Health-related Emergency Department Research Articles

Population-Tailored Care for Homeless Veterans and Acute Care Use, Cost, and Satisfaction: A Prospective Quasi-Experimental Trial.

IntroductionAlthough traditional patient-centered medical homes (PCMHs) are effective for patients with complex needs, it is unclear whether homeless-tailored PCMHs work better for homeless veterans. We examined the impact of enrollment in a Veterans Health Administration (VHA) homeless-tailored PCMH on health services use, cost, and satisfaction compared with enrollment in a traditional, nontailored PCMH.MethodsWe conducted a prospective, multicenter, quasi-experimental, single-blinded study at 2 VHA medical centers to assess health services use, cost, and satisfaction during 12 months among 2 groups of homeless veterans: 1) veterans receiving VHA homeless-tailored primary care (Homeless-Patient Aligned Care Team [H-PACT]) and 2) veterans receiving traditional primary care services (PACT). A cohort of 266 homeless veterans enrolled from June 2012 through January 2014.ResultsCompared with PACT patients, H-PACT patients had more social work visits (4.6 vs 2.7 visits) and fewer emergency department (ED) visits for ambulatory care-sensitive conditions (0 vs 0.2 visits); a significantly smaller percentage of veterans in H-PACT were hospitalized (23.1% vs 35.4%) or had mental health–related ED visits (34.1% vs 47.6%). We found significant differences in primary care provider–specific visits (H-PACT, 5.1 vs PACT, 3.6 visits), mental health care visits (H-PACT, 8.8 vs PACT, 13.4 visits), 30-day prescription drug fills (H-PACT, 40.5 vs PACT, 58.8 fills), and use of group therapy (H-PACT, 40.1% vs PACT, 53.7%). Annual costs per patient were significantly higher in the PACT group than the H-PACT group ($37,415 vs $28,036). In logistic regression model of acute care use, assignment to the H-PACT model was protective as was rating health “good” or better.ConclusionHomeless veterans enrolled in the population-tailored primary care approach used less acute care and costs were lower. Tailored-care models have implications for care coordination in the US Department of Veterans Affairs VA and community health systems.

Association Between Burn Injury and Mental Illness among Burn Survivors: A Population-Based, Self-Matched, Longitudinal Cohort Study

Mental health disorders are prevalent before and after burn injury. However, the impact of burn injury on risk of subsequent mental health disorders is unknown. We conducted a population-based, self-matched longitudinal cohort study using administrative data in Ontario, Canada between 2003 and 2011. All adults who survived to discharge after major burn injury were included, and all mental health-related emergency department visits were identified. Rate ratios (RRs) for mental health visits in the 3 years after burn, compared with the 3 years before, were estimated using negative binomial generalized estimating equations. Among 1,530 patients with major burn injury, mental health visits were common both before (141 per 1,000 person years) and after (154 per 1,000 person years) injury. Mental health visits were most common in the 12 weeks immediately preceding injury. No significant difference in the overall visit rate was observed after burn (RR 0.97; 95% CI 0.78 to 1.20), although among patients with less than 1 pre-injury visit, mental health visits tripled (RR 3.72; 95% CI 2.70 to 5.14). Self-harm emergencies increased 2-fold (RR 1.95; 95% CI 1.15 to 3.33). Mental health emergencies are prevalent among burn-injured patients. Although the overall rate of mental health visits is not increased after burn, the rate increases significantly among patients with one or fewer visits pre-injury. Self-harm risk increases significantly after burn injury, underscoring the need for screening and targeted interventions after discharge. An increased rate immediately before burn suggests an opportunity for injury prevention through mental healthcare.

Monitoring child mental health related emergency department visits in New York City

