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Service Delivery Innovation Profile

Streamlined Evaluation, Transfer, and Admission Processes Significantly Reduce Waiting Times for Emergency Department Patients Awaiting Admission to Psychiatric Facility


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Snapshot

Summary

A multidisciplinary team from Maine Medical Center and Spring Harbor Hospital (Maine Medical Center's affiliated psychiatric facility) streamlined the evaluation, transfer, and admission processes for psychiatric patients presenting to Maine Medical Center's emergency department. The program reduced the average amount of time that these patients spend in the emergency department before being transferred to Spring Harbor Hospital from more than 10 hours to approximately 6 hours.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key metrics, including average ED LOS and the number of ED patients waiting more than 12 hours before being admitted to a psychiatric facility.
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Developing Organizations

Maine Medical Center; Spring Harbor Hospital
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Date First Implemented

2002
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Patient Population

Vulnerable Populations > Mentally illend pp

Problem Addressed

Reduced availability of public mental health and substance abuse services has contributed to an increase in patients with psychiatric conditions presenting to emergency departments (EDs). Most patients with psychiatric emergencies require admission to an inpatient psychiatric facility; however, due to a shortage of capacity, most patients must wait in the ED for hours until a bed becomes available. The increase in psychiatric "boarders" in the ED has negative repercussions for ED staff and for patients with psychiatric and nonpsychiatric emergencies.1
  • Many psychiatric patients being boarded in EDs: A 2008 survey of 328 physicians conducted by the American College of Emergency Physicians found that 79 percent of respondents had "boarded" psychiatric patients in the ED. Among those responding affirmatively, 90 percent indicated that boarding occurs weekly, and 55 percent said it occurs daily or several times a week.2
  • Leading to long waits without treatment: Even after the decision to admit to a psychiatric facility has been made, more than 60 percent of patients remain in the ED for 4 hours or more, 33 percent stay more than 8 hours, and 6 percent stay more than 24 hours. At Maine Medical Center, the problem was particularly acute, with 59 percent of psychiatric patients spending 10 hours or longer in the ED. The aforementioned survey also found that 62 percent of hospital EDs are unable to provide psychiatric services to patients while they await transfer,2 which can lead to increased patient agitation and/or aggression.
  • Negative impact on staff and other patients: In addition to the negative impact on psychiatric patients, the increase in psychiatric "boarders" and the long waits limit the ability of ED staff to care for other patients, thus increasing their overall wait times and levels of frustration.1

What They Did

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Description of the Innovative Activity

A multidisciplinary team from Maine Medical Center and Spring Harbor Hospital streamlined the evaluation, transfer, and admission processes for psychiatric patients presenting to Maine Medical Center's ED, with the goal of reducing waiting times before patients are admitted to the psychiatric facility. Key elements of the program include the following:
  • Concurrent medical/psychiatric evaluation: Previously, psychiatric evaluation occurred only after completion of the medical clearance process to confirm that the patient is medically healthy enough to be transferred to Spring Harbor Hospital (which does not provide advanced medical treatments). Now, the psychiatric evaluation occurs concurrently with the medical clearance process, with psychiatric staff beginning the evaluation while ED clinicians perform a medical evaluation and/or await diagnostic test results.
  • Standardized assessment and documentation: Staff at the Maine Medical Center ED, the Maine Medical Center psychiatric department, and Spring Harbor Hospital use standardized psychiatric assessment and documentation tools, thus eliminating duplicative information-gathering processes. Previously, each facility used different tools.
  • Redesigned ED layout to protect privacy, safety: The Maine Medical Center ED has been redesigned to maximize patient safety and privacy. For example, the psychiatric area is now a locked unit with six private rooms that can be monitored from the nurses' station. In addition, new unit fixtures that maximize patient safety have been installed.
  • Streamlined precertification process: Previously, Maine Medical Center staff performed the precertification process for managed care patients, meaning that patients had to wait in the ED for precertification before transfer. Now, patients are transferred first, with Spring Harbor staff performing precertification after patients arrive at the facility.
  • Streamlined admission process at psychiatric facility: To expedite admission at Spring Harbor Hospital, dedicated admission teams staffed by nurses, social workers, and bachelor's-level psychiatric technicians are assigned to patients transferred from the Maine Medical Center ED. The Spring Harbor Hospital admission process also allows some flexibility in bed assignment to facilitate timely admission; for example, if no open beds are available on an adolescent psychiatric unit, an adolescent can be admitted to an adult unit rather than waiting indefinitely in the Maine Medical Center ED.
  • Ongoing monitoring: The team monitors monthly performance indicators to evaluate the program's impact (see the Planning and Development section for more information on the performance indicators that are tracked).

Context of the Innovation

Maine Medical Center, a tertiary academic medical center serving the greater Portland region, functions as the primary referral hospital for the state. Maine Medical Center's ED serves approximately 80,000 patients annually, including roughly 5,000 psychiatric patients. The ED transfers psychiatric patients who require inpatient care to Spring Harbor Hospital, a 100-bed freestanding psychiatric hospital affiliated with Maine Medical Center; roughly 60 percent of Spring Harbor admissions come from Maine Medical Center's ED. The two facilities jointly operate two dozen psychiatric programs that comprise Maine's Mental Health Network, and Spring Harbor's chief medical officer serves as the chief psychiatrist at Maine Medical Center, which helps ensure consistency of clinical practice. The program was developed after physicians and staff realized that a significant number of patients with psychiatric emergencies who presented to Maine Medical Center's ED had to wait several hours before being admitted to Spring Harbor.

Did It Work?

