Misek Ryan K, DeBarba Ashley E, Brill April
Midwestern University, Chicago College of Osteopathic Medicine, Department of Emergency Medicine, Downers Grove, Illinois.
West J Emerg Med. 2015 Jan;16(1):71-5. doi: 10.5811/westjem.2014.10.23011. Epub 2014 Nov 26.
The emergency psychiatric care is system is overburdened in the United States. Patients experiencing psychiatric emergencies often require resources not available at the initial treating facility and frequently require transfer to an appropriate psychiatric facility. Boarding of psychiatric patients, defined as a length of stay greater than four hours after medical clearance, is ubiquitous throughout emergency departments (EDs) nationwide. Boarding is recognized as a major cause of ambulance diversions and ED crowding and has a significant adverse impact on healthcare providers, patient satisfaction, and hospital costs. We sought to identify differences between patients who boarded versus patients who did not board, to identify factors amenable to change and identify interventions that could lead to a decrease in overall psychiatric patient length of stay and improve patient care.
This study is a retrospective multicenter cohort study of all patients assessed to require inpatient psychiatric hospitalization at two community EDs in Illinois from July 1, 2010 through June 30, 2012. We identified 671 patients and collected insurance status, sex, age, time of arrival, time of disposition and time of transfer.
There was a statistically significant difference in the insurance status between the cohort of patients boarding in the ED compared to non-boarders prior to inpatient psychiatric admission. Our study identified 95.4% of uninsured patients who were boarded in the ED, compared to 71.8% of Medicare/Medicaid patients and 78.3% of patients with private insurance (χ(2)=50.6, df=2, p<0.001). We found the length of stay to be longer for patients transferred to publicly funded psychiatric facilities compared to those transferred to private facilities, with a mean time spent in the ED of 1,661 minutes and 705 minutes, respectively (p<0.001). Patients with Medicare/Medicaid were nearly twice as likely to return to the ED for psychiatric emergencies than self-pay and privately insured patients, requiring repeat inpatient psychiatric admission (estimate=0.649, p=0.035, OR=1.914).
This study found that unfunded patients boarded significantly longer than Medicare/Medicaid and privately insured patients. Patients with private insurance boarded longer than those with Medicare/Medicaid. Patients transferred to publicly funded facilities had significantly longer ED length of stay than patients transferred to private facilities.
美国的紧急精神病护理系统负担过重。经历精神科紧急情况的患者通常需要初始治疗机构无法提供的资源，并且经常需要转至合适的精神病治疗机构。精神病患者滞留，定义为在医疗检查后住院时间超过四小时，在全国急诊科普遍存在。滞留被认为是救护车分流和急诊科拥挤的主要原因，并且对医疗服务提供者、患者满意度和医院成本有重大不利影响。我们试图找出滞留患者与未滞留患者之间的差异，确定可改变的因素，并确定能够减少整体精神科患者住院时间并改善患者护理的干预措施。
本研究是一项回顾性多中心队列研究，研究对象为2010年7月1日至2012年6月30日期间在伊利诺伊州两家社区急诊科被评估需要住院精神病治疗的所有患者。我们确定了671名患者，并收集了保险状况、性别、年龄、到达时间、出院时间和转院时间。
与住院前未滞留的患者相比，急诊科滞留患者队列的保险状况存在统计学上的显著差异。我们的研究发现，95.4%的未参保患者在急诊科滞留，相比之下，医疗保险/医疗补助患者为71.8%，私人保险患者为78.3%（χ(2)=50.6，自由度=2，p<0.001）。我们发现，转至公立精神病治疗机构的患者住院时间比转至私立机构的患者更长，在急诊科的平均停留时间分别为1661分钟和705分钟（p<0.001）。医疗保险/医疗补助患者因精神科紧急情况返回急诊科的可能性几乎是自费和私人保险患者的两倍，需要再次住院接受精神病治疗（估计值=0.649，p=0.035，比值比=1.914）。
本研究发现，无资金保障的患者滞留时间明显长于医疗保险/医疗补助患者和私人保险患者。有私人保险的患者滞留时间比有医疗保险/医疗补助的患者长。转至公立机构的患者在急诊科的停留时间明显长于转至私立机构的患者。
