Impact of a Rapid-Access Ambulatory Psychiatry Encounter on Subsequent Emergency Department Utilization.

The authors sought to determine whether providing a rapid-access ambulatory psychiatry encounter correlated with emergency department utilization during a 6-month follow-up period. Electronic medical records of patients who accessed ambulatory psychiatric care through an urgent care psychiatry clinic that offers treatment exclusively on a walk-in basis over a 1-year period (N = 157) were reviewed retrospectively to track emergency department encounters with and without a psychiatric chief complaint in the 6 months before and after the initial psychiatry evaluation. Among patients who had not previously received ambulatory psychiatric care (N = 88), emergency department utilization decreased from 0.68 visits per patient to 0.36, and this difference was statistically significant (p = 0.0147). No statistically significant differences were found between the average number of emergency department encounters in the 6 months before and after the rapid-access ambulatory psychiatry encounter, regardless of chief complaint, when all patients were included in the analysis. Providing a rapid-access ambulatory psychiatry encounter may reduce subsequent emergency department utilization among patients who have not previously received ambulatory psychiatric care.

Clinical Severity Alone Does Not Determine Disposition Decisions for Patients in the Emergency Department with Suicide Risk.

BACKGROUND: Boarding of patients with suicide risk in emergency departments (EDs) negatively affects both patients and society. Factors other than clinical severity may frequently preclude safe outpatient dispositions among suicidal patients boarding for psychiatric admission in the ED. OBJECTIVE: To determine the extent to which nonclinical factors preclude safe outpatient discharge from the ED among patients boarding for psychiatric admission based on suicide risk. METHODS: A survey regarding the importance of 13 clinical and 19 nonclinical barriers to safe outpatient disposition was administered in the ED to 40 adults who were determined by psychiatrists to require inpatient level of psychiatric care due to suicide risk. A second survey regarding whether addressing the nonclinical factors would have enabled a safe outpatient disposition in each case was administered to the psychiatrists who evaluated each patient participant. RESULTS: Out of 40 patient participants, 39 cited at least one nonclinical factor that could have enabled a safe outpatient disposition had it been correctable in the ED. According to the psychiatrists who made the decision to hospitalize, 10 (25%) of the patient participants could have been discharged had social support become available. CONCLUSION: Both clinical and nonclinical factors affect disposition from the ED after an evaluation for suicide risk. Attention to nonclinical factors should be considered in programmatic efforts to reduce ED boarding of patients with suicide risk.

Psychosomatic medicine training as a bridge to practice: training and professional practice patterns of early career psychosomatic medicine specialists.

BACKGROUND: The number of interested candidates for psychosomatic medicine (PM) training programs has not matched the growing need for psychiatrists trained to care for complex medically ill patients. The reasons for this lack of growth may be found in the experience of new entrants into the subspecialty. OBJECTIVE: To investigate this issue, we conducted a survey of early career psychiatrists (ECPs) practicing PM to identify the personal and professional characteristics of ECP PM specialists and to examine the relevance of PM training to professional practice. METHODS: ECPs who attended the 2012 Academy of Psychosomatic Medicine annual meeting or who were registered members of the Academy of Psychosomatic Medicine completed a survey on training and work experiences. Decisional factors associated with pursuit of subspecialty fellowship education and professional practice patterns were identified using descriptive statistics and chi-square tests. RESULTS: A total of 102 ECPs completed the survey. Of the respondents, 67 (67%) had completed a PM fellowship. Motivating factors for pursuing fellowship training included (1) obtaining additional clinical training, (2) developing a special interest in PM training, and (3) improving job candidacy. Overall, 80% of ECPs desired inpatient consultation-liaison positions at the time of fellowship graduation. Overall, 22% reported difficulty in obtaining employment in PM after training. Chi-square tests between subjects who pursued a PM fellowship and those who did not proved nonsignificant. CONCLUSIONS: PM fellowship training remains relevant and important to ECPs in this sample. The survey results can be used to shape institutional and professional supports to better meet early career transition needs for PM psychiatrists.

Recommendations for training psychiatry residents in psychosomatic medicine.

