A Quality Measurement Framework for Emergency Department Care of Psychiatric Emergencies.

As a primary access point for crisis psychiatric care, the emergency department (ED) is uniquely positioned to improve the quality of care and outcomes for patients with psychiatric emergencies. Quality measurement is the first key step in understanding the gaps and variations in emergency psychiatric care to guide quality improvement initiatives. Our objective was to develop a quality measurement framework informed by a comprehensive review and gap analysis of quality measures for ED psychiatric care. We conducted a systematic literature review and convened an expert panel in emergency medicine, psychiatry, and quality improvement to consider if and how existing quality measures evaluate the delivery of emergency psychiatric care in the ED setting. The expert panel reviewed 48 measures, of which 5 were standardized, and 3 had active National Quality Forum endorsement. Drawing from the measure appraisal, we developed a quality measurement framework with specific structural, process, and outcome measures across the ED care continuum. This framework can help shape an emergency medicine roadmap for future clinical quality improvement initiatives, research, and advocacy work designed to improve outcomes for patients presenting with psychiatric emergencies.

Comparison of Self-Administered Post Traumatic Stress Disorder Tool vs. Researcher Administered Tool in the Emergency Department.

BACKGROUND: Recent studies have shown that there is a high rate of post traumatic stress disorder in the inner city. OBJECTIVE: The purpose of this study was to determine whether patients in the Emergency Department would use a post traumatic stress disorder (PTSD) assessment. Additionally, did the type of administration of the PTSD tool impact the usage of PTSD services? METHODS: The sample population was taken from patients, 12 years or older, who presented with a non psychiatric illness. This study was done at a level one inner city adult and pediatric Emergency Department. The PTSD validated survey, was randomized between being self or research fellow administered. Half of the patients completed the survey on their own and half were administered by a research fellow. Those who screen positive on the tool were contacted one week later. This was done to determine if they have scheduled an appointment or were seen for a follow-up appointment. This study was IRB approved. RESULTS: A total of 299 participants completed the survey. Half (149) of which used a PTSD tool that was self administered. The total amount of participants who tested positive for PTSD was 35% (105). There was a significant difference (0.01) between those who self administered the tool 26% (40) and those who had the tool administered 12% (18). This was seen in relationship to who was more likely to follow up with behavioral health referrals. CONCLUSIONS: These results reveal that 35% of the participants tested positive for PTSD. The majority of those that screened positive and used follow up services had self administered the tool. This indicates that they are more likely to seek out services based on their results.

Evidence-Based Review Of Pharmacotherapy For Acute Agitation. Part 2: Safety.

BACKGROUND: The management of acute agitation in the emergency department often requires the administration of rapid-acting antipsychotic agents. However, there are few comparative studies and little guidance regarding the risks associated with use of such drugs in the acute setting. OBJECTIVE: This structured evidence-based review compared the safety of antipsychotic pharmacotherapies for acute agitation using data from randomized controlled trials identified by a literature search of the PubMed database. RESULTS: Based on findings from 34 blinded, randomized controlled trials, common acute adverse effects of second-generation antipsychotics and haloperidol were headache, dizziness, insomnia, and somnolence. There were some differences in incidence of extrapyramidal symptoms (EPS), degree of sedation, and acute QTc prolongations between agents. CONCLUSIONS: The results of this review demonstrate the improved safety (particularly regarding EPS and over-sedation) of certain newer-generation antipsychotic agents compared with haloperidol and benzodiazepines for the treatment of acutely agitated patients. The risk of prolonged QT interval and torsade de pointes needs to be considered with haloperidol and some of the second-generation antipsychotics.

Evidence-Based Review of Pharmacotherapy for Acute Agitation. Part 1: Onset of Efficacy.

