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Samantha Margaritis, BS, OMSIII; Ryan Misek , DO; Ashley DeBarba , DO; April Brill, DO FACOEP

The Effect of Psychiatric Patient Boarding Times in the Emergency Department Following Closure of a Public Psychiatric Hospital. Samantha Margaritis, BS, OMSIII; Ryan Misek , DO; Ashley DeBarba , DO; April Brill, DO FACOEP.

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Samantha Margaritis, BS, OMSIII; Ryan Misek , DO; Ashley DeBarba , DO; April Brill, DO FACOEP

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  1. The Effect of Psychiatric Patient Boarding Times in the Emergency Department Following Closure of a Public Psychiatric Hospital Samantha Margaritis, BS, OMSIII; Ryan Misek, DO; Ashley DeBarba, DO; April Brill, DO FACOEP

  2. Significant shortage of inpatient psychiatric beds nationwide 2,9 • 1970: 400,000 state and county psychiatric inpatient beds • 2006: 50,000 inpatient psychiatric beds

  3. Deinstitutionalization • Intended to integrate into the community with monetary support to community hospitals • Displacement to other facilities • Nursing homes • Prisons/Jails • Hospital Emergency Departments (ED)

  4. ED “crowding” leads to increased morbidity and mortality 5 • In 2007, 12.8% of all ED visits were related to substance abuse or mental health problems10 • 84% of all EDs reported board psychiatric patients in 20143 • Psychiatric patients have been found to stay in the ED 3.2 times longer than a non-psychiatric patient8 • 89% of EDs transfer mental health patients every week due to unavailable psychiatric beds at their respective hospitals1 • 85% of ED directors agree that ED wait times would improve if there were better psychiatric services available1

  5. Objective • Recently, a 75-bed state operated inpatient psychiatric hospital closed near our hospital system. We analyzed the effect of closing this public mental health facility on psychiatric patient boarding times in the Emergency Department (ED) and to evaluate predictive factors that may affect this boarding time.

  6. Methods • Retrospective multicenter cohort study • St. James Chicago Heights and St. James Olympia Fields, IL

  7. Inclusions • All patients presenting to these EDs requiring inpatient psychiatric hospitalization • July 1, 2010-May 10, 2013

  8. Exclusions • Patients < 16 or >65 • Pregnant patients • Patients discharged from ED prior to transfer to psychiatric hospital • Required stabilization prior to transfer

  9. Data Chief Complaint Age Sex Insurance Status Toxicology Report Alcohol levels Diagnostic imaging Restraint use • Date, time and day of week of first presentation to ED • Date and time of disposition • Date and time of transfer to psychiatric facility • Place of transfer

  10. Data • Boarding Time (min) = time of transfer (min)-time of disposition (min)

  11. Statistics • Total of 1,108 patients evaluated • Before: 666 • After: 442 • Using SPSS software, a two-sample t-test with correction for unequal variance analyzed boarding times before and after the psychiatric hospital closure on July 1, 2012.

  12. Results

  13. Results 558.84 452.05

  14. Results 450.04 465.02 297.87 416.89

  15. 1449.65 1390.88 558.84 452.05

  16. Conclusions • No statistically significant difference in overall psychiatric patient boarding in the ED • Patients who were transferred to private psychiatric facilities experienced longer ED boarding times following the closure • 1.2 x increase • Statistically significant correlation of increased boarding times in both Medicaid/Medicare and privately insured patient groups following closure of the state funded hospital • Medicaid/Medicare patients experienced 1.1x increase in boarding time • Private insurance experienced 1.6x increase in boarding time

  17. Implications • ED staff spends twice as long looking for psychiatric patient beds than non psychiatric patient beds10 • Psychiatric patient boarding preventing 2.2 bed turnovers or additional patients left without being seen8 • $2,264 cost of boarding a psychiatric patient • Including patients without being seen, loss of bed turnover, and boarding costs 8 • 91% of ED physicians report boarding lead to violent behavior of distressed psychiatric patient, bed shortages or distracted staff3 • Major cause of ambulance diversion5

  18. Conclusion • We hope to bring attention to the need for increased psychiatric services during a time when there is a nationwide trend towards the reduction of available inpatient psychiatric beds.

  19. References • ACEP Psychiatric and Substance Abuse Survey 2008. Irving, TX:American College of Emergency Physicians; 2008. <http://www.acep.org/uploadedfiles/ACEP/Advocacy/federal_issues/PsychiatricBoardingSummary.pdf>. Accessed 1 Jul 2013. • Alakeson V, Pande N, Ludwig M. A plan to reduce emergency room 'boarding' of psychiatric patients. Health Aff (Millwood). 2010;29(9):1637-42. • Baldyga, Mike. "Psychiatric "Boarding" in Emergency Departments Ruled Unconstitutional in Washington State." Online posting. American College of Emergency Physicians. N.p., 15 Aug. 2014. Web. 24 Aug. 2014. <http://newsroom.acep.org/2014-08-15-Psychiatric-Boarding-in-Emergency-Departments-Ruled-Unconstitutional-in-Washington-State>. • Falvo T, Grove L, Stachura R, et al. The opportunity loss of boarding admitted patients in the emergency department. AcadEmerg Med. 2007;14(4):332-7 • Foley, Mathew, MD, MS, NizarKifaieh, MD, and William K. Mallon, MD. "Financial Impact of Emergency Department Crowding." West J Emerg Med. 12.2 (2011): 192-97. PubMed Central. Web. 2 Apr. 2013. • Hoot, Nathan R., and DominikAronsky. "Systematic review of emergency department crowding: causes, effects, and solutions." Annals of emergency medicine 52.2 (2008): 126-136. • Keilman, John. "Cuts Would Slash Access to State Mental Hospitals." Chicago Tribune News. The Chicago Tribune, 18 Oct. 2011. Web. 2 Apr. 2013. <http://articles.chicagotribune.com/2011-10-18/news/ct-met-mental-hospitals-20111018_1_mental-hospitals-psychiatric-hospitals-suzanne-andriukaitis>. • Nicks, B.A., and D. M. Manthey. "The Impact of Psychiatric Patient Boarding in Emergency Departments." Emergency Medicine International (2012): n. pag.NCBI. U.S. National Library of Medicine, 22 July 2012. Web. 17 Nov. 2013. • Ormsby, David. "Bipartisan Budget Cut Fantasies: Illinois Mental Health Care Decline Is No Fairy Tale." The Huffington Post. TheHuffingtonPost.com, 21 Mar. 2011. Web. 28 Sept. 2013. • Tuttle GA. “Report of the Council on Medical Service, American Medical Association: access to psychiatric beds and impact on emergency medicine.” 2008. AMA. Chicago, IL. • Zeller, Scott L., Nicole M. Calma, and Ashley Stone. "Effect of a Regional Dedicated Psychiatric Emergency Service on Boarding and Hospitalization of Psychiatric Patients in Area Emergency Departments." Western Journal of Emergency Medicine (2013): n. pag.PubMed. Web. 2 June 2014. <http://www.ncbi.nlm.nih.gov/pubmed/24578760>.

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