ObjectiveTo assess the use of syndromic surveillance to assess trends inmental health-related emergency department (ED) visits amongschool-aged children and adolescents in New York City (NYC).IntroductionFrom 2001-2011, mental health-related hospitalizations and EDvisits increased among United States children nationwide [1]. Duringthis period, mental health-related hospitalizations among NYCchildren increased nearly 23% [2]. To estimate mental health-relatedED visits in NYC and assess the use of syndromic surveillance chiefcomplaint data to monitor these visits, we compared trends from anear real-time syndromic system with those from a less timely, codedED visit database.MethodsThe NYC ED syndromic surveillance system receives anonymizedpatient chief complaint and basic demographic data for nearly everyED visit citywide to provide timely surveillance information tohealth authorities. Using NYC ED syndromic surveillance datafrom 2003-2015, we applied previously developed definitions forgeneral psychiatric syndromes. We aggregated ED visits by agegroup (5-12 years, 13-17 years, and 18-20 years), geography, andtemporality. Syndromic data were compared with Statewide Planningand Research Collaborative System (SPARCS) data from 2006-2014which reported mental health diagnosis (ICD-9), treatment, service,and basic demographics for patients visiting facilities in NYC. Usingthese two data sources, we compared daily visit patterns and annualtrends overall as well as stratified by age group, area-based poverty(ZIP code), and time of visit.ResultsBoth syndromic surveillance and SPARCS data for NYC showedan increasing trend during the period. While both showed relativeincreases with similar slopes, mental health-related chief complaintdata captured fewer overall visits than the ICD-9 coded SPARCSdata. Trends in syndromic data during 2003-2015 differed by age-group and area-based poverty, e.g., among children ages 5-12 yearsthe annual proportion of mental health-related ED visits increasedroughly 3-fold from 1.2% to 3.8% in the poorest areas, which wasgreater than the increase in the richest areas (1.7% to 2.6%). Seasonal,day-of-week, and school holiday patterns found far fewer visits duringthe periods of NYC public school breaks (Figure).ConclusionsWe conclude that syndromic surveillance data can provide areliable indicator of mental health-related ED visit trends. Thesefindings suggest potential benefit of syndromic surveillance data asthey may help capture temporal and spatial clustering of events in amuch more timely manner than the >1 year delay in availability ofED discharge data. Next steps include a qualitative study exploringthe causes of these patterns and the role of various factors drivingthem, as well as use of patient disposition and matched data to bettercharacterize ED visit patient outcomes.

Factors Associated With the Likelihood of Hospitalization Following Emergency Department Visits for Behavioral Health Conditions.

Behavioral health-related emergency department (ED) visits have been linked with ED overcrowding, an increased demand on limited resources, and a longer length of stay (LOS) due in part to patients being admitted to the hospital but waiting for an inpatient bed. This study examines factors associated with the likelihood of hospital admission for ED patients with behavioral health conditions at 16 hospital-based EDs in a large urban area in the southern United States. Using Andersen's Behavioral Model of Health Service Use for guidance, the study examined the relationship between predisposing (characteristics of the individual, i.e., age, sex, race/ethnicity), enabling (system or structural factors affecting healthcare access), and need (clinical) factors and the likelihood of hospitalization following ED visits for behavioral health conditions (n = 28,716 ED visits). In the adjusted analysis, a logistic fixed-effects model with blockwise entry was used to estimate the relative importance of predisposing, enabling, and need variables added separately as blocks while controlling for variation in unobserved hospital-specific practices across hospitals and time in years. Significant predisposing factors associated with an increased likelihood of hospitalization following an ED visit included increasing age, while African American race was associated with a lower likelihood of hospitalization. Among enabling factors, arrival by emergency transport and a longer ED LOS were associated with a greater likelihood of hospitalization while being uninsured and the availability of community-based behavioral health services within 5 miles of the ED were associated with lower odds. Among need factors, having a discharge diagnosis of schizophrenia/psychotic spectrum disorder, an affective disorder, a personality disorder, dementia, or an impulse control disorder as well as secondary diagnoses of suicidal ideation and/or suicidal behavior increased the likelihood of hospitalization following an ED visit. The block of enabling factors was the strongest predictor of hospitalization following an ED visit compared to predisposing and need factors. Our findings also provide evidence of disparities in hospitalization of the uninsured and racial and ethnic minority patients with ED visits for behavioral health conditions. Thus, improved access to community-based behavioral health services and an increased capacity for inpatient psychiatric hospitals for treating indigent patients may be needed to improve the efficiency of ED services in our region for patients with behavioral health conditions. Among need factors, a discharge diagnosis of schizophrenia/psychotic spectrum disorder, an affective disorder, a personality disorder, an impulse control disorder, or dementia as well as secondary diagnoses of suicidal ideation and/or suicidal behavior increased the likelihood of hospitalization following an ED visit, also suggesting an opportunity for improving the efficiency of ED care through the provision of psychiatric services to stabilize and treat patients with serious mental illness.

