodemographic and clinical data upon ED admission and discharge. All interventions performed at the ED (e.g., medications, hospitalization, clinical advice at discharge) were collected as well. The LOS for psychiatric patients was relatively short (6.5 h), and substance/alcohol intoxication was the main factor impacting LOS. Upon ED arrival, hospitalized patients were mostly men, most often had a yellow/severe triage code, and most often had a positive history of psychiatric illness, psychotic symptoms, euphoric mood, or suicidal ideation. Manic symptoms and suicidal ideation were the conditions most frequently leading to hospitalization. Given the paucity of real-world data on psychiatric patients' LOS and outcomes in the ED context, our findings show that psychiatric patients are evaluated in a reasonable amount of time. Their hospitalization is mostly influenced by clinical conditions rather than predisposing (e.g., age) or system-related factors (e.g., mode of arrival).

Public Health Surveillance of Behavioral Health Emergencies through Emergency Medical Services Data

Objective: To identify the demographic, clinical and EMS characteristics of events documented as behavioral health emergencies (BHE) by EMS. Methods: This was a cross-sectional study using the 2018 National Emergency Medical Services Information System (NEMSIS) Version 3 dataset. All events that had patient care provided with a documented impression (field diagnosis) of ICD-10 codes F01-F99 (i.e., mental, behavioral, and neurodevelopmental disorders) were labeled a BHE and included. Descriptive statistics were calculated. Results: A total of 1,594,821 (7.3%) EMS calls had a BHE impression. The most common was mental and behavioral disorders due to psychoactive substance use (42.3%). More males than females had BHEs (54.6% vs. 45.4%), and most patients were ages 18-34 (31.5%). Most BHE occurred in urban settings (89.6%). Almost half (47.9%) were dispatched with a complaint unrelated to behavioral health. Conclusion: BHEs were noted in 7.3% of NEMSIS events, and the majority were associated with substance use disorders. EMS professionals need comprehensive training on best practices for BHE. Stakeholders should have information on prevalence of BHEs to ensure proper educational standards, training practices, and resource allocation.

Analysis of Factors Associated With Length of Stay of Opioid-Related Emergency Department Visits

Introduction and Objective: Emergency department (ED) length of stay (LOS) is an important indicator of the quality of care in ED and is associated with patients’ outcomes and healthcare costs. However, there is limited data on how the patient characteristics affect the ED LOS of opioid-related visits. This study aims to identify and quantify the effect of patient-related characteristics on LOS of opioid-related ED visits.

Methods: This is a retrospective analysis of electronic health records (EHR) of patients with diagnoses of opioid abuse. The study included patients with a diagnosis of opioid abuse who visited the ED at Christiana Care Hospital from January 1, 2017, to December 31, 2018 (N=5,661). The opioid-related visits were identified using ICD-10 diagnosis codes. We used accelerated failure time (AFT) models, a time-to-event analysis approach to evaluate the relationships of different patient characteristics with ED LOS.

Results: The mean age of the study population was 39 years. The study population had 40% female, 20% Black/African American, and 5% Hispanic or Latino. The prevalence of co-use of cocaine and co-use of alcohol was 11%, and 9%, respectively. Also, 58% had mental health comorbidity, and 1% were homeless. The distribution of ED LOS was right-skewed with a median of 4.3 (IQR: 2.6, 6.8). Co-use of alcohol (time ratio, TR: 1.31, CI: 1.23-1.40), co-use of cocaine (TR: 1.18, CI: 1.11-1.25), the presence of mental health comorbidity (TR: 1.05, CI 1.01-1.09), and homelessness (TR: 1.57, CI: 1.32-1.86) were associated with increased ED LOS.

Conclusions: Co-use of alcohol, co-use of cocaine, homelessness, and mental health comorbidity are associated with the longer LOS of opioid-related ED visits.

Association of emergency department boarding times on hospital length of stay for patients with psychiatric illness

BACKGROUND

Extended periods awaiting an inpatient bed in the emergency department (ED) may exacerbate the state of patients with acute psychiatric illness, increasing the time it takes to stabilise their acute problem in hospital. Therefore, we assessed the association between boarding time and hospital length of stay for psychiatric patients.

METHODS

ED clinical records were linked to inpatient administrative records for all patients with a primary psychiatric diagnosis admitted to a Calgary, Alberta hospital between April 2014 and March 2018. The primary exposure was boarding time (admission decision to inpatient bed transfer), and primary outcome was inpatient length of stay. Confounders for this relationship, including indicators of illness severity, were selected a priori then the association was assessed using hierarchical Bayesian Poisson regression, which accounts for repeat observations of the same patient and differences between hospital sites. Changes in length of stay were measured using a rate ratio (ie, expected change in length of stay for each 1 hour increase in boarding time).

RESULTS

A total of 19 212 admissions (14 261 unique patients) were included in the analysis. The average boarding time was 14 hours (range: 0-186 hours). Patients who were boarded for greater than 14 hours more frequently required a high-observation bed (14% vs 3.5%), received an antipsychotic (44% vs 14%) or received sedation (55% vs 33%) while in the ED. The probability that boarding time increased hospital length of stay (rate ratio: >1) was 92%, with a median increase for a patient boarded for 24 hours of 0.01 days.