BACKGROUND: The main goal of antipsychotic medication in the management of acute agitation in the emergency department is to rapidly induce calm without oversedation, enabling patients to participate in their own care. However, there is a paucity of comparative studies, particularly with newer fast-acting second-generation antipsychotic agents. OBJECTIVE OF THE REVIEW: This structured evidence-based review compared the onset of efficacy of antipsychotic treatments for acute agitation using data from randomized controlled trials identified by a literature search of the PubMed database. RESULTS: Based on findings from 28 blinded randomized controlled trials, onset of efficacy was rapid and generally observed at the first time point after intramuscular administration of ziprasidone (15-30 min) or olanzapine (15-30 min), but was more likely to be delayed with intramuscular haloperidol, even when combined with lorazepam (30-60 min), and intramuscular aripiprazole (45-90 min). When administered orally, rapid onset of efficacy was also consistently observed at the first assessment time point with olanzapine (15-120 min), risperidone (30-120 min), and sublingual asenapine (15 min). Significant effects were apparent for inhaled loxapine within 10-20 min. Effects were apparent within approximately 5-10 min with i.v. droperidol. Onset of efficacy was typically more rapid with second-generation antipsychotic agents than benzodiazepines, but data are limited. CONCLUSIONS: Although the patient populations of trials included in this review do not truly reflect that of the emergency department, the results provide useful information to emergency physicians on the rapid efficacy of certain newer-generation antipsychotic agents for the treatment of acutely agitated patients.

Identifying Undiagnosed Pediatric Mental Illness in the Emergency Department.

BACKGROUND: It is well known that pediatric psychiatric patients frequent emergency department (ED), but the number of patients with undiagnosed psychiatric illness presenting to an ED is not well known. Identification and referral of these patients may provide an opportunity for improved patient care. The primary study objective was to identify a tool that can screen for unsuspected psychiatric illness in pediatric patients who present to the ED with non-psychiatric-related complaints. METHODS: The MINI International Neuropsychiatric Interview for Children and Adolescents screening tool was administered to 200 pediatric consenting patients and guardians. The inclusion criteria were English-speaking patients who presented in the ED with a nonpsychiatric complaint who were stable and able to communicate. The study was conducted in a level 1 trauma center ED of an inner-city hospital that serves a predominantly African American and Hispanic population. This study was institutional review board approved. RESULTS: The study populations consisted of 53% African American (107), 45% Hispanic (90), 1% white (2), and 0.5% Asian (1). Their age range was divided, with 49% between 12 and 14 years (98) and 51% between 15 and 17 years (102). The sex was evenly split, with 50% male (100) and 50% female (100). The 41% who did screen positive for an undiagnosed mental illness had a range of diagnoses. The top modules with positive results were oppositional defiant (13.5%, 27), attention-deficit/hyperactivity disorder (13%, 25), depression (10%, 11), conduct disorder (9%, 19), and anxiety (5%, 11). CONCLUSIONS: The pediatric Mini International Neuropsychiatric Interview was effective in screening for undiagnosed mental illness in pediatric patients who presented to the ED with no psychiatric-related illness. The screening tool indicated that 41% of pediatric patients screened positive for an undiagnosed mental illness, with attention deficit-related disorders being the most widely seen. Further study should be conducted to test the tools used in a range of ED settings.

Enhanced Versus Basic Referral for Intimate Partner Violence in an Urban Emergency Department Setting.

BACKGROUND: Victims of intimate partner violence (IPV) frequently do not disclose abuse to medical providers. Therefore, research has examined the most effective screening and referral methods to help identify victims of abuse and connect them to needed resources. OBJECTIVES: To determine the efficacy of referrals intended to connect IPV victims with behavioral health resources, while taking into consideration demographic and mental health variables. METHODS: We examined a convenience sample of medically stable individuals in an emergency department setting. Participants were given the Mini-International Neuropsychiatric Interview and Partner Violence Screen measures to assess mental health and IPV victimization. Individuals that screened positive were randomized to a basic or enhanced referral and given a follow-up interview to determine referral success. Referrals were considered successful if an individual scheduled an appointment with provided behavioral health resources within the follow-up interval. RESULTS: Two-hundred and one individuals were enrolled. Forty-one (20.4%) participants screened positive for IPV victimization. Male and female participants in the enhanced referral group were more likely to have a successful referral than those in the basic referral group, with a large effect size such that 72.7% of participants in the enhanced referral and 15.7% of participants in the basic referral group contacted referral resources. Both referral type and marital status significantly predicted referral success. CONCLUSION: Comorbidity with mental health concerns measured as high within those that screened positive for IPV victimization. The enhanced referral showed to be an effective way to encourage participants to contact behavioral health resources.

