The extended boarding of psychiatric patients is an issue facing many emergency departments today. Appropriate and timely treatment alternatives aren’t always readily available. And as a result, patients are left to wait in EDs, occupying much-needed beds and increasing the hospital’s average length of stay (LOS).
In most instances, psychiatric patients don’t require the services an ED is equipped to provide. However, the closing of mental health and substance abuse facilities in states across the country result in fewer options for immediate care for patients suffering from psychiatric disorders. For many of these patients, the ED is nothing more than a waiting room.
An account of how one ED in Maine — Maine Medical Center — was able to transform its evaluation, transfer and admission process for its psychiatric patients offers sound strategies many EDs can adopt for reducing overall length of stay for these patients.
The researchers, whose report was published by the Institute for Healthcare Improvement, had a simple goal: decrease the ED’s average LOS for psychiatric patients from 10 hours to 6 hours. Over the next year, they worked to identify strategies to meet their goal.
What did they do?
For starters, researchers looked at the data. They identified key measures to help guide the steps needed to be taken to decrease LOS among its psychiatric patients. For example, they looked at total psychiatric admissions by month and patients per month with an LOS greater than 12 hours. Researchers also looked at the LOS for psychiatric patients and non-psychiatric patients admitted to the hospital and the mean security hours of each admitted patient per month.
After evaluating the data, researchers decided upon, and implemented, these eight changes to Maine Medical Center’s evaluation, transfer and admission process of psychiatric patients:
- Streamline and standardize clinical information collected
- Establish targets for LOS
- Standardize patient assessment tools for outpatient and inpatient acute psychiatry
- Establish medical clearance standards and provided staff education
- Move pre-certification process from ED to receiving psychiatric units
- Re-engineer admission process at Spring Harbor Hospital (SHH), an affiliated psychiatric facility
- Create multigenerational unit at SHH to increase flexibility in patient placement
- Form dedicated admission teams at SHH
A key change for Maine Medical Center was to work with its affiliated psychiatric facility — Spring Harbor Hospital — to help streamline the transfer and admission process. They did this while also tackling internal security issues related to the use of restraint and seclusion of psychiatric patients. (This was necessary to heighten safety of both patient and staff.)
By implementing a few strategies while focusing on security, safety and teamwork, researchers witnessed dramatic results. LOS dropped from its peak of almost 18 hours to just over 6 hours, even though Maine Medical Center experienced a 37-percent increase in the number of psychiatric patients it saw. And with this decrease in LOS, came less need for security staff.
What can other EDs learn from the experience of Maine Medical Center? Researchers sum it up this way:
- Include the right members on the interdisciplinary team.
- When appropriately focused and coordinated, the interdisciplinary workteam can do much to streamline patient management and disposition processes.
- Think openly. Broad-based and simultaneous revisions of care processes engender much more process improvement than sequential, more narrowly based efforts.
- Are psychiatric patients presenting to your emergency department experiencing an increased length of stay? Donovan and Partners can assess your current processes to help expedite the evaluation, transfer and admission of psychiatric patients arriving at your ED. Feel free to drop me a line or message me directly.
Institute for Healthcare Improvement: “Improvement Report: Reducing Length of Stay in the Emergency Department for Psychiatric Patients”