CONCLUSION

Boarding in the ED was associated with a high probability of increasing the hospital length of stay for psychiatric patients; however, the absolute increase is minimal. Although slight, this signal for longer length of stay may be a sign of increased morbidity for psychiatric patients held in the ED.

A Quality Improvement Project on Agitation Management in the Emergency Department

INTRODUCTION

Agitation is common in the emergency department. When agitation is not detected early, patients can become aggressive and violent, potentially leading to restraint use and subsequent injury. The goals of the project were early detection and management of patient agitation, reduction of restraint use in the emergency department, and determination of the usability of the Behavioral Activity Rating Scale.

METHODS

This quality improvement project was assessed using a pre- and posttest single unit design, comparing 4 months of postimplementation data to historic controls at the same time of year in the previous year. The intervention was implementing the Behavioral Activity Rating Scale in the ED electronic medical record. Data were collected through retrospective chart review and nurse survey. From September through December of both 2017 and 2018, data were collected on restraint use. The 4-month 2018 data collection period included measures of Behavioral Activity Rating Scale documentation and the System Usability Scale survey for nurses to measure ease of usability of the Behavioral Activity Rating Scale.

RESULTS

The Behavioral Activity Rating Scale was documented frequently (n = 4 867 documentations) by emergency nurses to assess patients with behavioral health and medical complaints (n = 780). Nurses identified 18 episodes of violent behavior in behavioral health patients on the Behavioral Activity Rating Scale (2.31%) and applied restraints 18 times. The most common chief complaints for patients who were identified as violent was suicidal ideation (n = 6; 33.33%). In 2017, there were 20 episodes of restraint use during the same time period, a nonsignificant difference (χ² = 0.72; P = 0.40). However, only 2 patients were kept in restraints longer than 1 day in 2018 compared with 8 in 2017. Emergency nurses found the Behavioral Activity Rating Scale to be usable in the structured usability assessment (μ = 83.46; SD = 11.73).

DISCUSSION

The Behavioral Activity Rating Scale is a usable tool for emergency nurses to assess for patient agitation. With the incorporation of agitation management interventions, the ED team can potentially manage agitation before violence occurs. Further studies are needed on the use of agitation or aggression assessment tools for managing patient behavioral activity such as aggression in the emergency department.

Characteristics, clinical care, and disposition barriers for mental health patients boarding in the emergency department

BACKGROUND AND OBJECTIVES

Lack of mental health resources, such as inpatient psychiatric beds, has increased frequency and duration of boarding for mental health patients presenting to U.S. emergency departments (EDs). The purpose of this study is to describe characteristics of mental health patients with an ED length of stay of one week or longer and to identify barriers to their disposition.

METHODS

This study was conducted in an academic ED in which emergency psychiatric evaluations and care are provided by a Psychiatric Emergency Services (PES) team contained within the Department of Emergency Medicine. Prolonged boarding was defined as an ED length of stay of 7 days or more. Pediatric, adult, and geriatric mental health patients with prolonged ED boarding from January 1 to August 31, 2019 were included. This study includes prospective data collection of the boarding group and retrospective identification and data collection of a comparison group of non-barding patients over the same 8-month period to compare patient characteristics and outcomes for each group.

RESULTS

Between January 1 and August 31, 2019, the PES team completed 2,745 new assessments of mental health patients, of whom 39 met criteria for prolonged ED boarding. The following characteristics were associated with boarding: child (8%), male (64%), having Medicaid (49%) or both Medicaid and Medicare (18%), and having either a neurodevelopmental (15%) or neurocognitive disorder (15%) with a median stay of 18 days. Barriers to discharge included being declined from all state inpatient psychiatric hospitals (69%), declined from community living environments (21%), or declined from both (10%). The most common ED non-boarding patients were: Caucasian (64%), have a diagnosis of unspecified mental disorder (including suicidal ideation) or other specified mental disorder (59%) and have private insurance (42%) with a median stay of 1 day.

CONCLUSION

In this study of mental health patients with prolonged ED stays, the primary barrier to disposition was the lack of patient acceptance to inpatient psychiatric hospitals, community settings, or other housing. Early identification of potential prolonged boarding, quality treatment and care for those patients, and effective case management, may resolve the ongoing challenges of boarding within the ED.

The Impact of the North Carolina Statewide Telepsychiatry Program (NC-STeP) on Patients' Dispositions From Emergency Departments

OBJECTIVE

The number of patients seeking treatment in emergency departments (EDs) for mental health reasons is rising, and these patients are often kept in the ED until they can be treated or discharged, leading to overcrowding. Telepsychiatry may alleviate overcrowding by increasing the rate of discharges home.

METHODS

ED discharge records for 86,931 patients with psychiatric symptoms were examined to compare patient disposition and length of stay (LOS) between times when the North Carolina Statewide Telepsychiatry Program (NC-STeP) program was available or unavailable.