Validation of Hearts-Map, A Psychosocial Assessment Tool Applied to Children and Youth with Mental Health-Related Paediatric Emergency Visits

Abstract BACKGROUND: Mental health-related pediatric emergency department (PED) visits are increasing annually, and there is a need for a validated comprehensive standardized assessment tool to better manage these patients. OBJECTIVES: The primary objective of this study was to evaluate HEARTSS-MAP, a psychosocial assessment tool, in terms of inter-rater agreement among clinicians as well as the tool’s performance in predicting needs for acute psychiatric consultation for hospitalization. DESIGN/METHODS: The HEARTSS-MAP evaluation was done in two phases. We retrospectively reviewed 101 cases randomly sampled from a cohort of patients who sought care at the BC Children’s Hospital (BCCH) PED for mental health complaints. Narratives pertaining to each patient’s psychosocial assessment were recorded. Clinicians, including two emergency physicians, a bedside nurse, a nurse practitioner, and two psychiatrists, were blinded to the patients' outcomes, and individually applied the HEARTSS-MAP tool to the clinical narratives. The inter-rater agreement was calculated using Cohen’s kappa statistics. We then evaluated the tool’s sensitivity and specificity in predicting admission for the retrospective cohort, as well as a prospective cohort of 62 patients assessed and managed by a PED clinician using the HEARTSS-MAP. RESULTS: There was substantial agreement between the two pediatric emergency reviewers (κ=0.7), and moderate agreement between the pedi-atric emergency physicians and the nurse practitioner (κ=0.6), and the bedside nurse (κ=0.5). Pediatric psychiatrists had fair agreement between themselves (κ=0.3), and between psychiatrists and emergency physicians (κ=0.4). Based on retrospective data, HEARTSS-MAP had a sensitivity of 91% (95%CI: 71 to 99%), and a specificity of 41% (95%CI: 30 to 53%). When applied to prospectively collected data, the sensitivity was 100% (95%CI: 75 to 100%), and specificity was 33% (95%CI: 20 to 48%). CONCLUSION: HEARTSS-MAP, the first standardized psychosocial assessment tool to be implemented at BCCH PED, demonstrates strong inter-rater reliability between emergency clinicians, with a high sensitivity in identifying patients with mental health complaints requiring hospital admission.

Enrollment with a primary care provider does not preclude ED visits for patients with woman’s health–related problems

ObjectiveThe Affordable Care Act places primary care at the cornerstone of health maintenance. It is believed that increasing access to primary health care providers will limit emergency department (ED) use. This study examines woman’s health–related ED visits by patients enrolled in an obstetric/gynecologic (OB/GYN) clinic. MethodsA database was created combining patient information from a hospital-affiliated OB/GYN clinic and the electronic medical records from the ED of the affiliated hospital. This database was used to evaluate woman’s health–related ED use by patients registered in this OB/GYN clinic compared with patients not affiliated with the clinic. ResultsOver an 23-month period, there were 41,791 ED visits made by 21,223 individual women >12 years of age. A total of 7251 (17.4%) of the ED visits were for OB/GYN-related conditions. There were 6430 individual women registered at the OB/GYN clinic, 1411 (22.0%) of whom made 2415 woman’s health–related visits to the ED. Of the OB/GYN-related ED visits by clinic patients, 1794 (74.3%) were made during weekdays and 1023 (42.3%) were made during hours when the clinic was open for care. Study patients had diagnostic studies beyond a urine analysis or pregnancy test performed during 61% of ED visits, with an admission rate of 2%. ConclusionEnrollment with a primary care provider alone does not eliminate the need for ED use in women with health-related conditions.

The Impact of Integrating Behavioral Health Care in the Emergency Department at HMC.

Patients experiencing psychiatric emergencies often require resources not available at the hospital to which they present and frequently require transfer to an appropriate psychiatric facility as it is the case at the Emergency department of HGH. This typically involves being held in the Emergency Department (ED) until a psychiatric bed is available. Boarding of psychiatric patients, (defined as a length of stay greater than four hours after medical clearance), is ubiquitous throughout emergency departments nationwide (USA).1 The limited number of inpatient psychiatric beds combined with the increase in mental health related ED visits have amplified the number of patients boarding in the ED.1 Our Emergency department established in 2014 an innovative and pioneering psychiatric liaison service based in ED, it is the first in the Gulf Area. In this study we are set to look at the difference in response time, boarding time, and disposition during the last four month compared to a similar period of a previous year. The preliminary results indicate a substantial decrease of total admissions, a similar decrease in overnight boarding and a shorter turnaround time to disposition. more results and parameters will be discussed as well as different models of implementation. Conclusion having a dedicated psychiatric team embedded in a busy emergency department is conducive to providing a higher quality of mental health care, decrease the adverse occurences associated with boarding the severely mentally ill.