BACKGROUND: The Accreditation Council of Graduate Medical Education (ACGME) mandates that residents in psychiatry training programs learn to provide psychiatric consultation to other medical and surgical services. The ACGME, however, offers little information to instruct academic faculty and institutions to what constitutes a quality educational experience in psychosomatic medicine/consultation-liaison psychiatry for the resident trainee. METHODS: These recommendations were developed through a collaborative process between educators in C-L psychiatry and members of the Academy of Psychosomatic Medicine's Residency Education Subcommittee. RESULTS: This manuscript provides a broad framework for what constitutes a well-rounded clinical and academic resident rotation on psychiatric consultation-liaison services. A rotation that is viewed positively by residents is important as it likely provides a foundation for a growing interest in Psychosomatic Medicine and the development of future fellows and subspecialty trained physicians.

Patient- and practice-related determinants of emergency department length of stay for patients with psychiatric illness.

STUDY OBJECTIVE: To identify patient and clinical management factors related to emergency department (ED) length of stay for psychiatric patients. METHODS: This was a prospective study of 1,092 adults treated at one of 5 EDs between June 2008 and May 2009. Regression analyses were used to identify factors associated with ED length of stay and its 4 subcomponents. Secondary analyses considered patients discharged to home and those who were admitted or transferred separately. RESULTS: The overall mean ED length of stay was 11.5 hours (median 8.2 hours). ED length of stay varied by discharge disposition, with patients discharged to home staying 8.6 hours (95% confidence interval 7.7 to 9.5 hours) and patients transferred to a hospital outside the system of care staying 15 hours (95% confidence interval 12.7 to 17.6 hours) on average. Older age and being uninsured were associated with increased ED length of stay, whereas race, sex, and homelessness had no association. Patients with a positive toxicology screen result for alcohol stayed an average of 6.2 hours longer than patients without toxicology screens, an effect observed primarily in the periods before disposition decision. Diagnostic imaging was associated with an average 3.2-hour greater length of stay, prolonging both early and late components of the ED stay. Restraint use had a similar effect, leading to a length of stay 4.2 hours longer than that of patients not requiring restraints. CONCLUSION: Psychiatric patients spent more than 11 hours in the ED on average when seeking care. The need for hospitalization, restraint use, and the completion of diagnostic imaging had the greatest effect on postassessment boarding time, whereas the presence of alcohol on toxicology screening led to delays earlier in the ED stay. Identification and sharing of best practices associated with each of these factors would provide an opportunity for improvement in ED care for this population.

Hospital variability in emergency department length of stay for adult patients receiving psychiatric consultation: a prospective study.

STUDY OBJECTIVE: We ascertain the components of emergency department (ED) length of stay for adult patients receiving psychiatric evaluation and to examine their variability across 5 hospitals within a health care system. METHODS: This was a prospective study of 1,092 adults treated between June 2008 and May 2009. Research staff abstracted length of stay and clinical information from the medical records. Clinicians completed a time log for each patient contact. Main outcomes were median times for the overall ED length of stay and its 4 components, or time from triage to request for psychiatric evaluation, request to start of psychiatric evaluation, start to completion of psychiatric evaluation with a disposition decision, and disposition decision to discharge from the ED. RESULTS: The overall median length of stay was more than 8 hours. Median times for the components were 1.8 hours from triage to request, 15 minutes from request to start of psychiatric evaluation, 75 minutes from start of psychiatric evaluation to disposition decision, and nearly 3 hours from disposition decision to ED discharge. The median disposition decision to discharge time was substantially shorter for patients who went home (40 minutes) than for patients who were admitted (2.5 hours) or transferred for psychiatric admission at other facilities (6.3 hours). When adjustments for patient and clinical factors were made, differences in ED length of stay persisted between hospitals. CONCLUSION: ED length of stay for psychiatric patients varied greatly between hospitals, highlighting differences in the organization of psychiatric services and inpatient bed availability. Findings may not generalize to other settings or populations.

Virtual monitoring of suicide risk in the general hospital and emergency department.

OBJECTIVE: To determine whether continuous virtual monitoring, an intervention that facilitates patient observation through video technology, can be used to monitor suicide risk in the general hospital and emergency department (ED). METHOD: This was a retrospective analysis of a protocol in which select patients on suicide precautions in the general hospital and ED received virtual monitoring between June 2017 and March 2018. The primary outcome was the number of adverse events among patients who received virtual monitoring for suicide risk. Secondary outcomes were the percentage of patients for whom virtual monitoring was discontinued for behavioral reasons and the preference for observation type among nurses. RESULTS: 39 patients on suicide precautions received virtual monitoring. There were 0 adverse events (95% confidence interval (CI) = 0.000-0.090). Virtual monitoring was discontinued for behavioral reasons in 4/38 cases for which the reason for terminating was recorded (0.105, 95%CI = 0.029-0.248). We were unable to draw conclusions regarding preference for observation type among nurses due to a low response rate to our survey. CONCLUSIONS: Suicide risk can feasibly be monitored virtually in the general hospital or ED when their providers carefully select patients for low impulsivity risk.