RESULTS

For patients with a LOS of >2 days (N=3,144) and when NC-STeP was available, 62% (N=1,941) were discharged home, and 29% (N=922) were transferred to a psychiatric facility. When NC-STeP was unavailable (N=2,662), 43% (N=1,139) of these patients were discharged home, and 46% (N=1,230) were transferred to a psychiatric facility. For patients with a LOS of 1-2 days and when NC-STeP was available (N=41,713), 77.0% (N=32,131) were discharged home, and 15.4% (N=6,441) were transferred to a psychiatric facility, compared with 74.2% (N=29,237) discharged home and 13.9% (N=5,495) transferred to a psychiatric facility when NC-STeP was unavailable (N=39,412). The increases in discharges home and decreases in referrals to psychiatric facilities when NC-STeP was available were statistically significant for patients in both groups (p<0.001).

CONCLUSIONS

Results suggest that telepsychiatry programs such as NC-STeP increase the number of discharges home and decrease transfers to psychiatric facilities, likely promoting patient satisfaction and improving ED efficiency.

Achieving Access Parity for Inpatient Psychiatric Care Requires Repealing the Medicaid Institutions for Mental Disease Exclusion Rule

Approximately 3.4% of Americans have a mental health condition and suicide is the 10th leading cause of death. While the rate of mental health conditions has slightly increased for adult populations, America's youth has experienced a significant rise in depression. From 2008 to 2017, occurrence of depression in the adolescent population increased from 8.3% to 13.3%. As adolescents mature into adults; it is likely the rate of mental health conditions for the adult population will rise as well as it is the common thread that binds the diseases of despair: drug abuse, alcoholism, and suicide. Arising out of the deinstitutionalization movement of the 1960s, the Medicaid Institutions for Mental Disease (IMD) Exclusion Rule (§1905(a)(B) of the Social Security Act) prohibits reimbursement for Medicaid recipients ages 21 to 64 years receiving inpatient care at a psychiatric hospital with 16 or more beds. Consequently, the rule limits payment for psychiatric treatment to general hospitals and smaller, nonspecialized centers, which blocks patients from receiving inpatient care and transfers the financial burden of care onto psychiatric hospitals. The IMD Rule is approaching its 55th anniversary. It requires reevaluation. Although a state waiver process is available, use of this option has the potential to increase the incidence of racial and ethnic disparities across states. Full repeal of the IMD Exclusion Rule could help provide immediate access to inpatient care that is consistent nationwide and be a vital step toward creating financial, treatment and ethical parity for mental health services.

Young children with psychiatric complaints in the pediatric emergency department

INTRODUCTION

Children are increasingly diagnosed with mental illnesses and self-harm behaviors. They present frequently to the emergency department (ED) for evaluation. The aim of this study is to describe the youngest children in the ED with psychiatric issues.

METHODS

This is a retrospective chart review of all consecutive children less than 10 years of age with a psychiatric complaint who received a psychiatric consultation in the pediatric emergency department in the last four years.

RESULTS

The number of children with psychiatric issues increased over the study period. The ED length of stay also increased. Violent behavior and aggression were the most common chief complaints, and some children required chemical or physical restraint in the ED. Many children had pre-existing psychiatric issues and a history of adverse childhood experiences. Half of patients were deemed safe for discharge home by psychiatric consultation.

CONCLUSION

The number of young children with psychiatric complaints presenting to the ED has increased. However, a large number are found to be stable for discharge home. Increase in urgent outpatient psychiatric resources could help decrease ED utilization.

Added Cost and Time Spent by Patients With History of Abuse in Florida Emergency Departments

Interpersonal violence is known to lead to both short- and long-term health effects. Victims of sexual abuse tend to have higher healthcare costs and higher rates of physical and mental health issues than nonvictims. In this study, we investigate whether the comorbidity of mental illness and a personal history of adult physical and sexual abuse (HAPSA) results in higher healthcare costs and length of emergency department (ED) stay among Florida residents. A Negative Binomial and Log-Linear Regression Analysis suggest increased ED visit duration for those with a history of abuse, Hispanics, the uninsured, and those with multiple comorbidities. In addition, increased costs were found to be associated with White race, the uninsured, those with multiple comorbidities, and the facility type (for-profit hospitals).

Patients with mental health conditions in the emergency department: Why so long a wait?

OBJECTIVES

Patients presenting with a mental health disorder (MHD) wait longer in the ED compared to those presenting for other reasons, potentially placing vulnerable patients at further risk for deterioration. The present study identified factors associated with a long ED stay for patients with a MHD.

METHODS

Linked ambulance, emergency, pathology, imaging and admission data for an 18-month period were analysed for ED presentations diagnosed with an MHD ICD-10 at a large teaching hospital. Admissions and discharges were considered separately; a long ED stay was defined as the 90th percentile length of stay. Multivariable generalised linear models were built, identifying predictors of a long ED stay for presentations diagnosed with a MHD.

