A Quality Measurement Framework for Emergency Department Care of Psychiatric Emergencies.

As a primary access point for crisis psychiatric care, the emergency department (ED) is uniquely positioned to improve the quality of care and outcomes for patients with psychiatric emergencies. Quality measurement is the first key step in understanding the gaps and variations in emergency psychiatric care to guide quality improvement initiatives. Our objective was to develop a quality measurement framework informed by a comprehensive review and gap analysis of quality measures for ED psychiatric care. We conducted a systematic literature review and convened an expert panel in emergency medicine, psychiatry, and quality improvement to consider if and how existing quality measures evaluate the delivery of emergency psychiatric care in the ED setting. The expert panel reviewed 48 measures, of which 5 were standardized, and 3 had active National Quality Forum endorsement. Drawing from the measure appraisal, we developed a quality measurement framework with specific structural, process, and outcome measures across the ED care continuum. This framework can help shape an emergency medicine roadmap for future clinical quality improvement initiatives, research, and advocacy work designed to improve outcomes for patients presenting with psychiatric emergencies.

Comparison of Self-Administered Post Traumatic Stress Disorder Tool vs. Researcher Administered Tool in the Emergency Department.

BACKGROUND: Recent studies have shown that there is a high rate of post traumatic stress disorder in the inner city. OBJECTIVE: The purpose of this study was to determine whether patients in the Emergency Department would use a post traumatic stress disorder (PTSD) assessment. Additionally, did the type of administration of the PTSD tool impact the usage of PTSD services? METHODS: The sample population was taken from patients, 12 years or older, who presented with a non psychiatric illness. This study was done at a level one inner city adult and pediatric Emergency Department. The PTSD validated survey, was randomized between being self or research fellow administered. Half of the patients completed the survey on their own and half were administered by a research fellow. Those who screen positive on the tool were contacted one week later. This was done to determine if they have scheduled an appointment or were seen for a follow-up appointment. This study was IRB approved. RESULTS: A total of 299 participants completed the survey. Half (149) of which used a PTSD tool that was self administered. The total amount of participants who tested positive for PTSD was 35% (105). There was a significant difference (0.01) between those who self administered the tool 26% (40) and those who had the tool administered 12% (18). This was seen in relationship to who was more likely to follow up with behavioral health referrals. CONCLUSIONS: These results reveal that 35% of the participants tested positive for PTSD. The majority of those that screened positive and used follow up services had self administered the tool. This indicates that they are more likely to seek out services based on their results.

Evidence-Based Review Of Pharmacotherapy For Acute Agitation. Part 2: Safety.

BACKGROUND: The management of acute agitation in the emergency department often requires the administration of rapid-acting antipsychotic agents. However, there are few comparative studies and little guidance regarding the risks associated with use of such drugs in the acute setting. OBJECTIVE: This structured evidence-based review compared the safety of antipsychotic pharmacotherapies for acute agitation using data from randomized controlled trials identified by a literature search of the PubMed database. RESULTS: Based on findings from 34 blinded, randomized controlled trials, common acute adverse effects of second-generation antipsychotics and haloperidol were headache, dizziness, insomnia, and somnolence. There were some differences in incidence of extrapyramidal symptoms (EPS), degree of sedation, and acute QTc prolongations between agents. CONCLUSIONS: The results of this review demonstrate the improved safety (particularly regarding EPS and over-sedation) of certain newer-generation antipsychotic agents compared with haloperidol and benzodiazepines for the treatment of acutely agitated patients. The risk of prolonged QT interval and torsade de pointes needs to be considered with haloperidol and some of the second-generation antipsychotics.

Evidence-Based Review of Pharmacotherapy for Acute Agitation. Part 1: Onset of Efficacy.

BACKGROUND: The main goal of antipsychotic medication in the management of acute agitation in the emergency department is to rapidly induce calm without oversedation, enabling patients to participate in their own care. However, there is a paucity of comparative studies, particularly with newer fast-acting second-generation antipsychotic agents. OBJECTIVE OF THE REVIEW: This structured evidence-based review compared the onset of efficacy of antipsychotic treatments for acute agitation using data from randomized controlled trials identified by a literature search of the PubMed database. RESULTS: Based on findings from 28 blinded randomized controlled trials, onset of efficacy was rapid and generally observed at the first time point after intramuscular administration of ziprasidone (15-30 min) or olanzapine (15-30 min), but was more likely to be delayed with intramuscular haloperidol, even when combined with lorazepam (30-60 min), and intramuscular aripiprazole (45-90 min). When administered orally, rapid onset of efficacy was also consistently observed at the first assessment time point with olanzapine (15-120 min), risperidone (30-120 min), and sublingual asenapine (15 min). Significant effects were apparent for inhaled loxapine within 10-20 min. Effects were apparent within approximately 5-10 min with i.v. droperidol. Onset of efficacy was typically more rapid with second-generation antipsychotic agents than benzodiazepines, but data are limited. CONCLUSIONS: Although the patient populations of trials included in this review do not truly reflect that of the emergency department, the results provide useful information to emergency physicians on the rapid efficacy of certain newer-generation antipsychotic agents for the treatment of acutely agitated patients.