A Successful Walk-In Psychiatric Model for Integrated Care.

PURPOSE: Accommodating walk-in psychiatry visits in primary care can improve access to psychiatric care for patients from historically underserved groups. We sought to determine whether a walk-in psychiatry model embedded within an integrated care practice could be sustained over time, and to characterize the patients who accessed care through it. METHODS: We reviewed electronic health records linked to 811 psychiatry encounters in an integrated care practice between October 1, 2015 and September 30, 2017. Primary outcomes were the initial and return psychiatry encounters per month. Secondary outcomes were the demographics and diagnoses of patients who accessed their initial visits through walk-in sessions and scheduled appointments. RESULTS: 490 initial psychiatry evaluations and 321 return encounters took place over the 2-year study period. The volume of initial psychiatry evaluations per month did not significantly change, but the volume of psychiatry follow-up encounters significantly increased after the walk-in session expanded. Medicaid recipients (OR, 1.9; 95% CI, 1.2 to 3.0); individuals without a college degree (OR, 1.7; 95% CI, 1.1 to 2.5); individuals who were single, divorced, or separated (OR, 1.7; 95% CI, 1.1 to 2.5); and individuals who identified as Black or Hispanic (OR, 2.5; 95% CI, 1.7 to 3.6) were more likely to access an initial psychiatry evaluation through a walk-in session as opposed to a scheduled appointment. CONCLUSIONS: Providing psychiatric care on a walk-in basis in integrated care is sustainable. Patients from historically underserved groups may access psychiatric care disproportionately through a walk-in option when it is available.

Longitudinal Urgent Care Psychiatry as a Unique Access Point for Underserved Patients.

OBJECTIVE: The authors sought to determine whether a walk-in psychiatry model with longitudinal follow-up capability could improve access for patients who traditionally miss appointments. METHODS: An urgent care clinic that offers treatment exclusively on a walk-in basis was opened within an adult psychiatry practice to accommodate patients who missed prior scheduled appointments. Electronic health records for patients who received an initial psychiatry evaluation at the practice during a 6-month period (N=355) were reviewed retrospectively to track the clinic's productivity and patient demographic characteristics. RESULTS: Eighty patients (23%) accessed their initial psychiatry encounters through the walk-in clinic. Medicaid recipients (odds ratio [OR]=1.89, 95% confidence interval [CI]=1.10-3.24) and individuals without a college degree (OR=1.86, 95% CI=1.04-3.32) were more likely than patients with other insurance carriers and those with a college degree, respectively, to access care through a walk-in encounter versus a scheduled appointment. CONCLUSIONS: Longitudinal walk-in psychiatry services can feasibly be offered through the longitudinal urgent care psychiatry model. This model may serve as a unique access point for patients from historically underserved groups.

The Psychiatry Morbidity and Mortality Incident Reporting Tool Increases Psychiatrist Participation in Reporting Adverse Events.

OBJECTIVES: Although the reporting of adverse events (AEs) is widely thought to be a key first step to improving patient safety in hospital systems, underreporting remains a common problem, particularly among physicians. We aimed to increase the number of safety reports filed by psychiatrists in our hospital system. METHODS: We piloted an online survey for psychiatry-specific AE reporting, the Psychiatry Morbidity and Mortality Incident Reporting Tool (PMIRT) for a 1-year period. An e-mail prompt containing a link to the survey was sent on a weekly basis to all psychiatry department clinical staff. The primary outcome was the total number of events reported by psychiatrists through PMIRT; secondary outcomes were the total number of AEs and the number of serious harm events filed by psychiatrists in our hospital's formal event reporting system before and after implementation of the new protocol. RESULTS: Psychiatrists filed 65 reports in PMIRT during the study period. The average number of AEs reported by psychiatrists in the hospital's formal event reporting system significantly increased after the intervention (P = 0.0251), and the average number of serious harm events reported by psychiatrists increased nonsignificantly (P = 0.1394). CONCLUSIONS: The combination of an increase in awareness of event reporting with a psychiatry-specific AE reporting tool resulted in a significant improvement in the number of reports by psychiatrists.