RESULTS

The sample comprised 1163 admissions and 2242 discharges. For admissions, significant predictors for long ED stay were investigations (pathology or imaging tests), a triage score of 1 or 2, arrival out-of-hours (18.00-05.59 hours) and arrival by ambulance. For discharges, significant predictors of a long ED stay were investigations (pathology or imaging tests), arrival out-of-hours, arrival by ambulance and increasing age.

CONCLUSIONS

Some factors predictive of a long ED stay for patients presenting to the ED and diagnosed with a MHD varied based on their disposition. For admissions, the most urgent presentations were likely to stay longest. Strategies to reduce ED stay for both admissions and discharges should consider addressing modifiable aspects, including the need for certain investigations, and non-modifiable aspects, including the need for further access to after-hours mental health services in hospital and in the community.

Typology of patients who use emergency departments for mental and substance use disorders

BACKGROUND

Identifying profiles of people with mental and substance use disorders who use emergency departments may help guide the development of interventions more appropriate to their particular characteristics and needs.

AIMS

To develop a typology for the frequency of visits to the emergency department for mental health reasons based on the Andersen model.

METHOD

Questionnaires were completed by patients who attended an emergency department (n = 320), recruited in Quebec (Canada), and administrative data were obtained related to sociodemographic/socioeconomic characteristics, mental health diagnoses including alcohol and drug use, and emergency department and mental health service utilization. A cluster analysis was performed, identifying needs, predisposing and enabling factors that differentiated subclasses of participants according to frequency of emergency department visits for mental health reasons.

RESULTS

Four classes were identified. Class 1 comprised individuals with moderate emergency department use and low use of other health services; mostly young, economically disadvantaged males with substance use disorders. Class 2 comprised individuals with high emergency department and specialized health service use, with multiple mental and substance use disorders. Class 3 comprised middle-aged, economically advantaged females with common mental disorders, who made moderate use of emergency departments but consulted general practitioners. Class 4 comprised older individuals with multiple chronic physical illnesses co-occurring with mental disorders, who made moderate use of the emergency department, but mainly consulted general practitioners.

CONCLUSIONS

The study found heterogeneity in emergency department use for mental health reasons, as each of the four classes represented distinct needs, predisposing and enabling factors. As such, interventions should be tailored to different classes of patients who use emergency departments, based on their characteristics.

Analyzing Main and Interaction Effects of Length of Stay Determinants in Emergency Departments

BACKGROUND

Measuring and understanding main determinants of length of stay (LOS) in emergency departments (EDs) is critical from an operations perspective, since LOS is one of the main performance indicators of ED operations. Therefore, this study analyzes both the main and interaction effects of four widely-used independent determinants of ED-LOS.

METHODS

The analysis was conducted using secondary data from an ED of a large urban hospital in Izmir, Turkey. Between-subject factorial analysis of variance (ANOVA) was used to test the main and interaction effects of the corresponding factors. P values <.05 were considered statistically significant.

RESULTS

While the main effect of gender was insignificant, age, mode of arrival, and clinical acuity had significant effects, whereby ED-LOS was significantly higher for the elderly, those arriving by ambulance, and clinically-categorized high-acuity patients. Additionally, there was an interaction between the age and clinical acuity in that, while ED-LOS increased with age for high acuity patients, the opposite trend occurred for low acuity patients. When ED-LOS was modeled using gender, age, and mode of arrival, there was a significant interaction between age and mode of arrival. However, this interaction was not significant when the model included age, mode of arrival, and clinical acuity.

CONCLUSION

Significant interactions exist between commonly used ED-LOS determinants. Therefore, interaction effects should be considered in analyzing and modelling ED-LOS.

Use of Emergency Rooms for Mental Health Reasons in Quebec: Barriers and Facilitators

This study explored barriers and facilitators in mental health (MH) patient management in four Quebec (Canada) emergency rooms (ERs) that used different operational models. Forty-nine stakeholders (managers, physicians, ER and addiction liaison team members) completed semi-structured interviews. Barriers and facilitators affecting patient management emanated from health systems, patients, organizations, and from professionals themselves. Effective management of MH patients requires ER access to a rich network of outpatient, community-based MH services; integration of general and psychiatric ERs; on-site addiction liaison teams; round-the-clock ER staffing, including psychiatrists; ER staff training in MH; and adaptation to frequent and challenging ER users.

Early short-term prediction of emergency department length of stay using natural language processing for low-acuity outpatients

BACKGROUND

Low-acuity outpatients constitute the majority of emergency department (ED) patients, and these patients often experience an unpredictable length of stay (LOS). Effective LOS prediction might improve the quality of ED care and reduce ED crowding.

OBJECTIVE

The objective of this study was to explore the potential of natural language processing (NLP) of the first ED physicians' clinical notes and to evaluate NLP-based short-term prediction models based on mixed-type clinical data.