Identifying Undiagnosed Pediatric Mental Illness in the Emergency Department.

BACKGROUND: It is well known that pediatric psychiatric patients frequent emergency department (ED), but the number of patients with undiagnosed psychiatric illness presenting to an ED is not well known. Identification and referral of these patients may provide an opportunity for improved patient care. The primary study objective was to identify a tool that can screen for unsuspected psychiatric illness in pediatric patients who present to the ED with non-psychiatric-related complaints. METHODS: The MINI International Neuropsychiatric Interview for Children and Adolescents screening tool was administered to 200 pediatric consenting patients and guardians. The inclusion criteria were English-speaking patients who presented in the ED with a nonpsychiatric complaint who were stable and able to communicate. The study was conducted in a level 1 trauma center ED of an inner-city hospital that serves a predominantly African American and Hispanic population. This study was institutional review board approved. RESULTS: The study populations consisted of 53% African American (107), 45% Hispanic (90), 1% white (2), and 0.5% Asian (1). Their age range was divided, with 49% between 12 and 14 years (98) and 51% between 15 and 17 years (102). The sex was evenly split, with 50% male (100) and 50% female (100). The 41% who did screen positive for an undiagnosed mental illness had a range of diagnoses. The top modules with positive results were oppositional defiant (13.5%, 27), attention-deficit/hyperactivity disorder (13%, 25), depression (10%, 11), conduct disorder (9%, 19), and anxiety (5%, 11). CONCLUSIONS: The pediatric Mini International Neuropsychiatric Interview was effective in screening for undiagnosed mental illness in pediatric patients who presented to the ED with no psychiatric-related illness. The screening tool indicated that 41% of pediatric patients screened positive for an undiagnosed mental illness, with attention deficit-related disorders being the most widely seen. Further study should be conducted to test the tools used in a range of ED settings.

American Association for Emergency Psychiatry Task Force on Medical Clearance of Adult Psychiatric Patients. Part II: Controversies over Medical Assessment, and Consensus Recommendations.

INTRODUCTION: The emergency medical evaluation of psychiatric patients presenting to United States emergency departments (ED), usually termed "medical clearance," often varies between EDs. A task force of the American Association for Emergency Psychiatry (AAEP), consisting of physicians from emergency medicine, physicians from psychiatry and a psychologist, was convened to form consensus recommendations for the medical evaluation of psychiatric patients presenting to U.S.EDs. METHODS: The task force reviewed existing literature on the topic of medical evaluation of psychiatric patients in the ED and then combined this with expert consensus. Consensus was achieved by group discussion as well as iterative revisions of the written document. The document was reviewed and approved by the AAEP Board of Directors. RESULTS: Eight recommendations were formulated. These recommendations cover various topics in emergency medical examination of psychiatric patients, including goals of medical screening in the ED, the identification of patients at low risk for co-existing medical disease, key elements in the ED evaluation of psychiatric patients including those with cognitive disorders, specific language replacing the term "medical clearance," and the need for better science in this area. CONCLUSION: The evidence indicates that a thorough history and physical examination, including vital signs and mental status examination, are the minimum necessary elements in the evaluation of psychiatric patients. With respect to laboratory testing, the picture is less clear and much more controversial.

Design of a pragmatic trial in minority children presenting to the emergency department with uncontrolled asthma: The CHICAGO Plan.

Among children with asthma, black children are two to four times as likely to have an emergency department (ED) visit and die from asthma, respectively, compared to white children in the United States. Despite the availability of evidence-based asthma management guidelines, minority children are less likely than white children to receive or use effective options for asthma care. The CHICAGO Plan is a three-arm multi-center randomized pragmatic trial of children 5 to 11years old presenting to the ED with uncontrolled asthma that compares: [1] an ED-focused intervention to improve the quality of care on discharge to home, [2] the same ED-focused intervention together with a home-based community health worker (CHW)-led intervention, and [3] enhanced usual care. All children receive spacers for the metered dose inhaler and teaching about its use. The Patient-Reported Outcomes Measurement Information System (PROMIS) Asthma Impact Scale and Satisfaction with Participation in Social Roles at 6months are the primary outcomes in children and in caregivers, respectively. Other patient-reported outcomes and indicators of healthcare utilization are assessed as secondary outcomes. Innovative features of the CHICAGO Plan include early and continuous engagement of children, caregivers, the Chicago Department of Public Health, and other stakeholders to inform the design and implementation of the study and a shared research infrastructure to coordinate study activities. The objective of this report is to describe the development of the CHICAGO Plan, including the methods and rationale for engaging stakeholders, the shared research infrastructure, and other features of the pragmatic clinical trial design.

