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.

• 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

• 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

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.

• 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