METHODS

A retrospective study was conducted at an ED of a tertiary teaching hospital in Taiwan from January 2017 to June 2017. In total, 12,962 low-acuity outpatients were enrolled. Using structured data (e.g., demographic variables and vital signs) and different sections of the first SOAP notes as predictors, we developed six NLP-based prediction models (i.e., term frequency-inverse document frequency (TF-IDF) and truncated singular value decomposition (SVD)) to predict LOS. The metric for model evaluation is the mean squared error (MSE).

RESULTS

Of the six NLP-based models, the model using structured data and all the sections of the first SOAP notes processed by the TF-IDF and truncated SVD method performed the best, with an MSE of 3.00 [95% CI: 2.94-3.06]. In addition, ten important topics extracted by the TF-IDF and truncated SVD method had significant effects on the LOS (p < 0.001).

CONCLUSION

NLP-based models can be used as an early short-term prediction of LOS and have the potential for mixed-type clinical data analysis. The proposed models would likely aid ED physicians' decision-making processes and improve ED quality of care.

Assessing psychiatric safety in suicidal emergency department patients

We provide a review of the assessment of suicidal emergency department patients and includes a legal and ethical perspective. Screening tools and psychiatric consultation are important adjuncts to the ED evaluation of potentially suicidal patients. Suicide risk should be assessed, and if positive, an appropriate and safe disposition should be arranged. The aim of this article is to review these assessment tools and consider ethical issues, such as patient autonomy, accountability of the emergency physician, and consultant to Emergency Medical Treatment and Labor Act (EMTALA) as well as confidentiality, privacy, and social issues.

Frequent Attendance to the Emergency Department after Release from Prison: a Prospective Data Linkage Study

The aim of this paper was to identify characteristics and predictors of frequent emergency department (ED) use among people released from prisons in Queensland, Australia. Baseline interview data from a sample of sentenced adults were linked to ED and hospital records. The association between baseline characteristics and frequent ED attendance was modelled by fitting multivariate logistic regression models. Participants who had ≥ 4 visits to the ED in any 365-day period of community follow-up were defined as frequent attenders (FA). The analyses included 1307 people and mean follow-up time in the community was 1063 days. After adjusting for covariates, those with a dual diagnoses of mental illness and substance use (RR = 2.42, 95% CI 1.47–3.99) and those with mental illness alone (RR = 2.47, 95% CI 1.29–4.73) were at higher risk of frequent ED attendance, compared with those with no disorder. Future research should assess whether individually tailored transition supports from prison to community reduce the frequency of ED use among this population.

Patient-Centered Values and Experiences with Emergency Department and Mental Health Crisis Care

Little is known about what patients value in psychiatric crisis services or how they compare community-based services with those received in the emergency department. Three focus groups (n = 27) were held of participants who had received psychiatric crisis services in emergency departments or a community mental health center. Participants described care experiences and preferences. Focus groups were audio recorded, transcribed, and coded using a value-based lens. Themes included appreciation for feeling respected, basic comforts, and shared decision-making as foundations of quality care. Participants preferred the community mental health center. Research should address long-term outcomes to motivate change in psychiatric crisis care.

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.

Analysis of emergency department length of stay for mental health visits: A case study of a Canadian academic hospital

Objective

The objective of this study was to examine temporal trends in mental health visits to the emergency department (ED) and to determine differences in length of stay (LOS) between mental health visits and visits for non-mental health conditions.

Methods

A population-based retrospective study was conducted for patients who visited the ED of an academic hospital located in Toronto, ON, between fiscal years 2012 and 2016. Trends in the number of visits and descriptive statistics were calculated for both mental health and non-mental health groups. Quantile regression was used to compare the median and 90th percentile LOS.

Results

In five years, the absolute increase in the number of mental health visits to the ED was 55.7%. The 90th percentile LOS was similar for mental and non-mental health visits that were internally transferred (10.7 hours v. 8.3 hours) but significantly higher for those who were discharged (11.4 hours v. 7.3 hours), admitted (52.6 hours v. 29.3 hours), and externally transferred (21.9 hours v. 10.0 hours). After adjusting for other variables, the 90th percentile LOS was 3.3 hours longer for mental health visits resulting in discharge (p<0.001), 24.5 hours longer for those admitted (p<0.001), and 12.7 hours longer for those externally transferred (p<0.001).

Conclusion

The number of mental health visits to the ED is linearly increasing over time, and the LOS in the ED is significantly longer for mental health visits for almost all discharge dispositions. Thus, systematic changes are needed to address the ED capacity to provide care for the growing mental health population.

Factors associated with prolonged length of stay in the psychiatric emergency service

OBJECTIVE

Dedicated regional psychiatric emergency services (PES) were proposed as a better care model for psychiatric emergencies and a possible solution to boarding of psychiatric patients in the emergency department. However, there are limited data on factors associated with prolonged length of stay (LOS) in the PES. The objective of this study was finding factors associated with prolonged LOS in the PES and moving towards a solution to this problem.

METHODS

The study sample comprised 200 PES visits randomly chosen from January 2011 to December 2015 in a psychiatric hospital in Taiwan. Relevant data were collected comprehensively through the health information system and by reviewing medical records. The primary outcome was LOS longer than 24 hours while LOS longer than 48 hours was used as the secondary outcome.

