Challenges Versus Solutions to Psychiatric Patients in the ED

Abstract

Session I presented Saturday, September 29, 10:00-11:00 am Purpose: Patients with psychiatric complaints are 7-10% (12 million) of annual ED visits nationally. Reduced availability of inpatient beds for treatment and an increase in under insured patients has rose over the last decade. Of the reported psychiatric ED visits 41% required inpatient hospital stays. Leading to many ED’s holding psychiatric patients in the ED for hours and days, until a final disposition is established. Likelihood of holding a psychiatric vs. non psychiatric patients in the ED was almost 5 times greater. Leading to poor patient outcomes, decreased patient satisfaction, increased morbidity and mortality, delays in care, increased elopement, and overcrowding in the ED. The Supreme Court in the State of Washington ruled in 2014 that boarding psychiatric patients in hospital EDs is unlawful. Design: This was a process improvement project focusing on the overall care of the behavioral health patient in the ED setting. Specific bench mark metrics were included;length of ED stay, management of patients with high utilization of the ED., and length of stay for intoxicated patients. Community partnerships were formed to provide better wrap around services and discharge planning for this patient population. Setting: The project was initiated in a northern Nevada multi-specialty level II trauma center, which serves as the regions only tertiary care facility. The healthcare system does not contain an inpatient psychiatric unit. The only inpatient psychiatric facility in the region is state operated, containing ten acute care beds. The ED has greater than 96, 000 patient visits annually. Participants/Subjects: Of the annual 96, 000 ED visits 10 to 12 percent focus on behavioral health complaints. Greater than 90% of the behavioral health population are on 72 hour legal holds, requiring care with a multidisciplinary collaborative approach. This project included stake holders from ED leadership, ED physicians, psychiatrists, social services, psychiatric case management, ED clinical ladder nurses, ED technicians, hospital security and community partners. Methods: A new staffing model was developed focusing on housing the crisis response team in the triage area 24 hours a day using a vanguard approach with screening patients presenting with psychiatric complaints and linking them with community partners. Biweekly conference calls with community partners were conducted and monthly process improvement committee meetings were held with staff and administrators. Additionally, quarterly formal report outs were done on the bench mark metrics. Policy and procedure revision was done and standard work created. Additionally nurse driven protocols were initiated. A stable psychiatric holding area was developed for patients awaiting transfer, with scheduled meals, activities, and ability to do ADL’s. Education to the ED staff included ENA modules and CPI training. Results/Outcomes: The results demonstrated a 56% reduction of patient with high utilization of the ED.The length of ED stay did not change for the psychiatric or detox populations. Implications: A finding affecting practice is the lack of acute psychiatric beds in the community and lack of psychiatric physicians. Mental Health Nurse Practitioners are being considered as solutions and contracted telemedicine psych services. Having a psychiatric team intervene early in the ED psych patient care is essential.