Study Addresses Factors Prolonging ED Visits For Psychiatric Patients

Michael Wilson, MD, PhD, FAAEM Attending Physician, UCSD Department of Emergency Medicine Director, Department of Emergency Medicine Behavioral Emergencies Research (DEMBER) lab UC San Diego Health SystemMedicalResearch.com Interview with:
Michael Wilson, MD, PhD, FAAEM
Attending Physician, UCSD Department of Emergency Medicine
Director, Department of Emergency Medicine Behavioral Emergencies Research (DEMBER) lab UC San Diego Health System

MedicalResearch: What is the background for this study? What are the main findings?

Dr. Wilson: Emergency departments (EDs) nationwide are crowded. Although psychiatric patients do not make up the largest proportion of repeat visitors to the emergency department, psychiatric patients stay longer in the ED than almost any other type of patient. So, it’s really important to find out things about these patients that may predict longer stays.

In this study, we looked at patients on involuntary mental health holds. The reasoning is simple: patients on involuntary mental health holds aren’t free to leave the ED. So, the only thing that should really matter is how quickly an Emergency department can release them from the involuntary hold. Surprisingly, though, this wasn’t the only thing that correlated with longer stays.

MedicalResearch: What should clinicians and patients take away from your report?

Dr. Wilson: Unlike other research which has focused solely on the structure of the ED and community resources, this study focused on what things that both the emergency department and the Emergency department physician did that seem to make disposition faster for patients on involuntary mental health holds.

This really is a new way to look at the problem. There are lots of things about the patient and about the way that the psychiatry service is structured that seem to correlate with longer stays for these patients. For instance, how quickly the psychiatry service can clear the hold really seems to matter a lot, just as you’d expect. So, patients in this study stayed longer on the weekends when the psychiatry attendings don’t round in our Emergency department.

Patient complaint also seems to correlate with longer stays. So, for instance, patients with thoughts of self-harm stay longer in the emergency department. Although we don’t know the reason for this, it may be because these patients need longer evaluations by trained specialists.

Most surprising was that medication by Emergency department physicians also seem to matter. Although presence of agitation didn’t seem to correlate with longer stays, the fact that patients received medications did. The reasons for this are unknown. It may be that the type of patients on involuntary health holds who receive medication naturally need more workup in the emergency department. It may also be that physicians in the emergency department tend to prescribe medications that make people sleep longer, and so it is more difficult to evaluate and discharge them. Or, it may be from some other combination of factors entirely.

Either way, it suggests that even in patients on involuntary health holds, both what the emergency department does and the type of working relationship the Emergency department has with psychiatry, matter greatly. Although we might all wish for better community resources, the ED itself can help speed evaluate and discharge these patients more quickly.

MedicalResearch: What recommendations do you have for future research as a result of this study?

Dr. Wilson: Further prospective research is badly needed, looking at 3 things:

1) Patient factors that might make a certain patient stay longer in the ED;

2) ED factors that might contribute to longer stays; and

3) Physician-specific factors that might contribute to the problem.

In other words, perhaps Emergency department physicians could use different types of medications that have been shown to calm patients but not put them to sleep. This might allow patients to leave the Emergency department more quickly. We also don’t know much about the optimum working relationship with psychiatry. How many mental health workers are needed? How often should they see patients? These sorts of questions are important for helping manage Emergency department overcrowding.

Citation:

Lengths of stay for involuntarily-held psychiatric patients in the emergency department are affected both by patient characteristics and medication use

Michael P. Wilson, MD, PhD Jesse J. Brennan, MA Lucia Modesti, MD James Deen, BA Laura Anderson, BA Gary M. Vilke, MD Edward M. Castillo, PhD, MPH The American Journal of Emergency Medicine Available online 20 January 2015

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MedicalResearch.com Interview with:, & Michael Wilson, MD, PhD, FAAEM (2015). Study Addresses Factors Prolonging ED Visits For Psychiatric Patients MedicalResearch.com

Last Updated on June 10, 2015 by Marie Benz MD FAAD