The walk-in clinic model improves access to psychiatry in primary care.

OBJECTIVE: Missed appointments decrease clinic capacity and negatively affect health outcomes. The objective of this study was to increase the proportion of filled initial psychiatry appointments in an urban, hospital-based primary care practice. METHODS: Patients were identified as having a high or low risk of missing their initial psychiatry appointments based on prior missed medical appointments. High-risk patients were referred to a walk-in clinic instead of a scheduled appointment. The primary outcome was ratio of filled appointments to booked appointments. We used a statistical process control chart (p chart) to measure improvement. Secondary outcomes were percentages of patients from historically underserved groups who received an initial psychiatry evaluation before and after the intervention. RESULTS: The average ratio of filled to booked initial appointments increased from 59% to 77% after the intervention, and the p chart confirmed that this change represented special cause variation. No statistically significant demographic differences between the patients who received psychiatric evaluations before and after the intervention were found. CONCLUSIONS: Missed initial psychiatry appointments can be accurately predicted by prior missed medical appointments. A referral-based walk-in clinic is feasible and does not reduce access to care for historically underserved patient groups.

The role of face transplantation in the self-inflicted gunshot wound.

BACKGROUND: Facial self-inflicted gunshot wounds (SIGSWs) cause a devastating midfacial defect and pose a challenging problem to the reconstructive surgeon. Face transplantation (FT) has the potential for near-normal restoration in otherwise non-reconstructible defects. Two out of 7 FT recipients at Brigham and Women's Hospital (BWH) sustained SIGSWs. In this study, we illustrate the role of FT in the management of SIGSWs through an aesthetic, functional, and psychosocial examination of outcomes. METHODS: We performed a retrospective analysis of individuals with SIGSWs who were screened at BWH between 2008 and 2015. We then collected data of the injuries, modes of conventional reconstruction (CR), and deficits. For the FT recipients, we critically reviewed the psychosocial screening process and post-transplantation aesthetic, functional, and psychosocial outcomes. RESULTS: A total of six individuals post-SIGSWs were screened for FT. All of them had undergone CR, with five receiving loco-regional flaps and free tissue transfers, and one undergoing serial debridement and primary soft-tissue repair. Following CR, all suffered from residual functional and aesthetic deficits. Two underwent partial FT and one is currently undergoing FT screening. We describe the pre-transplant psychosocial screening process and the aesthetic, functional, and psychosocial outcomes of the SIGSW FT recipients. CONCLUSIONS: We examined the facial SIGSW injury, outcomes of CR, and the mechanism of FT to offer a potential solution to the shortcomings of CR. More importantly, we highlight the critical nature of the psychosocial component of the multidisciplinary evaluation given the history of mental illness and suicidal behavior in this subset of patients.

Treatment of psychiatric hospital patients transferred to emergency departments.

Two hundred public psychiatric hospitals were surveyed regarding their management of inpatients with serious medical problems. Of the 102 hospitals responding, 98 had a formal arrangement with a medical facility for transfer and treatment. Fifty of the respondents felt they regularly had difficulty in receiving acceptable information from the receiving hospital, and 37 perceived that their patients regularly received less than optimal care. There was a significant direct correlation between difficulty obtaining information and the perception of suboptimal care. Seventy-nine hospitals had developed a referral form for the transfer of information to the receiving facility. The results point to an important area of discontinuity in the care of the seriously mentally ill.

Psychosomatic medicine: a new psychiatric subspecialty.

OBJECTIVE: Psychosomatic medicine, also known as consultation-liaison psychiatry, received approval as a subspecialty field of psychiatry by the American Board of Medical Specialties in the spring of 2003. This represents a crucial step in the development of the field of psychosomatic medicine and recognition by leaders in the fields of medicine and psychiatry of its importance. METHODS: The field was developed in response to evidence suggesting that a high prevalence of psychiatric disorders exists in patients with complex medical illnesses and that diagnosis and management of these disorders in this population is critical yet frequently complicated by the medical illnesses themselves. RESULTS: Psychosomatic medicine psychiatrists have developed specialized expertise in addressing these issues. CONCLUSION: The approval of subspecialty status for psychosomatic medicine will help promote the psychiatric care of patients with complex medical, surgical, obstetrical and neurological conditions, as well as foster further improvements in the quality of training and research in this important area.