Reasons for readmissions: what are the reasons for 90-day readmissions of psychiatric patients from the ED?

BACKGROUND: Frequent users of the emergency department (ED) contribute to the problem of overcrowding and are more likely to have psychiatric problems and a higher than average 90-day readmission rate. In addition, ED visits due to mental health problems have increased in recent years, thus driving up 90-day readmission rates. OBJECTIVES: The objective of the study is to determine the reasons for readmissions of psychiatric patients who have previously presented to the ED. METHODS: This is a retrospective chart review of a random sample of 350 psychiatric patients who presented to the ED and had a return visit within 90 days. This study was conducted at a 432-bed, urban, level I adult and pediatric trauma center with 50000 ED visits per year. The inclusion criterion was all psychiatric patients who presented to the ED since August 2011 and had a least 1 return visit within 90 days. The exclusion criterion was patients who presented with nonpsychiatric complaints. SPSS version 14 was used, and the study was institutional review board approved. RESULTS: There was a significant difference (P=.01) between the reasons for psychiatric patients to be readmitted to the hospital between their first, second, and third ED visits. The most common reasons for admission on the first visit were depression, schizophrenia, schizoaffective disorder, bipolar disorder, and psychosis. The most common reasons for the second and third visits, however, were psychiatric (61.9%), musculoskeletal (9.2%), cardiovascular (5.7%), neurologic (4.3%), and dermatological (3.2%). CONCLUSIONS: Psychiatric patients are not returning to the ED repeatedly for the same complaints or for only psychiatric complaints. A total of 30% of patients who presented for a second and third time within 90 days were admitted for medical illness, as opposed to their initial psychiatric presentation. This indicates that a 2-pronged approach toward treatment might have to be developed-one that focuses on specific types of mental illness and one that focuses on a separate set of physical illnesses-to reduce 90-day readmission rates within this patient population.

Implementing a third-year emergency medicine medical student curriculum.

BACKGROUND: Emergency medicine (EM) is commonly introduced in the fourth year of medical school because of a perceived need to have more experienced students in the complex and dynamic environment of the emergency department. However, there is no evidence supporting the optimal time or duration for an EM rotation, and a number of institutions offer third-year rotations. OBJECTIVE: A recently published syllabus provides areas of knowledge, skills, and attitudes that third-year EM rotation directors can use to develop curricula. This article expands on that syllabus by providing a comprehensive curricular guide for the third-year medical student rotation with a focus on implementation. DISCUSSION: Included are consensus-derived learning objectives, discussion of educational methods, considerations for implementation, and information on feedback and evaluation as proposed by the Clerkship Directors in Emergency Medicine Third-Year Curriculum Work Group. External validation results, derived from a survey of third-year rotation directors, are provided in the form of a content validity index for each content area. CONCLUSIONS: This consensus-derived curricular guide can be used by faculty who are developing or revising a third-year EM medical student rotation and provide guidance for implementing this curriculum at their institution.

Comparison of Canadian triage acuity scale to Australian Emergency Mental Health Scale triage system for psychiatric patients.

OBJECTIVES: The purpose of the study was to compare the Canadian Triage and Acuity Scale protocol to the Australian Emergency Mental Health Triage System protocol for evaluation of psychiatric patients and time to be evaluated in the emergency department. METHODS: A convenience sample of 105 patients who presented with psychiatric complaints at triage was given the Canadian Triage and Acuity Scale (CTAS) by the nurse at triage. A second triage assessment using the Australian Emergency Mental Health Triage Scale was performed by trained research fellows. The study was performed at an inner city level one trauma center with 40,000 visits per year during 2012. The study was approved by the IRB. RESULTS: Use of the CTAS rated almost half the patients (48%) urgent and (29%) emergent. The Australian Emergency Mental Health Triage Scale scored the same patients differently with (75%) coding as no danger to self or others, (18%) scoring as in moderate distress. The CTAS was not able to meet the recommended times to be seen, especially for patients rated as urgent. The Australian Emergency Mental Health Scale system, with the exception of triage level 1, was able to meet the recommendations for wait times to be medically evaluated and in the case of the lower levels seen sooner than recommended. CONCLUSIONS: The use of the CTAS protocol does not correlate with patients' being medically evaluated within the time frames recommended especially for the more urgent patients. The Australian Emergency Mental Health Scale rated patients' presentations as far less urgent and thus the time frame recommendations to be evaluated were more closely aligned with the protocol as compared to the CTAS system. The Australian Emergency Mental Health Scale provided less ambiguous mental health specific triage guidelines that allowed for improvements in patient outcomes by better matching the ED's resources to the psychiatric patients' specific needs.

