Consequences of the 48-h rule: A lens into the psychiatric patient flow through an emergency department.

OBJECTIVE: Psychiatric patient boarding in emergency department (ED) is a severe and growing problem. In July 2013, Minnesota implemented a law requiring jailed persons committed to state psychiatric facilities be transferred within 48-h of commitment. This study aims to quantify the effect of this law on a large ED's psychiatric patient flow. METHODS: A pre- and post- comparison of 2011-2015 ED length of stay (LOS) for adult psychiatric patients was performed using electronic medical record data. Comparisons of the median LOS were assessed using a segmented regression model with time series error, and risk differences (RD) were used to determine changes in the proportion of patients with LOS ≥3 and ≥5days. Changes in patient disposition proportions were assessed using risk ratios. RESULTS: The median ED LOS for patients admitted for psychiatric care increased by 5.22h from 2011 to 2015 (95% CI: (4.33, 7.15)), while the frequency of patient encounters remained constant. Although no significant difference in the rate of ED LOS increase was found pre- and post- implementation, the proportion of adults with LOS ≥3days and ≥15days increased (RD 0.017 (95% CI: (0.013, 0.021)); 0.002 (95% CI: (0.001,0.004)), respectively). CONCLUSIONS: The proportion of ED adult psychiatric patients experiencing prolonged LOS increased following the implementation of a statewide law requiring patients committed through the criminal justice system be transferred to a state psychiatric hospital within 48h. Identifying characteristics of subsets of psychiatric patients disproportionally affected could suggest focused healthcare system improvements to improve ED psychiatric care.

Prolonged length of stay in ED psychiatric patients: a multivariable predictive model.

BACKGROUND: We aimed to evaluate factors associated with prolonged emergency department (ED) length of stay (LOS) among psychiatric patients and to develop a multivariable predictive model to guide future interventions to reduce ED LOS. METHODS: Electronic health records of ED patients receiving a psychiatric consultation and providing research authorization were reviewed from September 14, 2010, through September 13, 2013, at an academic hospital with approximately 73000 visits annually. Prolonged LOS was defined as ≥8 hours. RESULTS: We identified 9247 visits among 6335 patients; median LOS was 4.1 hours, with 1424 visits (15%) with prolonged LOS. In the multivariable model, characteristics associated with an increased risk of a prolonged LOS included patient age 12 to 17 years (odds ratio [OR], 2.43; P<.001) or ≥65 years (OR, 1.46; P=.007); male gender (OR, 1.24; P=.002); Medicare insurance coverage (OR, 1.34; P=.008); use of restraints (OR, 2.25; P=.006); diagnoses of cognitive disorder (OR, 4.62; P<.001) or personality disorder (OR, 3.45; P<.001); transfer to an unaffiliated psychiatric hospital (OR, 22.82; P<.001); ED arrival from 11 pm through 6:59 am (OR, 1.53; P<.001) or on a Sunday (OR, 1.76; P<.001); or ED evaluation in February (OR, 1.59; P=.006), April (OR, 1.66; P=.002), and May (OR, 1.54; P=.007). CONCLUSIONS: Many psychiatric patients had a prolonged ED LOS. Understanding the multiple, patient-specific, ED operational, and seasonal factors that predict an increased LOS will help guide allocation of resources to improve overall ED processes and patient care.

EMTALA and patients with psychiatric emergencies: a review of relevant case law.

