Emergency Psychiatry in the General HospitalThe Psychiatric Emergency Research Collaboration-01: methods and results
Introduction
Of the more than 115 million annual visits to US emergency departments (EDs) [1], approximately one of every 20 patients presents for assessment and treatment of psychiatric and behavioral emergencies [2], [3], [4], [5]. Results from the National Hospital Ambulatory Medical Care Survey [1] documented 53 million mental health related visits to EDs 1992 and 2001. The annual proportion of psychiatric emergency visits increased over that time frame, from 4.9% of all ED visits in 1992 to 6.3% in 2001. These epidemiological data are corroborated by results from a recent large-scale survey of emergency care practitioners, which also reported an increasing number of ED patients presenting with psychiatric emergencies, resulting in significant increases in emergency psychiatric patients who are waiting in the ED until inpatient beds become available (i.e., “boarding”) [6], [7].
The assessment and management of patients presenting to EDs with psychiatric emergencies is complex, but little is known about either decision making processes or the quality of care provided in these settings. There is little information on the prevalence of important problems, such as agitation, administration of medications and use of restraints. The ACEP Clinical Policy Committee [8] reviewed the available evidence for four critical questions related to managing psychiatric emergencies and, in some cases, found no Class A evidence to address the question. In the absence of evidence, expert consensus may be helpful. Guidelines endorsed by the American Association for Emergency Psychiatry were developed using the Rand consensus methodology [9], [10]. Consensus was established around appropriate management of common clinical problems, like agitation and self-harm ideation. Nevertheless, empirical evidence to support these recommendations remains inadequate. Consequently, we created the Psychiatric Emergency Research Collaboration (PERC), a network of mental healthcare providers dedicated to advancing our understanding and management of psychiatric and behavioral emergencies. This inaugural article discusses a chart abstraction project developed to collect standardized clinical information from emergency mental health visits, as well as the results arising from using the abstraction tool in eight US EDs.
Section snippets
Setting, study design, participant selection
This study is a retrospective, structured chart review performed on psychiatric emergency patients presenting to eight PERC hospitals from January 1 through June 30, 2005. Table 1 lists the participating hospitals, including the model of their psychiatric emergency service and psychiatric patient volume during the study period. Each site generated a registry of all patients evaluated by psychiatric staff during the study period. Using a random number generator, the principal investigator
Descriptive statistics
Of the seven sites that completed double-data abstraction, four had Kappa <0.80 on at least one of the 10 primary indicators and had to reconcile their data using the original source documents. The final Kappas for the 10 items using the fully reconciled data are reported in Table 2.
The mean age of the subjects was 35 years old (S.D.=15 years, range=5–82 years). Two hundred five subjects (51%) were male, 227 (61%) white, 96 (26%) black/African American, 35 (9%) Hispanic and 14 (4%) of other
Discussion
Our study has implications for research, quality assurance and performance improvement efforts in emergency mental health settings. Our experience reinforced that chart abstractions can be unreliable, even when careful attention is devoted to establishing the tool's reliability in advance of its use and following rigorous protocols. Our instrument was created by experienced investigators, included domains covered by the Expert Consensus Guidelines for the Treatment of Behavioral Emergencies [9]
Conclusion
The lack of established benchmarks of care is a major impediment to quality assurance and performance improvement efforts in psychiatric emergency services. The PERC's efforts represent an attempt to characterize the nature of the emergency mental health problems seen in acute care settings and the manner in which the patients are assessed and managed. Caution should be used when interpreting these statistics, however, considering the small number of sites, the different practice models used
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US emergency nurses' perceptions of challenges and facilitators in the management of behavioural health patients in the emergency department: A mixed-methods study
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The emergency room is the interface between community and health care institution. Whether through outreach or in-hospital service, the psychiatrist in the general hospital must have specialized skill and knowledge to attend the increased numbers of mentally ill, substance abusers, homeless individuals, and those with greater acuity and comorbidity than previously known. This Special Section will address those overlapping aspects of psychiatric, medicine, neurology, psychopharmacology, and psychology of essential interest to the psychiatrist who provides emergency consultation and treatment to the general hospital population.