Who pays? How reimbursement impacts the emergency department.

BACKGROUND: Nationwide from 1996 to 2004, the overall proportion of Emergency Department (ED) reimbursement ratios for outpatient ED visits decreased from 57% to 42%. The continued falling of ED reimbursement ratios, which is the share of ED charges that are ultimately paid, is an indicator of the financial pressures facing the ED. Once the healthcare reforms are put in place what will the impact be on reimbursement rates of overburdened and underfunded emergency departments. PURPOSE: The purpose of this study is to examine if there is a declining disparity in payment rates for ED care based on payment sources in a safety net ED provider. Findings of this study could indicate how the healthcare reforms might impact these types of ED reimbursement ratios in the upcoming years. METHODS: This was a retrospective study that examined randomly selected charts of all ED visits charts from May 2002 to May 2008 at a level one adult and pediatric emergency trauma center with 45,000 annual visits. This study was IRB approved. RESULTS: A regression model was used to predict if there was a relationship between amount received and types of insurance payers within the ED. A significant relationship was found between types of insurance (payers) as the independent variable, and the dependent variables of charges (p = .00), payments (p = .00), amount of adjustments (p= .00), and balance remaining after 90 days (p = .00). CONCLUSIONS: Who pays for the ED services does impact the ED's bottom line. The privately funded patients will provide an ED with a higher reimbursement ratio per year as compared to those patients who are publicly or self pay. This explains why EDs that provide care for 40% or more publicly or self pay patients have seen a decline in reimbursement ratios. Healthcare reform has the potential to change and possibly improve safety net ED rate of reimbursement depending on how private, public and self pay patients pay for ED services.

Patient transfer from a rehabilitation hospital to an emergency department : a retrospective study of an American trauma center.

OBJECTIVE: To analyze medical indications and conditions for patients transferred from a rehabilitation hospital to an emergency department (ED). Are there differences in terms of which patients go to the ED during their stay and which do not? Specifically, what type of patient is most likely to be transferred? METHODOLOGY: A retrospective study was conducted at an American adult and pediatric urban trauma center that serves 40,000 patients per year. This study compared randomly selected samples of 534 patients having been transferred to the ED from a rehabilitation hospital and 500 patients who were directly admitted to the ED from the community. Variables examined were: demographics, ED diagnosis and level of care, length of hospital stay, costs, discharge condition and return within 60days to the ED. RESULTS: The patients transferred from the rehabilitation hospital were older (P<0.01), differed with regard to ethnicity (83% African American; P<0.01), the reason for hospitalization (P<0.01; the majority presented with cardiovascular disease, respiratory disease or altered mental status), had longer and more expensive stays (average: 4-8days, P<0.01), required a higher level of care (P<0.01), were more often admitted to surgery or telemetry, and, lastly, were more likely to be discharged in a frail or poor condition (P<0.01). CONCLUSIONS: The patients transferred from a rehabilitation hospital had complex, intense medical (and often psychological) issues. These patients' medical needs required a high level of resources in the ED. They frequently left the hospital in sub-optimal conditions, making it likely that they would return to the hospital via the ED prior to completing their treatment within the rehabilitation hospital.

Comparison of emergency nurses association Emergency Severity Triage and Australian emergency mental health triage systems for the evaluation of psychiatric patients.

The use of a triage system in the emergency department allows for the ability to reliably assign patients for treatment within a short amount of time in order to prioritize and treat on the basis of patients injury and illness. A 5 point triage system has been shown to have the highest correlation with effective resource utilizations, lower time to be seen and treatment times, and admission or release outcomes for patients. The problem is, however, that these triage scales were developed on the basis of physical illness and not on the ever-increasing number of patients who present with mental illness. This article compares one physical and one specific mental illness-based triage system to measure the differences in times to be seen by a physician. It found that the specialized psychiatric triage system decreased wait times and allowed symptoms to be addressed sooner for patients presenting with psychiatric complaints.

Does gun accessibility lead to violence-related injury?

