405 Crisis Stabilization Unit Reduces Admission Rates for Suicidal Patients in a Midwest Emergency Department

Abstract

In an attempt to improve patient care and hospital operations, our institution implemented a crisis stabilization unit (CSU) to provide psychiatric stabilization and treatment in a setting other than the emergency department (ED). After initial evaluation and medical clearance by an emergency medicine provider, patients transfer from the ED to the CSU. The CSU aims to decrease the time, space, and monetary burdens on the ED, and to preserve the limited inpatient psychiatry beds for patients who truly need admission, as patients may discharge home from the CSU. The purpose of this study is to determine the effect on hospital admission rates for suicidal patients in the emergency department after the opening of the CSU in a rural academic medical center. We performed a before-and-after analysis of introducing the CSU within a Midwestern tertiary referral center. We evaluated study periods of November 15, 2017 to May 15, 2018 and November 15, 2018 to May 15, 2019 to examine patients pre- and post-CSU implementation. Adult patients presenting with suicidal ideation or suicidal attempt were included. The primary outcome was difference in proportion of inpatient psychiatric admission of suicidal patients presenting to the ED. Secondary outcomes compared were changes in proportion of any admission, use of code greens (code activated in cases where patient poses a threat, requiring immediate attention by psychiatry and security), incomplete admission (a bed request is made but the patient leaves prior to admission), restraint use, scheduling of follow-up within 30 days of discharge, ED returns within 30 days, and mean difference in ED boarding hours. We performed a descriptive analysis of patient visit characteristics presenting before and after CSU implementation. Association between categorical outcomes was determined to estimate relative risks (RR) and 95% confidence intervals (CI). Continuous outcomes were examined as the mean difference (MD) by time period. There were 962 patients presenting with suicidality (n=435 pre-CSU, n=527 post-CSU). There were no differences in population during the two study periods by age, sex, race, homelessness, or insurance. Compared to the pre-CSU period, there was a reduction in psychiatric admission (RR: 0.48; 95% CI: 0.40-0.56), any admission (RR: 0.65; 95% CI: 0.58-0.73), discharge after bed request (RR: 0.22; 95% CI: 0.11-0.43), 30-day return to the ED (RR: 0.74; 95% CI: 0.56-0.98), ED boarding time among admitted patients (MD: -9.0 hours; 95% CI: -13.5, -4.6) and incomplete admissions (MD: -12.5 hours; 95% CI: -21.3, -3.7). There was no significant difference in restraint use or code green use in the ED. There was a 60% increase in a 30-day follow-up being scheduled (RR: 1.60; 95% CI: 1.40-1.82). This study showed that the rate of any inpatient admission, discharge after bed request, 30-day ED return, and ED boarding time decreased after the implementation of the CSU.