An Initiative to Improve Performance on a National Transition of Care Measure and to Reduce Readmissions in an Academic Psychiatric Hospital.

BACKGROUND: Inpatient psychiatry discharge planning through careful transition documentation may reduce adverse patient outcomes and decrease hospital readmissions. In 2017 a national psychiatry reporting program instituted a quality metric called the Transition Record with Specified Elements Received by Discharged Patients (TR-1). At Yale New Haven Psychiatric Hospital, the TR-1 metric had 0% provider compliance when the quality metric was instituted. The primary goal of this quality improvement project was to increase the TR-1 metric compliance through use of a structured clinical decision support (CDS) tool and, by extension, reduce the readmission rate. METHODS: This was a quality improvement project conducted in a 118-bed psych hospital from August 1, 2017, to July 31, 2020, and the preintervention period was from January 1 to July 31, 2017. Demographic and clinical diagnosis data were collected pre- and postintervention. A CDS tool composed of 11 discharge elements was developed and implemented. Primary measures were monthly TR-1 compliance rate as a process metric, and 30-day all-cause readmission rate as an outcome metric. RESULTS: The TR-1 compliance rate increased after CDS tool implementation, with a process mean of 48% in year 1, 56% in year 2, and 65% in year 3. The readmission rate was 9.6% for August 2017 to July 2018, 9.9% for August 2018 to July 2019, and 10.3% for August 2019 to July 2020. A slight upward trend in readmissions was observed over the course of the study, but this was not significant (p = 0.95). CONCLUSION: We found that implementing a CDS tool improved care transition documentation, which was sustained over time. However, the change was not associated with a decrease in 30-day readmission.

Reduction of restraint and seclusion through collaborative problem solving: a five-year prospective inpatient study.

OBJECTIVE: This study examined usage patterns of restraint and seclusion before and after the implementation of collaborative problem solving (CPS), a manualized therapeutic program for working with aggressive children and adolescents. METHODS: The clinical setting was a 15-bed psychiatric inpatient unit for school-age children. A total of 755 children were hospitalized for a total of 998 admissions from fiscal years 2003 to 2007 (median age=11 years; 64% boys). Data were collected for three years before and 1.5 years after the six-month implementation of the CPS model of care. RESULTS: There were 559 restraint and 1,671 seclusion events during the study period. After implementation of the CPS model there was a reduction in the use of restraints (from 263 events to seven events per year, representing a 37.6-fold reduction, slope [beta]=-.696) and seclusion (from 432 to 133 events per year, representing a 3.2-fold reduction, beta=-.423). The mean duration of restraints decreased from 41+/-8 to 18+/-20 minutes per episode, yielding cumulative unitwide restraint use that dropped from 16+/-10 to .3+/-.5 hours per month (a 45.5-fold reduction, beta=-.674). The mean duration of seclusion decreased from 27+/-5 to 21+/-5 minutes per episode, yielding cumulative unitwide seclusion use that dropped from 15+/-6 to 7+/-6 hours per month (a 2.2-fold reduction; p for trend .01 or better for all slopes). During the early phases of implementation there was a transient increase in staff injuries through patient assaults. CONCLUSIONS: CPS is a promising approach to reduce seclusion and restraint use in a child psychiatric inpatient setting. Future research and replication efforts are warranted to test its effectiveness in other restrictive settings.