Reasons for readmissions: what are the reasons for 90-day readmissions of psychiatric patients from the ED?

BACKGROUND: Frequent users of the emergency department (ED) contribute to the problem of overcrowding and are more likely to have psychiatric problems and a higher than average 90-day readmission rate. In addition, ED visits due to mental health problems have increased in recent years, thus driving up 90-day readmission rates. OBJECTIVES: The objective of the study is to determine the reasons for readmissions of psychiatric patients who have previously presented to the ED. METHODS: This is a retrospective chart review of a random sample of 350 psychiatric patients who presented to the ED and had a return visit within 90 days. This study was conducted at a 432-bed, urban, level I adult and pediatric trauma center with 50000 ED visits per year. The inclusion criterion was all psychiatric patients who presented to the ED since August 2011 and had a least 1 return visit within 90 days. The exclusion criterion was patients who presented with nonpsychiatric complaints. SPSS version 14 was used, and the study was institutional review board approved. RESULTS: There was a significant difference (P=.01) between the reasons for psychiatric patients to be readmitted to the hospital between their first, second, and third ED visits. The most common reasons for admission on the first visit were depression, schizophrenia, schizoaffective disorder, bipolar disorder, and psychosis. The most common reasons for the second and third visits, however, were psychiatric (61.9%), musculoskeletal (9.2%), cardiovascular (5.7%), neurologic (4.3%), and dermatological (3.2%). CONCLUSIONS: Psychiatric patients are not returning to the ED repeatedly for the same complaints or for only psychiatric complaints. A total of 30% of patients who presented for a second and third time within 90 days were admitted for medical illness, as opposed to their initial psychiatric presentation. This indicates that a 2-pronged approach toward treatment might have to be developed-one that focuses on specific types of mental illness and one that focuses on a separate set of physical illnesses-to reduce 90-day readmission rates within this patient population.

Implementing a third-year emergency medicine medical student curriculum.

BACKGROUND: Emergency medicine (EM) is commonly introduced in the fourth year of medical school because of a perceived need to have more experienced students in the complex and dynamic environment of the emergency department. However, there is no evidence supporting the optimal time or duration for an EM rotation, and a number of institutions offer third-year rotations. OBJECTIVE: A recently published syllabus provides areas of knowledge, skills, and attitudes that third-year EM rotation directors can use to develop curricula. This article expands on that syllabus by providing a comprehensive curricular guide for the third-year medical student rotation with a focus on implementation. DISCUSSION: Included are consensus-derived learning objectives, discussion of educational methods, considerations for implementation, and information on feedback and evaluation as proposed by the Clerkship Directors in Emergency Medicine Third-Year Curriculum Work Group. External validation results, derived from a survey of third-year rotation directors, are provided in the form of a content validity index for each content area. CONCLUSIONS: This consensus-derived curricular guide can be used by faculty who are developing or revising a third-year EM medical student rotation and provide guidance for implementing this curriculum at their institution.

Who pays? How reimbursement impacts the emergency department.

BACKGROUND: Nationwide from 1996 to 2004, the overall proportion of Emergency Department (ED) reimbursement ratios for outpatient ED visits decreased from 57% to 42%. The continued falling of ED reimbursement ratios, which is the share of ED charges that are ultimately paid, is an indicator of the financial pressures facing the ED. Once the healthcare reforms are put in place what will the impact be on reimbursement rates of overburdened and underfunded emergency departments. PURPOSE: The purpose of this study is to examine if there is a declining disparity in payment rates for ED care based on payment sources in a safety net ED provider. Findings of this study could indicate how the healthcare reforms might impact these types of ED reimbursement ratios in the upcoming years. METHODS: This was a retrospective study that examined randomly selected charts of all ED visits charts from May 2002 to May 2008 at a level one adult and pediatric emergency trauma center with 45,000 annual visits. This study was IRB approved. RESULTS: A regression model was used to predict if there was a relationship between amount received and types of insurance payers within the ED. A significant relationship was found between types of insurance (payers) as the independent variable, and the dependent variables of charges (p = .00), payments (p = .00), amount of adjustments (p= .00), and balance remaining after 90 days (p = .00). CONCLUSIONS: Who pays for the ED services does impact the ED's bottom line. The privately funded patients will provide an ED with a higher reimbursement ratio per year as compared to those patients who are publicly or self pay. This explains why EDs that provide care for 40% or more publicly or self pay patients have seen a decline in reimbursement ratios. Healthcare reform has the potential to change and possibly improve safety net ED rate of reimbursement depending on how private, public and self pay patients pay for ED services.