Accuracy of automatic syndromic classification of coded emergency department diagnoses in identifying mental health-related presentations for public health surveillance.

BackgroundSyndromic surveillance in emergency departments (EDs) may be used to deliver early warnings of increases in disease activity, to provide situational awareness during events of public health significance, to supplement other information on trends in acute disease and injury, and to support the development and monitoring of prevention or response strategies. Changes in mental health related ED presentations may be relevant to these goals, provided they can be identified accurately and efficiently. This study aimed to measure the accuracy of using diagnostic codes in electronic ED presentation records to identify mental health-related visits.MethodsWe selected a random sample of 500 records from a total of 1,815,588 ED electronic presentation records from 59 NSW public hospitals during 2010. ED diagnoses were recorded using any of ICD-9, ICD-10 or SNOMED CT classifications. Three clinicians, blinded to the automatically generated syndromic grouping and each other’s classification, reviewed the triage notes and classified each of the 500 visits as mental health-related or not. A “mental health problem presentation” for the purposes of this study was defined as any ED presentation where either a mental disorder or a mental health problem was the reason for the ED visit. The combined clinicians’ assessment of the records was used as reference standard to measure the sensitivity, specificity, and positive and negative predictive values of the automatic classification of coded emergency department diagnoses. Agreement between the reference standard and the automated coded classification was estimated using the Kappa statistic.ResultsAgreement between clinician’s classification and automated coded classification was substantial (Kappa = 0.73. 95% CI: 0.58 - 0.87). The automatic syndromic grouping of coded ED diagnoses for mental health-related visits was found to be moderately sensitive (68% 95% CI: 46%-84%) and highly specific at 99% (95% CI: 98%-99.7%) when compared with the reference standard in identifying mental health related ED visits. Positive predictive value was 81% (95% CI: 0.57 – 0.94) and negative predictive value was 98% (95% CI: 0.97-0.99).ConclusionsMental health presentations identified using diagnoses coded with various classifications in electronic ED presentation records offers sufficient accuracy for application in near real-time syndromic surveillance.

117 The Impact of Hurricane Sandy on Mental Health-Related Emergency Departments Visits

117 The Impact of Hurricane Sandy on Mental Health-Related Emergency Departments Visits

The Impact of California's Full-Service Partnership Program on Mental Health-Related Emergency Department Visits

This study examined the effects of California's 2005 Mental Health Services Act (MHSA) on the use of mental health-related emergency department visits. It focused on one MHSA program, the full-service partnership program, and hypothesized that individuals with public insurance who participate in the higher-quality full-service partnership program would have fewer emergency department visits compared with clients with public insurance who receive usual care. Data were obtained from the Short-Doyle/Medi-Cal (Medicaid) file, the Data Collection and Reporting system, and the Consumer and Service Information System, all maintained by the California Department of Mental Health. The analytic sample covered 931,218 observations (155,203 adults) ages 18 and older from January 2007 to June 2008. The data represented clients from seven counties, which made up 48.5% of the California population. Fixed-effects logistic regression was used and included a continuous measure of time, in quarters, in the full-service partnership program; separate quarter indicators; and quarter-county interaction terms. The model thus controlled for both time-invariant personal characteristics (including personality as well as psychiatric and medical history as of entry into the study) and all time-varying county-level characteristics. Relative to persons receiving usual care, the odds of full-service partnership participants visiting the emergency department were 54% less after four quarters of treatment and 68% less after six quarters. The full-service partnership program was highly effective in reducing emergency visits. A statewide cost-effectiveness study should be conducted to determine the economic viability of the program.

