Oral Papers: Medical Specialties III: Emergency Medicine, Surgery
Oral Paper
Heather Ward, MD
Psychiatry Resident
Brigham & Women's Hospital
Boston, MA
Naomi Schmelzer, MD, MPH
Associate Psychiatrist
Brigham And Women's Hospital
Boston, MA
Background: Nationally, there is a shortage of inpatient psychiatric beds and community mental health services, which has led to increased emergency department (ED) visits for psychiatric complaints (Handel, 2007). Psychiatric visits to the ED result in significantly longer length of stay (Zhu, 2016), which can lead to increased adverse events (Rhodes, 2016) and cost (Nicks, 2012).
Methods: We instituted interdisciplinary rounds (IR) in the ED, which allowed for formalized daily interdisciplinary treatment planning and care coordination of psychiatric patients awaiting disposition. Rounds included an ED physician, ED charge nurse, psychiatry consult team, security, and triage social worker. We utilized a pre-post study design of individuals who presented to the ED for a psychiatric complaint to compare length of stay, use of restraint, and disposition before and after IR was implemented. We also surveyed ED and psychiatry consult faculty and staff regarding their attitudes about IR and its impact on patient care.
Results: During the study period, 8483 patients presented to the ED for a psychiatric chief complaint (4470 pre- and 5002 post-intervention). There were 989 individuals (11.7%) who presented in both phases of the study period. After the implementation of IR the average length of stay increased (23.97 hours vs. 17.6 hours). We will present safety data, including use of restraints before and after the intervention. We will also present survey data of faculty and staff.
Discussion: In order to increase care coordination of behavioral health patients, we implemented IR in our ED. Paradoxically, length of stay increased after IR was instituted. We will discuss the effects of IR on patient safety. We will also discuss faculty and staff perceptions of IR. The pre-post design of this study limits the assessment of other confounding variables that could have contributed to increased length of stay.
Conclusions: Increased coordination of care between ED and psychiatry teams may not decrease length of stay for individuals with a psychiatric chief complaint boarding in the ED.
References:
Handel DA, Sklar DP, Hollander JE, et al. Executive summary: the Institute of Medicine report and the future of academic emergency medicine: the Society for Academic Emergency Medicine and Association of Academic Chairs in Emergency Medicine Panel: Association of American Medical Colleges annual meeting, October 28, 2006. Acad Emerg Med. 2007;14(3):261-267.
Zhu JM, Singhal A, Hsia RY. Emergency Department Length-Of-Stay For Psychiatric Visits Was Significantly Longer Than For Nonpsychiatric Visits, 2002-11. Health Aff (Millwood). 2016;35(9):1698-1706.
Rhodes SM, Patanwala AE, Cremer JK, et al. Predictors of Prolonged Length of Stay and Adverse Events among Older Adults with Behavioral Health-Related Emergency Department Visits: A Systematic Medical Record Review. J Emerg Med. 2016;50(1):143-152.
Nicks BA, Manthey DM. The impact of psychiatric patient boarding in emergency departments. Emerg Med Int. 2012;2012:360308.