Does gun accessibility lead to violence-related injury?

OBJECTIVES: Because of high rates of violent gun-related injuries seen in emergency department (EDs), the ED has become involved in prevention violence intervention. The purpose of the study was to determine the relation between access to guns and the risk of violence-related injuries in youth and young adults. METHODS: This study was a convenience sample in an inner-city level I trauma center. A 28-item validated questionnaire consisting of a short questionnaire about guns, the New York City Youth Violence Survey, and the SAGE Baseline Survey was given to 201 subjects. Half of the subjects were victims of violence and half were seen for nonviolence-related problems. RESULTS: Subjects with violence-related injuries did not have a higher rate of accessibility to guns. They did, however, show a difference in their attitudes toward guns. The subjects who came into the ED with violence-related injuries believed that having a weapon was a way to avoid a fight (F = 4.68, P = 0.032). They were more likely to have grabbed or shoved someone in the last 6 months (F = 5.18, P = 0.025), punched someone in the last 6 months (F = 11.9, P = 0.011), and have been seen in the ED within the last 6 months for a injury related to being punched, attacked, or shot (F = 117, P = 0.00), as compared to those with nonviolence-related injuries. CONCLUSIONS: There was no difference between the two subject groups in terms of their being victims of violence and the rate of gun accessibility. There was, however, a difference in their attitudes toward guns.

What constitutes a good hand offs in the emergency department: a patient's perspective.

PURPOSE: The aim is to determine, from the patient's perspective, what constitutes a good hand-off procedure in the emergency department (ED). The secondary purpose is to evaluate what impact a formalized hand-off had on patient knowledge, throughput and customer service DESIGN/METHODOLOGY/APPROACH: This study used a randomized controlled clinical trial involving two unique hand-off approaches and a convenience sample. The study alternated between the current hand-off process that documented the process but not specific elements (referred to as the informal process) to one using the IPASS the BATON process (considered the formal process). Consenting patients completed a 12-question validated questionnaire on how the process was perceived by patients and about their understanding why they waited in the ED. Statistical analysis using SPSS calculated descriptive frequencies and t-tests. FINDINGS: In total 107 patients were enrolled: 50 in the informal and 57 in the formal group. Most patients had positive answers to the customer survey. There were significant differences between formal and informal groups: recalling the oncoming and outgoing physician coming to the patient's bed (p = 0.000), with more formal group recalling that than informal group patients; the oncoming physician introducing him/herself (p = 0.01), with more from the formal group answering yes and the physician discussing tests and implications with formal group patients (p = 0.02). RESEARCH LIMITATIONS/IMPLICATIONS: This study was done at an urban inner city ED, a fact that may have skewed its results. A comparison of suburban and rural EDs would make the results stronger. It also reflected a very high level of customer satisfaction within the ED. This lack of variance may have meant that the correlation between customer service and handoffs was missed or underrepresented. There was no codified observation of either those using the IPASS the BATON script or those using informal procedures, so no comparison of level and types of information given between the two groups was done. There could have been a bias of those attending who had internalized the IPASS the BATON procedures and used them even when they were assigned to the informal group. PRACTICAL IMPLICATIONS: A hand off from one physician to the next in the emergency department is best done using a formalized process. IPASS the BATON is a useful tool for hand off in the ED in part because it involved the patient in the process. The formal hand off increased communication between patient and doctor as its use increased the patient's opportunity to ask and respond to questions. ORIGINALITY/VALUE: The researchers evaluated an ED physician specific hand-off process and illustrate the value and impact of involving patients in the hand-off process.

Coordinated Health Care Interventions for Childhood Asthma Gaps in Outcomes (CHICAGO) plan.