Heat and health in Adelaide, South Australia: Assessment of heat thresholds and temperature relationships

BackgroundClimate change projections have highlighted the need for public health planning for extreme heat. In Adelaide, South Australia, hot weather is characteristic of summer and heatwaves can have a significant health burden. This study examines the heat thresholds and temperature relationships for mortality and morbidity outcomes in Adelaide. MethodsDaily maximum and minimum temperatures, daily mortality, ambulance call-outs, emergency department (ED) presentations and hospital admissions were obtained for Adelaide, between 1993 and 2009. Heat thresholds for health outcomes were estimated using an observed/expected analysis. Generalized estimating equations were used to estimate the percentage increase in mortality and morbidity outcomes above the threshold temperatures, with adjustment for the effects of ozone (O3) and particulate matter<10μm in mass median aerodynamic diameter (PM10). Effect estimates are reported as incidence rate ratios (IRRs). ResultsHeat-related mortality and morbidity become apparent above maximum and minimum temperature thresholds of 30°C and 16°C for mortality; 26°C and 18°C for ambulance call-outs; and 34°C and 22°C for heat-related ED presentations. Most health outcomes showed a positive relationship with daily temperatures over thresholds. When adjusted for air pollutants, a 10°C increase in maximum temperature was associated with a 4.9% increase in daily ambulance call-outs (IRR 1.049; 95% CI 1.027–1.072), and a 3.4% increase in mental health related hospital admissions (IRR 1.034; 95% CI 1.009–1.059) for the all-age population. Heat-related ED presentations increased over 6-fold per 10°C increase in maximum temperature. Daily temperatures were also associated with all-cause and mental health related ED presentations. Associations between temperature over thresholds and daily mortality and renal hospital admissions were not significant when adjusted for ozone and PM10; however at extreme temperatures mortality increased significantly with increasing heat duration. ConclusionsHeat-attributable mortality and morbidity are associated with elevated summer temperatures in Adelaide, particularly ambulance call-outs, mental health and heat-related illness.

Trends in the Duration of Emergency Department Visits, 2001-2006

Trends in the Duration of Emergency Department Visits, 2001-2006

Profiling police presentations of mental health consumers to an emergency department

Public mental health systems have been called on to better meet the needs of consumers presenting to health services with the police, yet few studies have examined police presentations among mental health consumers in large public mental health systems. This study was designed to determine the frequency profile and characteristics of consumers of mental health services brought in by police to an emergency department (ED) in Sydney, Australia. Using data from the emergency department information system and obtaining the psychiatric assessment from the medical record, we have examined trends and characteristics in mental health presentations brought in by the police to a general ED between 2003 and 2005. The sample consisted of 542 consumers with a mental health problem brought in by the police to the ED of a 350-bed community hospital. The characteristics of this group were compared with those of all mental health related ED presentations for the same period using logistic regression. Results indicated that police presentations are likely to be young males who are unemployed, have past and present alcohol and other drugs use, present after hours, and are admitted to hospital as a result of their presentation. These consumers are likely to have a presenting problem of a psychotic disorder, less likely to have a presenting problem of depression and/or anxiety, and given a triage code of three or higher. The study results highlight the importance of the availability of 24-hour access to mental health care to ensure a quick care delivery response. Police presentations to EDs with mental health issues are an indicator of significant impact on health services, especially with the current overcrowding of EDs and the associated long waiting times. Systems need to be developed that facilitate collaboration between EDs, hospital security, police services, mental health, and ambulance services.

Trends in U.S. Emergency Department Visits for Mental Health Conditions, 1992 to 2001

The objective of this study was to ascertain trends in mental health-related visits to U.S. emergency departments. Data were obtained from the National Hospital Ambulatory Medical Care Survey by using mental health-related ICD-9-CM, E, and V codes as well as mental health-related reasons for visit. From 1992 to 2001, there were 53 million mental health-related visits, representing an increase from 4.9 percent to 6.3 percent of all emergency department visits and an increase from 17.1 to 23.6 visits per 1,000 U.S. population across the decade. The most prevalent diagnoses were substance-related disorders (22 percent of visits), mood disorders (17 percent), and anxiety disorders (16 percent). Mental health-related visits increased significantly among non-Hispanic whites, patients older than 70 years, and patients with insurance. Medications were administered during 61 percent of all mental health-related visits, most commonly psychotropic medication, the prescription rate of which increased from 22 percent to 31 percent of visits over the decade. Ten-year increases in mental health-related emergency department visits were significant for all U.S. geographic regions except the Midwest. Mental health-related visits constitute a significant and increasing burden of care in U.S. emergency departments.