Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Introduction: As the population of New Orleans continues to increase, psychiatric services at its main safety-net hospital, the relatively new University Medical Center New Orleans (UMCNO), have had to increase with it. At UMCNO, psychiatric patients in the emergency department (ED) are ideally managed in the behavioral health emergency room (BHER) until either admission, transfer, or discharge. The BHER holds 26 beds, but staffing limitations prevent all 26 from being open continuously. Historically, there are fewer discharges from inpatient psychiatric units citywide on weekends, which then causes overflow of the BHER into the main ED and slows throughput throughout the hospital. Because of this, elasticity in the system and effective reassessments by the emergency psychiatry consult service are key to minimizing lengths of stay and saturation events.

Methods: In April 2018, efforts were undertaken to create more elasticity in the BHER as well as more effective handoffs to easily identify what is needed for each patient to ensure a safe discharge. Changes included the following: actively anticipating the need to expand to 26 beds starting Sunday evening; creating a mindset of “continuously seeking an inpatient bed” during peak times; and using the electronic health record (EHR) for handoffs between providers. Lengths of stay (LOS) for patients in the BHER as well as hours on psychiatric saturation were tracked monthly before and after the changes were made, as were the total number of emergency psychiatry consults, discharge rates, and transfer rates.

Results: The number of consults per day has been increasing by about 13.8% a month over the last few years and is now around 16-17 a day. The service discharges about 45% of the patients consulted to us; and of those requiring admission, about 35% are transferred to other psychiatric unit, with the rest being admitted to UMCNO’s 60-bed inpatient psychiatric unit. Looking at the seven months before and after the changes were made, the average LOS has decreased from 15.98 hours to 13.78 hours (a 17% decrease), and the number of hours on saturation decreased from 42.3 hours a month to 19.2 hours (a 55% decrease).

Discussion: While our goal of zero hours on saturation was not met, the data show that by planning for the increase in volume during the weekend with more staff starting Sunday evening to open all 26 beds, we were able to lower saturation hours, which helps throughput in the main ED and throughout the hospital. Furthermore, by increasing the hours of clerks on weekends (who are responsible for transferring patients when our inpatient unit is full), we were able to transfer more patients throughout the weekend than previously. And finally, by integrating our handoff within our EHR, we were able to quickly identify those patients who could potentially be discharged safely and what was needed to ensure that safe discharge. Combined, these efforts lowered the average of LOS in the BHER.