Hospital-based EDs are increasingly overburdened throughout the United States, resulting in a widening gap between the quality of emergency care Americans expect and the quality of care they actually receive. Longer lengths of stay within the ED have led to increased provider stress, greater risks for adverse events, and reduced patient satisfaction. Length of stay for patients seeking psychiatric care in the ED appears to be even longer than that of people without psychiatric concerns. This fact, when coupled with an increasing volume of psychiatric visits to EDs (23% growth between 2000 and 2007), have led to a real crisis for this vulnerable population in psychiatric distress.
Identifying patient and clinical factors associated with long ED lengths of stay for psychiatric patients is critical to the development and implementation of targeted quality improvement efforts. To that end, my colleagues and I conducted a study to seek out these factors in this patient population and measure the effect of these variables on time spent within the ED. Our prospective analysis, published in the May 2, 2012 Annals of Emergency Medicine, involved 1,092 adults treated at one of five EDs. Secondary analyses considered patients discharged home and those who were admitted or transferred separately.
Factors That Increase Hospital Length of Stay
According to the findings from our study, the average length of stay in the ED was 11.5 hours for psychiatric patients, but lengths varied based on certain characteristics. Patients who were discharged home stayed 8.6 hours in the ED, while those admitted to psychiatric units within the hospital stayed 11.0 hours. Patients transferred to outside units within the local healthcare system waited in the ED for an average of 12.9 hours, but those transferred to facilities outside the local healthcare system waited 15.0 hours.
“Factors outside the direct control of the ED, including bed availability, may have an even more dramatic influence on ED length of stay.”
In addition, our investigation showed that older age and insurance status were linked to longer ED lengths of stay. Younger patients (aged 18 to 39) with psychiatric illnesses waited for less time in the ED than people who were older than 60 (10.7 vs 12.6 hours). Patients without insurance spent 4.0 hours longer in the ED than other groups. In addition, one-third of patients with psychiatric illnesses tested positive for alcohol on toxicology screenings. Patients with toxicology screens positive for alcohol stayed an average of 6.2 hours longer in EDs than those without positive toxicology screens. Diagnostic imaging was associated with a 3.2-hour greater length of stay and prolonged early and late components of the ED stay. Restraint use had a similar effect, leading to a 4.2-hour longer length of stay when compared with those not requiring restraints.
Important Implications for Psychiatric Patients
Our study identified some clear targets for improving throughput of psychiatric patients in the ED. For example, developing innovative methods for managing intoxicated patients and carefully reviewing protocols for toxicology screens, restraints, and diagnostic imaging may reduce wait times. Moreover, our study suggested that factors outside the direct control of the ED, including bed availability, may have an even more dramatic influence on ED length of stay. Further research to specifically examine care redesign interventions in this population is essential. In particular, understanding the impact on ED flow of changes outside the ED that may improve access to care (eg, expanding access to psychiatric inpatient beds) is an important next step.
Readings & Resources (click to view)
Weiss AP, Chang G, Rauch SL, et al. Patient and practice-related determinants of emergency department length of stay for patients with psychiatric illness. Ann Emerg Med. 2012 May 2 [Epub ahead of print]. Available at: http://www.annemergmed.com/webfiles/images/journals/ymem/FA-APWeiss.pdf.
American College of Emergency Physicians. Psychiatric and substance abuse survey 2008. Available at: http://www.acep.org/uploadedFiles/ACEP/Advocacy/federal_issues/PsychiatricBoardingSummary.pdf.
Slade EP, Dixon LB, Semmel S. Trends in the duration of emergency department visits, 2001-2006. Psychiatr Serv. 2010;61:878-884.
Kropp S, Andreis C, Te Wildt BT, et al. Psychiatric patients’ turnaround times in the emergency department. Clin Pract Epidemiol Ment Health. 2005;1:27.
Park JM, Park LT, Siefert CJ, et al. Factors associated with extended length of stay for patients presenting to an urban psychiatric emergency service: a case-control study. J Behav Health Serv Res. 2009;36:300-308.
Alakeson V, Pande N, Ludwig M. A plan to reduce emergency room “boarding” of psychiatric patients. Health Aff (Millwood). 2010;29:1637-1642.
Chang G, Weiss AP, Orav EJ, et al. Hospital variability in emergency department length of stay for adult patients receiving psychiatric consultation: a prospective study. Ann Emerg Med. 2011;58:127-136.
Lukens TW, Wolf SJ, Edlow JA, et al. Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med. 2006;47:79-99.
Slade M, Taber D, McGuire-Clarke M, et al. Best practices for the treatment of patients with mental and substance use illnesses in the emergency department. Dis Mon. 2007;53:536-580.