精神科急症患者实施共管模式后住院时间明显缩短。

Marked reduction in length of stay for patients with psychiatric emergencies after implementation of a comanagement model.

机构信息

Department of Emergency Medicine , University of California, San Francisco, CA, USA.

出版信息

Acad Emerg Med. 2013 Apr;20(4):338-43. doi: 10.1111/acem.12105.

DOI:10.1111/acem.12105

PMID:23701340

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC3671493/

Abstract

OBJECTIVES

Patients with psychiatric emergencies often spend excessive time in an emergency department (ED) due to limited inpatient psychiatric bed capacity. The objective was to compare traditional resident consultation with a new model (comanagement) to reduce length of stay (LOS) for patients with psychiatric emergencies. The costs of this model were compared to those of standard care.

METHODS

This was a before-and-after study conducted in the ED of an urban academic medical center without an inpatient psychiatry unit from January 1, 2007, through December 31, 2009. Subjects were all adult patients seen by ED clinicians and determined to be a danger to self or others or gravely disabled. At baseline, psychiatry residents evaluated patients and made therapeutic recommendations after consultation with faculty. The comanagement model was fully implemented in September 2008. In this model, psychiatrists directly ordered pharmacotherapy, regularly monitored effects, and intensified efforts toward appropriate disposition. Additionally, increased attending-level involvement expedited focused evaluation and disposition of patients. An interrupted time series analysis was used to study the effects of this intervention on LOS for all psychiatric patients transferred for inpatient psychiatric care. Secondary outcomes included mean number of hours on ambulance diversion per month and the mean number of patients who left without being seen (LWBS) from the ED.

RESULTS

A total of 1,884 patient visits were considered. Compared to the preintervention phase, median LOS for patients transferred for inpatient psychiatric care decreased by about 22% (p < 0.0005, 95% confidence interval [CI] = 15% to 28%) in the postintervention phase. Ambulance diversion hours increased by about 40 hours per month (p = 0.008, 95% CI = 11 to 69 hours) and the mean number of patients who LWBS decreased by about 26 per month (p = 0.106; 95% CI = -60 to 5.9 visits per month) in the postintervention phase.

CONCLUSIONS

A comanagement model was associated with a marked reduction in the LOS for this patient population.

摘要

目的

由于精神科住院床位有限，精神科急症患者在急诊部（ED）花费的时间往往过多。本研究的目的是比较传统住院医生会诊与新的共管模式，以缩短精神科急症患者的住院时间（LOS）。比较了这种模式的成本与标准护理的成本。

方法

这是一项在 2007 年 1 月 1 日至 2009 年 12 月 31 日期间在无住院精神科病房的城市学术医疗中心的 ED 进行的前后对照研究。所有患者均为经 ED 临床医生评估为自伤或伤人危险或严重残疾的成年患者。在基线时，精神科住院医生在与教师咨询后评估患者并提出治疗建议。共管模式于 2008 年 9 月全面实施。在该模式中，精神科医生直接开出药物治疗，定期监测效果，并加强对适当处置的努力。此外，增加主治医生的参与，加快对患者的重点评估和处置。采用中断时间序列分析来研究该干预措施对所有转往精神科住院治疗的精神科患者的 LOS 的影响。次要结果包括每月救护车转院的平均小时数和每月从 ED 离开而未接受治疗（LWBS）的患者的平均人数。

结果

共考虑了 1884 例患者就诊。与干预前阶段相比，转往精神科住院治疗的患者的 LOS 中位数在干预后阶段缩短了约 22%（p<0.0005，95%置信区间[CI]为 15%至 28%）。每月救护车转院时间增加了约 40 小时（p=0.008，95%CI=11 至 69 小时），每月 LWBS 的患者人数减少了约 26 人（p=0.106；95%CI=-60 至 5.9 次就诊/月）在干预后阶段。