RESULTS

Mean LOS was 17.6±23.2 hours, with 53 (26.5%) visits lasting more than 24 hours and 15 (7.5%) visits lasting more than 48 hours. After adjusting for related confounders, LOS longer than 24 hours was associated with use of restraints in the PES (adjusted odds ratio (aOR) = 3.13, 95% CI = 1.59-6.15) and history of illicit substance use (aOR = 2.46, 95% CI = 1.11-5.44). LOS longer than 48 hours was associated with use of restraints in the PES (aOR = 4.11, 95% CI = 1.2-14.14), history of illicit substance use (aOR = 6.16, 95% CI = 1.37-27.62) and first time visit to the hospital (aOR = 8.54, 95% CI = 2.03-35.96). Neither outcome was associated with transfer to an inpatient unit.

CONCLUSION

Prolonged LOS was common in the study sample. Discharged patients had an equally high rate of prolonged LOS as admitted patients. Therefore measures should be taken to facilitate timely discharge. Use of restraints and history of illicit substance use were common among patients with prolonged LOS.

The Impact of Behavioral Health Patients on a Pediatric Emergency Department's Length of Stay and Left Without Being Seen

OBJECTIVE

Emergency department (ED) boarding of admitted patients negatively impacts ED length of stay (LOS). Behavioral health (BH) patients are often challenging to safely discharge. We examined the association between daily BH census and non-BH LOS and left without being seen (LWBS) rates.

METHODS

Retrospective analysis of BH and non-BH patients at a high-volume tertiary care pediatric ED from December 2014 to June 2016 examined the association between BH patients and non-BH LOS and LWBS rates. Behavioral health patients were identified by presence of social work assessment and BH chief complaint and/or final diagnosis. Data were analyzed using 1-sample test of proportions, Student t test, Spearman and Pearson correlations, logistic regression, and odds ratios with 95% confidence intervals.

RESULTS

A total of 143,141 patients were seen, 3% (n = 4351) for BH presentations. Median LOS for discharged non-BH patients was 128 minutes compared with 446 minutes for BH patients. Daily LOS and bed hold hours were significantly longer for BH than for non-BH patients (P < 0.0001 for each analysis). After adjusting for ED census, daily BH census was significantly associated with increasing LWBS rates and non-BH LOS.

CONCLUSIONS

Behavioral health census and bed hold hours were significantly associated with increased LOS and LWBS rates and with our inability to meet desired LOS and LWBS rates. These associations support the existence of a threshold where the ED has reached capacity and is no longer able to absorb BH patients. Improving BH facility access may help improve overall pediatric ED patient care.

Emergency Department Length-Of-Stay For Psychiatric Visits Was Significantly Longer Than For Nonpsychiatric Visits, 2002-11

Despite increases in the use of emergency department (EDs) for mental health care, there are limited data on whether psychiatric patients disproportionately contribute to ED crowding. We conducted a retrospective analysis using a national database of ED visits in the period 2002-11 to describe trends in median and ninetieth-percentile length-of-stay for patients with psychiatric versus nonpsychiatric primary diagnoses. Psychiatric patients who visited the ED were transferred to another facility at six times the rate of nonpsychiatric patients. Median lengths-of-stay were similar for psychiatric and nonpsychiatric patients among those who were admitted to the hospital (264 versus 269 minutes) but significantly different for those who were admitted for observation (355 versus 279 minutes), transferred (312 versus 195 minutes), or discharged (189 versus 144 minutes). Overall, differences in ED length-of-stay between psychiatric and nonpsychiatric patients did not narrow over time. These findings suggest deficiencies in ED capacity for psychiatric care, which may necessitate improvements in both throughput and alternative models of care.

Evaluating the Effectiveness of Community and Hospital Medical Record Integration on Management of Behavioral Health in the Emergency Department

This study evaluated the correlation of an emergency department embedded care coordinator with access to community and medical records in decreasing hospital and emergency department use in patients with behavioral health issues. This retrospective cohort study presents a 6-month pre-post analysis on patients seen by the care coordinator (n=524). Looking at all-cause healthcare utilization, care coordination was associated with a significant median decrease of one emergency department visit per patient (p < 0.001) and a decrease of 9.5 h in emergency department length of stay per average visit per patient (p<0.001). There was no significant effect on the number of hospitalizations or hospital length of stay. This intervention demonstrated a correlation with reducing emergency department use in patients with behavioral health issues, but no correlation with reducing hospital utilization. This under-researched approach of integrating medical records at point-of-care could serve as a model for better emergency department management of behavioral health patients.

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.

Correlates of Length of Stay and Boarding in Florida Emergency Departments for Patients With Psychiatric Diagnoses

OBJECTIVE

Length of stay (LOS) and boarding in the emergency department (ED) for psychiatric patients have been the subject of concern, given the problems with crowding and excessive wait times in EDs. This investigation examined correlates of LOS and boarding in Florida EDs for patients presenting with psychiatric complaints from 2010 to 2013.