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Results

Pre- and post-implementation data from fiscal years 2002 and 2003 show that, over 12 months, the program significantly reduced waiting times for psychiatric patients in Maine Medical Center's ED.
  • Shorter waits: The average length of stay (LOS) for psychiatric patients in Maine Medical Center's ED fell from more than 10 hours to 6 hours (meeting the program's stated goal), with the improvement being sustained over time.
  • Fewer lengthy waits: The mean number of ED psychiatric patients who had to wait more than 12 hours before admission to Spring Harbor Hospital fell from 29 to 15 per month. This decline occurred despite an increase in the mean number of monthly psychiatric inpatient admissions, from 118 to 148.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key metrics, including average ED LOS and the number of ED patients waiting more than 12 hours before being admitted to a psychiatric facility.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Forming performance improvement team: With support from Maine Medical Center's executive team (chief executive officer, chief financial officer, chief medical officer, and chief nursing officer), a multidisciplinary team (consisting of psychiatrists, ED physicians, nurses, and social workers from Spring Harbor Hospital, Maine Medical Center's ED, and Maine Medical Center's psychiatric department) formed to evaluate the problem and develop performance improvement goals, strategies for meeting those goals, and performance indicators for evaluating success. (See below for more information on these performance indicators.)
  • Collecting and analyzing data: The team analyzed data on ED LOS and studied patient and workflow processes. The analysis of ED psychiatric admissions and LOS revealed that 59 percent of psychiatric patients spent 10 hours or longer in the ED.
  • Securing staff support: The team showed the data to staff members and emphasized that processes could be revised to improve care and service quality to patients.
  • Determining source(s) of delay: A review of care process steps identified several causes of delay, including inconsistencies in the medical clearance process, a requirement that clinicians complete the medical clearance process before initiating a psychiatric evaluation, lack of standardized psychiatric assessment and documentation forms across the facilities, and a requirement for precertification for managed care patients.
  • Selecting improvement indicators and targets: The team identified several indicators to track on a monthly basis, including number of psychiatric patients admitted, average ED LOS for psychiatric and nonpsychiatric admissions, number of patients admitted to a psychiatric facility who wait in ED for more than 12 hours, and number of patients who leave the ED before being discharged. The team also established a target LOS of 6 hours for psychiatric patients in the Maine Medical Center ED.
  • Staff education: Staff on the inpatient and admitting units of Spring Harbor Hospital received inservice training to educate them about the importance of timely transfer from the ED to the psychiatric hospital.
  • Facility redesign: A committee of psychiatry staff and consumers met to discuss ways to redesign the facility to maximize patient safety and privacy.

Resources Used and Skills Needed

  • Staffing: No additional personnel were required for development or ongoing operation of the program; staff incorporate new processes as part of their existing duties.
  • Costs: Program costs are minimal, because staff participate as part of their regular duties.
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Funding Sources

Maine Medical Center
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Adoption Considerations

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Getting Started with This Innovation

  • Form interdisciplinary team: The team should consist of hospital staff involved in caring for patients with psychiatric emergencies, including psychiatrists and ED physicians. The team should promote the common goal of transferring patients quickly and safely.
  • Identify and quantify magnitude of problems: Collect data on the number of psychiatric admissions and average ED waiting times, and share these data with relevant stakeholders to highlight the magnitude of the overall problem. Break the data down to highlight different components of the problem (e.g., time spent waiting to see the doctor, getting medical clearance, awaiting handoffs), and then use this data to identify specific opportunities for improvement. In addition, consider collecting data on the types of psychiatric patients who use the ED and the reasons they do so; for example, if some mentally ill patients use the ED for primary care needs, the hospital could consider strategies for improving access to these services.
  • Get input from the team: Share the data with the team and ask members for input on needed process improvements.
  • Target across-the-board improvements: Broad-based revisions in care processes are generally more effective than sequential, narrow efforts.
  • Involve and educate frontline staff: Educate and get input from the staff that will be responsible for implementing the new policies. Without this step, it may be difficult to change traditional beliefs about psychiatric admissions.

Sustaining This Innovation

  • Monitor outcomes and make refinements as needed: Continue to monitor data to determine whether progress is being maintained; make program adjustments if the data identify new problem areas. Without such monitoring, it is easy to slip back into old patterns of behavior.
  • Emphasize multidisciplinary cooperation: Maintain the focus on patient-centered care and inter-hospital, multidisciplinary cooperation to avoid retreating into a "silo" mindset.
  • Expect delays with complex patients: Medically complex patients will inevitably take longer to evaluate and admit to the psychiatric facility. Consider developing special psychiatric units to handle these complex, hard-to-place psychiatric patients, such as children or adults with developmental disorders.

More Information

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Contact the Innovator

Girard E. Robinson, MD
Professor of Psychiatry
Tufts University School of Medicine
Chief of Psychiatry, Maine Medical Center
Chief Medical Officer, Spring Harbor Hospital
123 Andover Rd.
Westbrook, ME 04092
Phone: (207) 761-2204
Fax: (207) 761-2108
E-mail: Robinsong@memhp.org

Innovator Disclosures

Dr. Robinson has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Improvement report: reducing length of stay in the emergency department for psychiatric patients. Institute for Healthcare Improvement. Available at: http://www.ihi.org/knowledge/Pages/ImprovementStories
/MemberReportReducingLengthofStayintheEDforPsychiatricPatients.aspx

Footnotes

1 Mulligan KM. ER docs report large increase in psychiatric patients. Professional News. Psychiatric News; June 18, 2004. Available at: http://psychnews.psychiatryonline.org/newsArticle.aspx?articleid=107619
2 American College of Physicians Psychiatric and Substance Abuse Survey 2008. Available at: http://www.acep.org/uploadedFiles/ACEP/Advocacy/federal_issues/PsychiatricBoardingSummary.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
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Original publication: April 14, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: May 22, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: April 18, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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