Morris David W, Ghose Subroto, Williams Ella, Brown Kevin, Khan Fuad
Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, TX, USA.
Department of Psychiatry, Parkland Memorial Hospital, Dallas, TX, USA.
Neuropsychiatr Dis Treat. 2018 Mar 1;14:671-679. doi: 10.2147/NDT.S143004. eCollection 2018.
Hospital emergency departments (EDs) around the country are being challenged by an ever-increasing volume of patients seeking psychiatric services. This manuscript describes a study performed to identify internal and external factors contributing to repeated psychiatric patient admissions to the hospital main ED.
Data from ED visits of patients who were admitted to the Parkland Memorial Hospital ED (the community hospital for Dallas County, TX, USA) with a psychiatric complaint more than once within a 30-day period were evaluated (n=202). A 50-item readmission survey was used to collect information on demographic and clinical factors associated with 30-day readmission, as well as to identify quality improvement opportunities by assessing related moderating factors. An analysis of acute readmission visits (occurring within 3 days of previous discharge) was also performed.
Patients readmitted to the ED commonly present with a combination of acute psychiatric symptoms, substance use (especially in the case of acute readmission), and violent or suicidal behavior. The vast majority of cases reviewed found that readmitted patients had difficulties coordinating care outside the ED. A number of moderating factors were identified and targeted for quality improvement including additional support for filling prescriptions, transportation, communication with family and outside providers, drug and alcohol treatment, intensive case management, and housing.
Many of the resources necessary to reduce psychiatric patient visits to hospital EDs are available within the community. There is no formal method of integrating and insuring the continuity of community services that may reduce the demand for psychiatric and related services in the ED. While agreements between community service providers may be challenging and require considerable vigilance to maintain equitable agreements between parties, this route of improving efficiency may be the only available method, given the current and projected patient care needs.
全国各地的医院急诊科正面临着寻求精神科服务的患者数量不断增加的挑战。本手稿描述了一项旨在确定导致精神病患者反复入住医院主要急诊科的内部和外部因素的研究。
对美国德克萨斯州达拉斯县社区医院帕克兰纪念医院急诊科在30天内多次因精神科疾病就诊并入院的患者的急诊就诊数据进行评估（n = 202）。使用一份包含50个项目的再入院调查问卷收集与30天再入院相关的人口统计学和临床因素信息，并通过评估相关调节因素来确定质量改进机会。还对急性再入院就诊（发生在前次出院后3天内）进行了分析。
再次入住急诊科的患者通常表现为急性精神症状、物质使用（尤其是急性再入院的情况）以及暴力或自杀行为的综合症状。绝大多数病例审查发现，再次入院的患者在急诊科外协调护理方面存在困难。确定了一些调节因素并将其作为质量改进的目标，包括在处方配药、交通、与家人及外部医疗服务提供者的沟通、药物和酒精治疗、强化病例管理以及住房方面提供额外支持。
社区内具备许多减少精神病患者前往医院急诊科就诊所需的资源。目前没有正式的方法来整合和确保社区服务的连续性，而这些服务可能会减少对急诊科精神科及相关服务的需求。虽然社区服务提供者之间达成协议可能具有挑战性，并且需要各方保持相当的警惕以维持公平的协议，但鉴于当前和预计的患者护理需求，这条提高效率的途径可能是唯一可行的方法。