METHODS

Utilizing the Florida ED discharge database, the authors examined the association of LOS and boarding with hospital and encounter factors for adult patients presenting with a primary psychiatric diagnosis (N=597,541).

RESULTS

The mean LOS was 7.77 hours. Anxiety disorders were the most frequent psychiatric complaint and were associated with the lowest mean LOS compared with other diagnoses (p<.05). Patient encounters resulting in a presentation of intentional self-harm and suicidality or schizophrenia were associated with significantly longer stays compared with other psychiatric diagnoses. Commercial insurance was associated with the shortest average LOS. African Americans, Hispanics, and patients age 45 and older were associated with a longer average LOS. Smaller hospital size, for-profit ownership, and rural designation were associated with a shorter average LOS. Teaching status was not associated with LOS. Furthermore, 73% of encounters resulting in transfers qualified as episodes of boarding (a stay of more than six or more hours in the ED).

CONCLUSIONS

Extended LOS was endemic for psychiatric patients in Florida EDs.

Antipsychotic Selection for Acute Agitation and Time to Repeat Use in a Psychiatric Emergency Department

BACKGROUND

Early recognition and treatment of agitated patients is essential to avoid violence in the psychiatric emergency department (ED). Antipsychotics have established efficacy in managing agitation, yet little is known about how the choice of initial antipsychotic impacts time to repeat use and length of stay (LOS) in the psychiatric ED.

OBJECTIVE

To describe the impact of initial antipsychotic selection on time to repeat use and LOS in the psychiatric ED.

METHODS

A chart review identified 388 cases in which patients were administered an antipsychotic for agitation in the psychiatric ED between July 1 and August 31, 2014. Time to repeat use and LOS were compared for intramuscular (IM) haloperidol, other IM antipsychotics, and oral second-generation antipsychotics (SGAs) using the Kruskal-Wallis or Wilcoxon-Mann-Whitney test.

RESULTS

Of the 388 cases, 31% (n=122) required repeat medications. Mean time to repeat use for IM haloperidol was 20.1±18.4 hours, which was not significantly different from mean time to repeat use in the groups receiving other IM antipsychotics or oral SGAs (P=0.35). The mean LOS was 29.7±28.7 hours for IM haloperidol, 30.3±36.9 hours for other IM antipsychotics, and 22.6±28.0 hours for oral SGAs. Significant differences in LOS between repeat and nonrepeat users of IM haloperidol and other IM antipsychotics were observed, but not among those who received oral SGAs.

CONCLUSIONS

Mean time to repeat use ranged from 14 to 20 hours with IM haloperidol, other IM antipsychotics, and oral SGAs without significant differences in time to repeat use in the 3 different groups. Repeat users of IM antipsychotics had a significantly longer LOS in the ED compared with nonrepeat users of IM antipsychotics. However, patients who were initially administered oral SGAs did not have longer LOS in the ED even if a repeat dose was given.

Hours and Miles: Patient and Health System Implications of Transfer for Psychiatric Bed Capacity

Introduction

An increasing number of behavioral health (BH) patients are presenting to the emergency department (ED) while BH resources continue to decline. This situation-may lead to more external transfers to find care.

Methods

This is a retrospective cohort study of consecutive patients presenting to a tertiary care academic ED from February 1, 2013, through January 31, 2014. Patients were identified through electronic health record documentation of psychiatric consultation during ED evaluation. We reviewed electronic health records for demographic characteristics, diagnoses, payer source, ED length of stay, ED disposition, arrival method, and distance traveled to an external facility for inpatient admission. Univariable and multivariable associations with transfer to an external facility in comparison with patients admitted internally were evaluated with logistic regression models and summarized with odds ratios (OR).

Results

We identified 2,585 BH visits, of which 1,083 (41.9%) resulted in discharge. A total of 1,502 patient visits required inpatient psychiatric admission, and of these cases, 177 patients (11.8%; 95% CI = [10.2–13.5]) required transfer to an external facility. The median ED length of stay for transferred patients was 13.9 hours (interquartile range [IQR], 9.3–20.2 hours; range, 3.0–243.0 hours). The median distance for transport was 83 miles (IQR, 42–111 miles; range, 42–237 miles). In multivariable analysis, patients with suicidal or homicidal ideation had increased risk of transfer (odds ratio [OR] [95% CI], 1.93 [1.22–3.06]; P=0.005). Children younger than 18 years (OR [95% CI], 2.34 [1.60–3.40]; P<0.001) and adults older than 65 years (OR [95% CI], 3.46 [1.93–6.19]; P<0.001) were more likely to require transfer and travel farther to access care.

Conclusion

Patients requiring external transfer for inpatient psychiatric care were found to have prolonged ED lengths of stay. Patients with suicidal and homicidal ideation as well as children and adults older than 65 years are more likely to require transfer.

Identifying disparity in emergency department length of stay and admission likelihood

BACKGROUND

To assess whether insurance status has an effect on emergency department (ED) length of stay (LOS) and likelihood for admission or transfer to an operating room.

