Rapid Emergency Department Medical Clearance Protocol for Psychiatric Patients

Abstract

Over the recent years, interest in emergency department (ED) length of stay (LOS) has become an important performance measure. In 2008, the National Quality Forum approved two quality measures related to ED length of stay: the median time from arrival to ED departure for both admitted and discharged patients. Additionally, increasing LOS is inversely related to patient satisfaction. If pay for performance becomes tied to ED LOS, this criterion will become even more important. The objective of this study was to see if implementation of a rapid medical clearance protocol for ambulatory, “low-risk” psychiatric patients presenting to the ED resulted in a lower ED LOS. This was a prospective cohort study. A protocol was developed to identify low-risk, ambulatory psychiatric patients who were unlikely to need extensive ED evaluation and move them rapidly from the ED to the psychiatric evaluation unit (PEU). The criteria for low-risk patients were based on vital signs, past medical history, presence of ingestion and alcohol history. The following times were compared for the month prior and the month following protocol implementation: ED arrival to arrival at PU (total time in ED) and time seen by ED provider to arrival at PEU. Data was analyzed using R 2.15 software (Vienna, Austria) and the two-sample Kolmogorov-Smirnov (KS) test. A total of 654 records (post n=290, pre n=364) had complete data for analysis of ED arrival time to arrival at PEU. Four hundred thirty-one records (post n=184, pre n=247) had complete data for analysis of time seen by provider to arrival at PEU. The median total time in ED dropped from 90 minutes to 62 minutes after protocol implementation. The median time from seen by provider to PEU arrival dropped from 106 minutes to 77 minutes after protocol implementation. Missing data led to two different patient samples; thus, the time difference between the two time-stamp groups appears incongruous. Post-implementation time from seen by provider to PEU arrival was statistically smaller than pre-implementation time (KS test, p=.0005). Lastly, the percentage of patients with seen by provider to PEU arrival times within 60 minutes increased from 23% to 36% after protocol implementation. Implementation of a protocol to expedite medical clearance in ambulatory, “low-risk” psychiatric patients can decrease ED LOS to a meaningful degree. Further evaluation of the protocol must be done to ensure that this does not lead to expedited clearance of those who needed more extensive evaluation. Similarly, the success of the protocol to date suggests we may want to look for other patients who would fit the ambulatory, “low-risk” category.