(190) High Utilizers of Psychiatric Emergency Services: 10-year Analysis of Protocol for Reducing Frequent Utilization

Background: High utilizers comprise a small percentage of individuals seeking emergency psychiatric care and disproportionately use hospital resources.¹ Few studies have examined predictors of recurrent high emergency department use². Treating high utilizers, often including patients seeking inpatient psychiatry admission for secondary gain (i.e., shelter), presents significant clinical and ethical challenges. In our center, a high utilizer list was developed between the emergency and consult liaison psychiatry departments with the goal of managing these patients in a non-judgmental manner, and exploring alternative discharge options such as intensive outpatient programs.

Methods: Emergency room physicians, social workers and the psychiatry department identified patients demonstrating a cycle of frequent inpatient psychiatry admissions and emergency department visits following poor adherence to therapy and entered their names to lists stored in a confidential EPIC server. After IRB approval, chart review of patients maintained on the high utilizer list was conducted for the period of June 20, 2014 to July 30, 2023 to provide comparative pre-list and post-list data on the frequency of emergency department visits.

Preliminary

Results: An initial patient list created in 2017 consisted of four adult males, with a mean age of 60 years old. Average number of emergency department visits in the three years before and after list implementation were 16 and 18 visits per patient, respectively, with percent change ranging from -27% to 54%. A second list initiated in 2023 has one female and four male patients averaging 51 years old. Average number of emergency department visits in the two years prior to this list implementation was 46 visits per patient, with one patient being seen 100 times. Visits after list implementation decreased to an average of 27 per patient. Data for 2020 and 2021 are limited due to the COVID-19 pandemic. Analysis of differences in disposition plan, length of stay, cost, and visits to other facilities is ongoing.

Discussion: Barriers to successful treatment of high utilizers exist at the patient level (i.e., non-adherence) and of the health care system (i.e., lack of specialized resources).³ Historically, final disposition planning is up to the discretion of the attending physician, with significant variation in opinions on this challenging problem. A unified protocol shared between the emergency and consult-liaison psychiatry departments has been continually helpful as teams attempt to identify and treat high utilizing patients.

Conclusion: This ongoing protocol represents an interdisciplinary approach to management of a widespread issue in consultation-liaison psychiatry. Studies are required to develop and maintain a balanced and non-judgmental approach while managing patients who visit the emergency department frequently and request inpatient psychiatry admission.

References:

1.  Pasic J, Russo J, Roy-Byrne P. High utilizers of psychiatric emergency services. Psychiatr Serv. 2005 Jun;56(6):678-84.

2. Gentil L, Grenier G, et al. Predictors of Recurrent High Emergency Department Use among Patients with Mental Disorders. Int J Environ Res Public Health. 2021 Apr 25;18(9):4559.

3.   Blonigen DM, Manfredi L, et al.  Reducing Frequent Utilization of Psychiatric Emergency Services Among Veterans While Maintaining Quality of Care, Psychiatry online, Published Online:1 Feb 2018

Presentation Eligibility: "Not previously published or presented"

Diversity, Equity, and Inclusion: This abstract addresses the challenges of patients from low socio economic group