Elsevier

General Hospital Psychiatry

Volume 31, Issue 6, November–December 2009, Pages 515-522
General Hospital Psychiatry

Emergency Psychiatry in the General Hospital
The Psychiatric Emergency Research Collaboration-01: methods and results

https://doi.org/10.1016/j.genhosppsych.2009.04.009Get rights and content

Abstract

Objective

To describe the Psychiatric Emergency Research Collaboration (PERC), the methods used to create a structured chart review tool and the results of our multicenter study.

Method

Members of the PERC Steering Committee created a structured chart review tool designed to provide a comprehensive picture of the assessment and management of psychiatric emergency patients. Ten primary indicators were chosen based on the Steering Committee's professional experience, the published literature and existing consensus panel guidelines. Eight emergency departments completed data abstraction of 50 randomly selected emergency psychiatric patients, with seven providing data from two independent raters. Inter-rater reliability (Kappas) and descriptive statistics were computed.

Results

Four hundred patient charts were abstracted. Initial concordance between raters was variable, with some sites achieving high agreement and others not. Reconciliation of discordant ratings through re-review of the original source documentation was necessary for four of the sites. Two hundred eighty-five (71%) subjects had some form of laboratory test performed, including 212 (53%) who had urine toxicology screening and 163 (41%) who had blood alcohol levels drawn. Agitation was present in 220 (52%), with 98 (25%) receiving a medication to reduce agitation and 22 (6%) being physically restrained. Self-harm ideation was present in 226 (55%), while other-harm ideation was present in 82 (20%). One hundred seventy-nine (45%) were admitted to an inpatient or observation unit.

Conclusion

Creating a common standard for documenting, abstracting and reporting on the nature and management of psychiatric emergencies is feasible across a wide range of health care institutions.

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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