Background: Evidence-based strategies to improve outcomes in minority children with uncontrolled asthma discharged from the emergency department (ED) are needed. Objectives: This multicenter pragmatic clinical trial was designed to compare an ED-only intervention (decision support tool), an ED-only intervention and home visits by community health workers for 6 months (ED-plus-home), and enhanced usual care (UC). Methods: Children aged 5 to 11 years with uncontrolled asthma were enrolled. The change over 6 months in the Patient-Reported Outcomes Measurement Information System Asthma Impact Scale score in children and Satisfaction with Participation in Social Roles score in caregivers were the primary outcomes. The secondary outcomes included guideline-recommended ED discharge care and self-management. Results: Recruitment was significantly lower than expected (373 vs 640 expected). Of the 373 children (64% Black and 31% Latino children), only 63% completed the 6-month follow-up visit. In multivariable analyses that accounted for missing data, the adjusted odds ratios and 98% CIs for differences in Asthma Impact Scores or caregivers' Satisfaction with Participation in Social Roles scores were not significant. However, guideline-recommended ED discharge care was significantly improved in the intervention groups versus in the UC group, and self-management behaviors were significantly improved in the ED-plus-home group versus in the ED-only and UC groups. Conclusions: The ED-based interventions did not significantly improve the primary clinical outcomes, although the study was likely underpowered. Although guideline-recommended ED discharge care and self-management did improve, their effect on clinical outcomes needs further study.

Pitfalls in the care of the psychiatric patient in the emergency department.

BACKGROUND: Care of the psychiatric patient in the Emergency Department (ED) is evolving. As with other disease states, there are a number of pitfalls that complicate the care of the psychiatric patient. OBJECTIVE: The purpose of this article is to update Emergency Physicians concerning the pitfalls in caring for the psychiatric patient, and possible solutions to deal with these pitfalls. DISCUSSION: The article will address the burden of the psychiatric patient, staff attitudes, medical clearance process, treatment of the agitated patient, suicidal patients, and admission decisions. CONCLUSIONS: Alternative care resources, collaboration with Psychiatry, staff education, improvement in the medical clearance process, proper use of restraint and seclusion, and appropriate choice of medication for agitated patients can help avoid some of the top pitfalls in the care of the psychiatric patient in the ED.

Undiagnosed mental illness in the emergency department.

BACKGROUND: Mental illness affects 8% of the population. The early identification and treatment of mental illness can reduce the progression and complications of the illness. OBJECTIVE: The objective of this study was to identify unsuspected psychiatric illness in patients presenting to the emergency department (ED) with non-psychiatric-related complaints. A comparison of the test results and the emergency physician assessments were then compared. METHODS: All consenting and stable patients who presented to the ED with non-psychiatric complaints were given the Mini-International Neuropsychiatric Interview (MINI). It was administered to the patient by a trained research fellow before the patient was seen by the physician. Before the patient's departure from the ED, the research fellow notified the emergency physician of the results of the MINI interview. After the emergency physician was notified of the diagnosis of the MINI, any change in the treatment was reviewed. RESULTS: A total of 211 patients were enrolled in the study. The majority of patients (55%) tested negative for all undiagnosed mental illnesses. The top diagnoses were as follows: major depression (24%), general anxiety (9%), and drug abuse (8%). Of all those patients who tested positive for an undiagnosed mental illness, only 2% were diagnosed by the ED attending. CONCLUSIONS: The idea that the ED is a good place to identify undiagnosed mental health illnesses was confirmed. The use of an independent test such as the MINI was also shown to be useful to aid the emergency physician in identifying undetected mental illnesses.

The impact of watching cartoons for distraction during painful procedures in the emergency department.

