Improvement Report: Reducing Length of Stay in the Emergency Department for Psychiatric Patients

Maine Medical Center and Spring Harbor Hospital
Portland, Maine, USA

Team
An interdisciplinary team was formed with members from both Maine Medical Center and Spring Harbor Hospital, an affiliate psychiatric facility.

David Bachman, MD, Associate Vice President for Inpatient Management, Maine Medical Center
Dennis King, Chief Executive Officer, Spring Harbor Hospital
Girard Robinson, MD, Chief of Psychiatry, Maine Medical Center and Spring Harbor Hospital
Joy Moody, MSN, Head Nurse, Emergency Services, Maine Medical Center
Michael Gibbs, MD, Chief of Emergency Medicine, Maine Medical Center
Mary Jane Krebs, APRN, Vice President of Clinical Services, Spring Harbor Hospital
Mary Jean Mork, LCSW, Director, Assistance Referral and Centralized Services, Spring Harbor Hospital
Jonathan McCarthy, MSN, Head Nurse, Psychiatry, Maine Medical Center
Michael Baumann, MD, Medical Director, Department of Emergency Services, Maine Medical Center
Joyce Cotton, APRN, Associate Chief of Nursing, Spring Harbor Hospital

Aim
The aim of this multidisciplinary initiative was to identify measures to decrease the emergency department (ED) length of stay (LOS) for patients requiring psychiatric inpatient admission from over 10 hours on average to 6 hours within 12 months.

Measures
  • Total psychiatric admissions by month
  • ED LOS for psychiatric and nonpsychiatric admissions
  • Patients per month with ED LOS > 12 hours
  • Mean security hours/admitted patient/month
  • Percent compliance with standards for nursing assessments and physician orders for patients in seclusion


Changes

The changes targeted initially were ones intended to streamline the evaluation, referral, and transfer of emergency department (ED) patients requiring psychiatric admission. As the project progressed, the need to address deficiencies in the use of restraint and seclusion, and to improve patient and staff safety, became evident and measures targeting those issues were introduced.

 
1. Length of stay (LOS)
  • Streamlined and standardized clinical information collected
  • Established targets for LOS
  • Standardized patient assessment tools for outpatient and inpatient acute psychiatry
  • Established medical clearance standards and provided staff education
  • Moved pre-certification process from ED to receiving psychiatric units
  •  Re-engineered admission process at Spring Harbor Hospital (SHH), an affiliated psychiatric facility
  • Created multigenerational unit at SHH to increase flexibility in patient placement
  • Formed dedicated admission teams at SHH
 
2. Seclusion and restraint utilization
  • Recognized need to decrease use of seclusion and restraint and to increase compliance with JCAHO standards
  • Established an Administrative Psychiatric Care Workteam
  • Established a Clinical Psychiatric Care Workteam
  • Initiated 100 percent audit of secluded and restrained patient charts
  • Developed Psychiatric Standard of Care and Psychiatric Care Guidelines
  • Created a dedicated psychiatric nurse assignment
  • Provided staff education
  • Created Seclusion and Restraint Order Sheet
  • Provided staff training on management of aggressive behavior
  • Trained all security and ED staff
  • Established an appropriate care area with controlled access by remodeling ED

 

 

Results


Graph_MaineMedical_TotalPsychiatricAdmissions.jpg

Graph_MaineMedical_LOSPsychiatricAdmissions.jpg

Graph_MaineMedical_PsychiatricAdmissionswithEDLOS.jpg
Graph_MaineMedical_SecuritlyhoursperAdmittedPatients.jpg


Graph_MaineMedical_PercentCompliancewithStandardsforPatientsinSeclusion.jpg

Summary of Results / Lessons Learned / Next Steps

Through a concerted interdisciplinary team effort, the ED length of stay for patients requiring psychiatric admission decreased from a peak of nearly 18 hours to just slightly over 6 hours by June 2003, with a marked decrease in the number of patients per month whose LOS was greater than 12 hours. As LOS decreased, the overall need for security staff also decreased and compliance with JCAHO standards for restraint and seclusion increased dramatically. All this occurred despite a 37 percent increase in the number of ED patients admitted for psychiatric care during the intervention period.

 
Lessons Learned:
  • 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.


Contact Information

David Bachman, MD Associate Vice President for Inpatient Management
Maine Medical Center
22 Bramhall Street
Portland, ME 04012
bachmd@mmc.org

 
[Storyboard presentation at IHI's National Forum, December 2003]

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