Integrating Psychiatric Services in the Emergency Room to Improve Patient Care by Using Quality Improvement Methods

Abstract

Prolonged length of stay in emergency departments (EDs) for patients with a psychiatric chief complaint is a widespread problem. Prolonged stays can lead to adverse outcomes and poor quality of care. We sought to improve quality of care for patients in the medical ED who needed psychiatric care. To identify the areas of weakness, we queried the ED staff via an online survey about the perception of the challenges working with our Comprehensive Psychiatric Emergency Program (CPEP), which is located adjacent to and works closely with the medical ED providing psychiatric consultation. We identified several action steps and used the Plan-Do-Study-Act methodology for implementation. We reported a reduction in time to complete consultations and improved communication between CPEP and the medical ED staff.

Improving emergency department care for adults presenting with mental illness: a systematic review of strategies and their impact on outcomes, experience, and performance

“…Twenty-six of the 46 articles reported on strategies that encompassed all mental illness presentations to the ED ( Table 4 ). The 11 types of strategies implemented in ED included decision support tools [e.g., modifications to electronic medical record (EMR)] ( 62 , 63 , 67 , 79 ), discharge and transfer of care (e.g., collaboration and communication processes) ( 62 , 63 , 81 ), liaison psychiatry services (e.g., included ED staff in meetings) ( 63 ), telepsychiatry (e.g., assessment) ( 64 , 82 ), changes to roles and rostering (e.g., mental health professions in ED) ( 63 , 65 , 69 , 73 , 78 , 80 , 83 ), specialised units within ED (e.g., behavioural assessment unit) ( 66 , 72 , 75 , 76 , 85 , 86 ), education and training (e.g., related to mental illness) ( 68 ), intervention teams (e.g., multidisciplinary team) ( 70 , 84 ), standardising protocols (e.g., procedures for agitated behaviour management) ( 71 , 78 , 79 , 86 , 87 ), environmental design (e.g., glass doors) ( 74 ), and case management (e.g., facilitating connections with services) ( 77 , 86 ). System performance effects (e.g., ED LoS and use of restraint) were reported for all 11 strategies, 7 strategies reported patient outcomes (e.g., ED utilisation), 6 strategies reported patient experience (e.g., preferences), and 8 strategies reported staff experience (e.g., confidence).…”

“…Fourteen of the 26 articles included an academic medical centre ( 63 , 65 , 66 , 68 , 70 , 74 , 76 , 77 , 79 , 83 – 87 ), and 3 of the 26 included a community hospital ( 62 , 69 , 73 ). Nine of the 26 studies did not report the type of participating hospital ( 64 , 67 , 71 , 72 , 75 , 78 , 80 – 82 ). Eighteen of the 26 articles were conducted in urban settings ( 63 , 65 , 66 , 68 – 70 , 72 , 75 – 77 , 79 – 81 , 83 – 87 ), with one reporting an additional rural site ( 84 ), and two reported only rural sites ( 73 , 82 ).…”

“…Eighteen of the 26 articles were conducted in urban settings ( 63 , 65 , 66 , 68 – 70 , 72 , 75 – 77 , 79 – 81 , 83 – 87 ), with one reporting an additional rural site ( 84 ), and two reported only rural sites ( 73 , 82 ). Five of the 26 studies did not report the setting as either urban or rural ( 62 , 64 , 67 , 71 , 74 , 78 ). Thirteen articles reported that the participating EDs were connected with psychiatric crisis services ( 62 , 69 – 71 , 74 – 76 , 78 , 79 , 82 , 85 – 87 ), and 13 did not ( 20 , 63 – 68 , 72 , 73 , 77 , 80 , 81 , 83 ).…”

“…Five of the 26 studies did not report the setting as either urban or rural ( 62 , 64 , 67 , 71 , 74 , 78 ). Thirteen articles reported that the participating EDs were connected with psychiatric crisis services ( 62 , 69 – 71 , 74 – 76 , 78 , 79 , 82 , 85 – 87 ), and 13 did not ( 20 , 63 – 68 , 72 , 73 , 77 , 80 , 81 , 83 ).…”

“…Similarly, strategies for suicide and deliberate self-harm presentations focused on assessment, care plan development and connecting with community-based support ( 53 – 55 , 58 – 61 ). Strategies for mental illness presentations in general included modifications to the EMR to support decision making ( 62 , 63 , 67 , 79 ), additional mental health roles ( 69 , 73 , 78 , 80 , 83 ) and intervention teams ( 70 , 84 ), designated spaces for psychosocial assessment, treatment and referral ( 66 , 72 , 75 , 76 , 86 ), and refined discharge processes ( 62 , 63 , 81 ). For EDs and the communities they serve, considered selection of strategies and measures is essential in ensuring responsive, safe, and timely emergency care; however, without detailed descriptions of ED settings and use of common outcome measures, identification of high-impact interventions that might be transferable is challenging.…”