OBJECTIVE: The purpose of this study was to determine whether the viewing of cartoons in the acute care setting reduces the perception of pain by pediatric patients. METHODS: A convenience prospective study of pediatric patients in pain was performed at a community teaching level I pediatric and adult emergency department, with 44,000 patient visits per year. The inclusion criteria for entry into the study were any child who presented to the emergency department in acute pain from any cause. The younger children were randomized to watch a Barney cartoon in Spanish or English, and the older children were randomized to view a Tarzan cartoon in Spanish or English. The younger children were assessed 5 minutes before the procedure, during the procedure, and 5 minutes after the procedure using Poker Chip Tool and Faces Scale. The older children were assessed at the same time interval using self-reporting and a visual analog scale. The study was internal review board approved. A difference of 20% or greater was considered a significant difference. The data were analyzed using a general linear model-repeated measures a priori level of significance of P < 0.05. RESULTS: There was a significant difference within subject effects: F(1)= 9.268, significant at 0.03, with observed power at 0.85 or 85%, with the α set at 0.05 or less. A comparison of the groups revealed that there were no differences in the causes of pain (F(1) = 0.301, P = 0.585), pain duration (F(1) = 0.062, P = 0.084), or type of anesthesia, if used (F(1) = 0.064, P = 0.804) between groups. This lack of difference was upheld for age (F(1) = 3.0407, P = 0.068), race (F(1) = 0.537, P = 0.466), and sex (F(1) = 0.002, P = 0.964). CONCLUSIONS: The finding that cartoon viewing was effective does illustrate 1 more pain relief tool for use in the ED when pediatric patients present. It is useful because of the fact that it does not interfere with assessment of patients' presenting or underlying problems. The need for more ways in which to address pediatric pain persists.

Electronic Health Record-Embedded Individualized Pain Plans for Emergency Department Treatment of Vaso-occlusive Episodes in Adults With Sickle Cell Disease: Protocol for a Preimplementation and Postimplementation Study.

BACKGROUND: Individuals living with sickle cell disease often require aggressive treatment of pain associated with vaso-occlusive episodes in the emergency department. Frequently, pain relief is poor. The 2014 National Heart, Lung, and Blood Institute evidence-based guidelines recommended an individualized treatment and monitoring protocol to improve pain management of vaso-occlusive episodes. OBJECTIVE: This study will implement an electronic health record-embedded individualized pain plan with provider and patient access in the emergency departments of 8 US academic centers to improve pain treatment for adult patients with sickle cell disease. This study will assess the overall effects of electronic health record-embedded individualized pain plans on improving patient and provider outcomes associated with pain treatment in the emergency department setting and explore barriers and facilitators to the implementation process. METHODS: A preimplementation and postimplementation study is being conducted by all 8 sites that are members of the National Heart, Lung, and Blood Institute-funded Sickle Cell Disease Implementation Consortium. Adults with sickle cell disease aged 18 to 45 years who had a visit to a participating emergency department for vaso-occlusive episodes within 90 days prior to enrollment will be eligible for inclusion. Patients will be enrolled in the clinic or remotely. The target analytical sample size of this study is 160 patient participants (20 per site) who have had an emergency department visit for vaso-occlusive episode treatment at participating emergency departments during the study period. Each site is expected to enroll approximately 40 participants to reach the analytical sample size. The electronic health record-embedded individualized pain plans will be written by the patient's sickle cell disease provider, and sites will work with the local informatics team to identify the best method to build the electronic health record-embedded individualized pain plan with patient and provider access. Each site will adopt required patient and provider implementation strategies and can choose to adopt optional strategies to improve the uptake and sustainability of the intervention. The study is informed by the Technology Acceptance Model 2 and the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. Provider and patient baseline survey, follow-up survey within 96 hours of an emergency department vaso-occlusive episode visit, and selected qualitative interviews within 2 weeks of an emergency department visit will be performed to assess the primary outcome, patient-perceived quality of emergency department pain treatment, and additional implementation and intervention outcomes. Electronic health record data will be used to analyze individualized pain plan adherence and additional secondary outcomes, such as hospital admission and readmission rates. RESULTS: The study is currently enrolling study participants. The active implementation period is 18 months. CONCLUSIONS: This study proposes a structured, framework-informed approach to implement electronic health record-embedded individualized pain plans with both patient and provider access in routine emergency department practice. The results of the study will inform the implementation of electronic health record-embedded individualized pain plans at a larger scale outside of Sickle Cell Disease Implementation Consortium centers. TRIAL REGISTRATION: ClinicalTrials.gov NCT04584528; https://clinicaltrials.gov/ct2/show/NCT04584528. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/24818.