Marked reduction in length of stay for patients with psychiatric emergencies after implementation of a comanagement model - PubMed (original) (raw)

Comparative Study

Marked reduction in length of stay for patients with psychiatric emergencies after implementation of a comanagement model

Steven K Polevoi et al. Acad Emerg Med. 2013 Apr.

Abstract

Objectives: Patients with psychiatric emergencies often spend excessive time in an emergency department (ED) due to limited inpatient psychiatric bed capacity. The objective was to compare traditional resident consultation with a new model (comanagement) to reduce length of stay (LOS) for patients with psychiatric emergencies. The costs of this model were compared to those of standard care.

Methods: This was a before-and-after study conducted in the ED of an urban academic medical center without an inpatient psychiatry unit from January 1, 2007, through December 31, 2009. Subjects were all adult patients seen by ED clinicians and determined to be a danger to self or others or gravely disabled. At baseline, psychiatry residents evaluated patients and made therapeutic recommendations after consultation with faculty. The comanagement model was fully implemented in September 2008. In this model, psychiatrists directly ordered pharmacotherapy, regularly monitored effects, and intensified efforts toward appropriate disposition. Additionally, increased attending-level involvement expedited focused evaluation and disposition of patients. An interrupted time series analysis was used to study the effects of this intervention on LOS for all psychiatric patients transferred for inpatient psychiatric care. Secondary outcomes included mean number of hours on ambulance diversion per month and the mean number of patients who left without being seen (LWBS) from the ED.

Results: A total of 1,884 patient visits were considered. Compared to the preintervention phase, median LOS for patients transferred for inpatient psychiatric care decreased by about 22% (p < 0.0005, 95% confidence interval [CI] = 15% to 28%) in the postintervention phase. Ambulance diversion hours increased by about 40 hours per month (p = 0.008, 95% CI = 11 to 69 hours) and the mean number of patients who LWBS decreased by about 26 per month (p = 0.106; 95% CI = -60 to 5.9 visits per month) in the postintervention phase.

Conclusions: A comanagement model was associated with a marked reduction in the LOS for this patient population.

© 2013 by the Society for Academic Emergency Medicine.

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Figures

Figure 1

Figure 1

ED LOS for patients transferred to a psychiatric inpatient facility. LOS is log transformed. The vertical line represents full implementation of the co-management model.

Figure 2

Figure 2

Change in the average hours of ambulance diversion per month. The vertical line represents full implementation of the co-management model.

Figure 3

Figure 3

Change in the average number of patients per month who left the ED without being seen by physicians. The vertical line represents full implementation of the co-management model.

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