OBJECTIVES: Because of high rates of violent gun-related injuries seen in emergency department (EDs), the ED has become involved in prevention violence intervention. The purpose of the study was to determine the relation between access to guns and the risk of violence-related injuries in youth and young adults. METHODS: This study was a convenience sample in an inner-city level I trauma center. A 28-item validated questionnaire consisting of a short questionnaire about guns, the New York City Youth Violence Survey, and the SAGE Baseline Survey was given to 201 subjects. Half of the subjects were victims of violence and half were seen for nonviolence-related problems. RESULTS: Subjects with violence-related injuries did not have a higher rate of accessibility to guns. They did, however, show a difference in their attitudes toward guns. The subjects who came into the ED with violence-related injuries believed that having a weapon was a way to avoid a fight (F = 4.68, P = 0.032). They were more likely to have grabbed or shoved someone in the last 6 months (F = 5.18, P = 0.025), punched someone in the last 6 months (F = 11.9, P = 0.011), and have been seen in the ED within the last 6 months for a injury related to being punched, attacked, or shot (F = 117, P = 0.00), as compared to those with nonviolence-related injuries. CONCLUSIONS: There was no difference between the two subject groups in terms of their being victims of violence and the rate of gun accessibility. There was, however, a difference in their attitudes toward guns.

The impact of watching cartoons for distraction during painful procedures in the emergency department.

OBJECTIVE: The purpose of this study was to determine whether the viewing of cartoons in the acute care setting reduces the perception of pain by pediatric patients. METHODS: A convenience prospective study of pediatric patients in pain was performed at a community teaching level I pediatric and adult emergency department, with 44,000 patient visits per year. The inclusion criteria for entry into the study were any child who presented to the emergency department in acute pain from any cause. The younger children were randomized to watch a Barney cartoon in Spanish or English, and the older children were randomized to view a Tarzan cartoon in Spanish or English. The younger children were assessed 5 minutes before the procedure, during the procedure, and 5 minutes after the procedure using Poker Chip Tool and Faces Scale. The older children were assessed at the same time interval using self-reporting and a visual analog scale. The study was internal review board approved. A difference of 20% or greater was considered a significant difference. The data were analyzed using a general linear model-repeated measures a priori level of significance of P < 0.05. RESULTS: There was a significant difference within subject effects: F(1)= 9.268, significant at 0.03, with observed power at 0.85 or 85%, with the α set at 0.05 or less. A comparison of the groups revealed that there were no differences in the causes of pain (F(1) = 0.301, P = 0.585), pain duration (F(1) = 0.062, P = 0.084), or type of anesthesia, if used (F(1) = 0.064, P = 0.804) between groups. This lack of difference was upheld for age (F(1) = 3.0407, P = 0.068), race (F(1) = 0.537, P = 0.466), and sex (F(1) = 0.002, P = 0.964). CONCLUSIONS: The finding that cartoon viewing was effective does illustrate 1 more pain relief tool for use in the ED when pediatric patients present. It is useful because of the fact that it does not interfere with assessment of patients' presenting or underlying problems. The need for more ways in which to address pediatric pain persists.

Pitfalls in the care of the psychiatric patient in the emergency department.

BACKGROUND: Care of the psychiatric patient in the Emergency Department (ED) is evolving. As with other disease states, there are a number of pitfalls that complicate the care of the psychiatric patient. OBJECTIVE: The purpose of this article is to update Emergency Physicians concerning the pitfalls in caring for the psychiatric patient, and possible solutions to deal with these pitfalls. DISCUSSION: The article will address the burden of the psychiatric patient, staff attitudes, medical clearance process, treatment of the agitated patient, suicidal patients, and admission decisions. CONCLUSIONS: Alternative care resources, collaboration with Psychiatry, staff education, improvement in the medical clearance process, proper use of restraint and seclusion, and appropriate choice of medication for agitated patients can help avoid some of the top pitfalls in the care of the psychiatric patient in the ED.

Medical evaluation and triage of the agitated patient: consensus statement of the american association for emergency psychiatry project Beta medical evaluation workgroup.

Numerous medical and psychiatric conditions can cause agitation; some of these causes are life threatening. It is important to be able to differentiate between medical and nonmedical causes of agitation so that patients can receive appropriate and timely treatment. This article aims to educate all clinicians in nonmedical settings, such as mental health clinics, and medical settings on the differing levels of severity in agitation, basic triage, use of de-escalation, and factors, symptoms, and signs in determining whether a medical etiology is likely. Lastly, this article focuses on the medical workup of agitation when a medical etiology is suspected or when etiology is unclear.