STUDY OBJECTIVE: Emergency department (ED) care for patients with psychiatric complaints has become increasingly challenging given recent nationwide declines in available inpatient psychiatric beds. This creates pressure to manage psychiatric patients in the ED or as outpatients and may place providers and institutions at risk for liability under the Emergency Medical Treatment and Labor Act (EMTALA). We describe the patient characteristics, disposition, and legal outcomes of EMTALA cases involving patients with psychiatric complaints. METHODS: Jury verdicts, settlements, and other litigation involving alleged EMTALA violations related to psychiatric patients between the law's enactment in 1986 and the end of 2012 were collected from 3 legal databases (Westlaw, Lexis, and Bloomberg Law). Details about the patient characteristics, disposition, and reasons for litigation were independently abstracted by 2 trained reviewers onto a standardized data form. RESULTS: Thirty-three relevant cases were identified. Two cases were decided in favor of the plaintiffs, 4 cases were settled, 10 cases had an unknown outcome, and 17 were decided in favor of the defendant institutions. Most patients in these 33 cases were men, had past psychiatric diagnoses, were not evaluated by a psychiatrist, and eventually committed or attempted suicide. The most frequently successful defense used by institutions was to demonstrate that their providers used a standard screening examination and did not detect an emergency medical condition that required stabilization. CONCLUSION: Lawsuits involving alleged EMTALA violations in the care of ED patients with psychiatric complaints are uncommon and rarely successful.

Patient-Centered Medical Home Membership Is Associated with Decreased Hospital Admissions for Emergency Department Behavioral Health Patients.

The objective was to examine the impact of a multipayer patient-centered medical home (PCMH) on health care utilization for behavioral health patients seen at a tertiary care emergency department (ED). A retrospective health records review was performed for PCMH and non-PCMH patients who presented and received a psychiatric consultation during a 2-year period in the ED of the Mayo Clinic Hospital in Rochester, Minnesota. Univariable and multivariable associations with the outcomes of admission and return visits within 72 hours were evaluated using logistic regression models and summarized with odds ratios (ORs) and 95% confidence intervals (CIs). There were 5398 visits among 3815 patients during the study period. Among these, there were 2440 (45%) PCMH patient visits. There were 2983 (55%) total patient visits resulting in an admission. In a univariable model, PCMH patients (53%) were less likely to be admitted from the ED compared with non-PCMH patients (57%) (OR 0.84; 95% CI 0.76-0.94; P = 0.002) and this remained statistically significant (OR 0.83; 95% CI 0.74-0.93; P = 0.001) after multivariable adjustment. Among the 2415 non-admitted patients, there was no significant difference in returns within 72 hours between PCMH patients (13%) and non-PCMH patients (12%) (OR 1.12; 95% CI 0.83-1.43; P = 0.36). PCMH membership was associated with a lower probability of inpatient hospitalization from the ED. PCMH interventions may be associated with a reduction in health care utilization.

A system-based approach to depression management in primary care using the Patient Health Questionnaire-9.

Primary care physicians are more likely to see patients with depression than with any other disorder except hypertension, and its management poses a challenge to busy primary care practices. The Patient Health Questionnaire-9, a simple self-administered tool of proven validity and reliability, is a commonly used screening instrument for depression in primary care practice. This review article provides a system-based approach to depression management using the Patient Health Questionnaire-9 to guide clinicians in the identification and treatment of depression and its follow-up care.

Development and implementation of an emergency department observation unit protocol for deliberate drug ingestion in adults - preliminary results.

BACKGROUND: Patients presenting after reported overdose are typically precluded from admission to emergency department observation units (EDOU). The purpose of this study was to describe the initial experience with an EDOU overdose protocol. METHODS: Retrospective chart review of all individuals presenting to a tertiary care hospital with a chief complaint of overdose or intoxication for the period 7/1/2004 through 12/24/2004. Inclusion criteria for EDOU placement included asymptomatic patients aged >or= 15 years presenting after known or suspected potentially toxic exposure. Exclusion criteria included isolated ethanol intoxication, presence of persistent self-injurious or violent behaviors, chronic intoxication, ingestion of sustained release preparation, and presence of previously defined high-risk criteria. RESULTS: Retrospective chart review demonstrated that 163 patients presented to the ED after ingestion during this time period, of which 15 were excluded secondary to age. Six patients were admitted to the EDOU. No patient eloped or attempted further self-harm while in the EDOU. No clinical decompensation occurred. Another 27 patients were retrospectively identified as EDOU candidates, eight of whom were admitted to the MICU. CONCLUSION: Although initial numbers are too small for meaningful analysis, the results suggest that prolonged observation of this problematic patient subset within an EDOU is feasible.