METHODS

This was a retrospective cross-sectional study of all encounters from January 2011 through October 2013 at an urban, academic trauma center. Analysis included multi-variable linear regression for ED LOS and logistic regression for the likelihood of admission.

RESULTS

Overall, 201 535 patients met the inclusion criteria, for which the mean age was 43.8 years, 55.9% were female, 23.4% were uninsured and 8% were of non-black race. Admission rate was 24.5% and operative rate was 1.4%. After adjusting for age, sex, triage acuity and race, the presence of insurance coverage was associated with an increased ED LOS of 575 (95%CI 552-598) vs. 567 (95%CI 543-591) minutes (P<0.01) among admitted patients and a decreased ED LOS of 456 (95%CI 381-531) vs. 499 (95%CI 423-575) minutes (P<0.01) among those transferred to an operating room. Adjusting for these same predictors, insured status remained a predictor for admission (odds ratio 1.24, 95%CI 1.20-1.28, P<0.01) and a negative predictor for transfer to the operating room (odds ratio 0.84, 95%CI 0.77-0.92, P<0.01).

CONCLUSION

The insured experienced a clinically insignificant increase in ED LOS when admitted and a 43-minute decrease in ED LOS when being transferred to the operating room. The insured were more likely to be admitted and less likely to be transferred to an operating room.

Use of a Dedicated, Non-Physician-led Mental Health Team to Reduce Pediatric Emergency Department Lengths of Stay

OBJECTIVES

Utilization of emergency departments (EDs) for pediatric mental health (MH) complaints is increasing. These patients require more resources and have higher admission rates than those with nonpsychiatric complaints.

METHODS

A multistage, multidisciplinary process to reduce length of stay (LOS) and improve the quality of care for patients with psychiatric complaints was performed at a tertiary care children's hospital's ED using Lean methodology. This process resulted in the implementation of a dedicated MH team, led by either a social worker or a psychiatric nurse, to evaluate patients, facilitate admissions, and arrange discharge planning. We conducted a retrospective, before-and-after study analyzing data 1 year before through 1 year after new process implementation (March 28, 2011). Our primary outcome was mean ED LOS.

RESULTS

After process implementation there was a statistically significant decrease in mean ED LOS (332 minutes vs. 244 minutes, p < 0.001). An x-bar chart of mean LOS shows special cause variation. Significant decreases were seen in median ED LOS (225 minutes vs. 204 minutes, p = 0.001), security physical interventions (2.0% vs. 0.4%, p = 0.004), and restraint use (1.7% vs. 0.1%, p < 0.001). No significant change was observed in admission rate, 72-hour return rate, or patient elopement/agitation events. Staff surveys showed improved perception of patient satisfaction, process efficacy, and patient safety.

CONCLUSIONS

Use of quality improvement methodology led to a redesign that was associated with a significant reduction in mean LOS of patients with psychiatric complaints and improved ED staff perception of care.

Predictors of psychiatric boarding in the emergency department

Introduction

The emergency psychiatric care is system is overburdened in the United States. Patients experiencing psychiatric emergencies often require resources not available at the initial treating facility and frequently require transfer to an appropriate psychiatric facility. Boarding of psychiatric patients, defined as a length of stay greater than four hours after medical clearance, is ubiquitous throughout emergency departments (EDs) nationwide. Boarding is recognized as a major cause of ambulance diversions and ED crowding and has a significant adverse impact on healthcare providers, patient satisfaction, and hospital costs. We sought to identify differences between patients who boarded versus patients who did not board, to identify factors amenable to change and identify interventions that could lead to a decrease in overall psychiatric patient length of stay and improve patient care.

Methods

This study is a retrospective multicenter cohort study of all patients assessed to require inpatient psychiatric hospitalization at two community EDs in Illinois from July 1, 2010 through June 30, 2012. We identified 671 patients and collected insurance status, sex, age, time of arrival, time of disposition and time of transfer.

Results

There was a statistically significant difference in the insurance status between the cohort of patients boarding in the ED compared to non-boarders prior to inpatient psychiatric admission. Our study identified 95.4% of uninsured patients who were boarded in the ED, compared to 71.8% of Medicare/Medicaid patients and 78.3% of patients with private insurance (χ²=50.6, df=2, p<0.001). We found the length of stay to be longer for patients transferred to publicly funded psychiatric facilities compared to those transferred to private facilities, with a mean time spent in the ED of 1,661 minutes and 705 minutes, respectively (p<0.001). Patients with Medicare/Medicaid were nearly twice as likely to return to the ED for psychiatric emergencies than self-pay and privately insured patients, requiring repeat inpatient psychiatric admission (estimate=0.649, p=0.035, OR=1.914).

Conclusion

This study found that unfunded patients boarded significantly longer than Medicare/Medicaid and privately insured patients. Patients with private insurance boarded longer than those with Medicare/Medicaid. Patients transferred to publicly funded facilities had significantly longer ED length of stay than patients transferred to private facilities.