Evaluation of an Emergency Department and Consultation-Liaison Psychiatry Co-Management Model at an Academic Medical Center

Virtual

Presenting Author(s)

Kalyn Reddy, MD, MPH (he/him/his)

Consultation-Liaison Fellow
University of California, Los Angeles
Los Angeles, California

PDF

Co-Author(s)

JY

Jennifer Yoon, MD

PGY-2 Resident
University of California Irvine
Orange, California
Eric N. Kramer, MD, MPH (he/him/his)

Resident Physician
UC Irvine
Orange, California
SS

Soheil Saadat, MD, MPH, PhD

Research Specialist
University of California Irvine Health
Orange, California
RG

Ryan Gibney, MD, Md

Associate medical director, care at home medical director
UC Irvine Health
Costa Mesa, California
LS

Lindsey Spiegelman, MD, MBA

Emergency Department Medical Director
UC Irvine Medical Center
Orange, California
John Luo, MD

Health Sciences Clinical Professor of Psychiatry
University of California Irvine
Orange, California

Abstract:

Background/Significance:

Prior studies have examined various models of psychiatric care in emergency department and medical settings including proactive and co-management models, both of which have suggested reductions in length of stay (Oldham, 2020). This study evaluates a new emergency department/psychiatry co-management model implemented in 2020, similar to one previously described at the University of California San Francisco (Polevoi, 2013).

Methods: We are completing a retrospective chart review before/after comparison study examining emergency department patients who received a psychiatric consultation during daytime hours during the study period. Outcomes will be compared before and after initiation of the various phases of the co-management model (inflection parts are start of model, start of psychiatrists directly entering discharge prescriptions into the electronic medical record). Statistical analysis will be performed for outcomes length of stay, rate of intramuscular (IM) emergency medications administration, readmission rates, frequency of discharge psychotropic prescriptions, and patient cost. Confounding variables under consideration include age ( < 18, 18-64, 65+), gender (male, female, non-binary), race, insurance, type of disposition (discharge home, admit to UCI psychiatry, admit to outside psychiatric hospital), diagnosis (psychotic disorder, substance use, depression, suicidal), COVID+, patient load, day of the week, holiday, time of consult.

Results: We hypothesize significant decreases in length of stay, rate of IM medication administrations, and readmission rates, as well as a significant increase in the frequency of discharge prescriptions.

Discussion: This intervention has implications for both psychiatric and emergency departments in their approach in management of mutual patients. Favorable results would further support implementation of co-management models in the emergency department setting. Our study has several limitations. Among other factors, variations in local laws regarding mental health services, access to inpatient psychiatric services, volume of psychiatric and non-psychiatric patients, patient demographics, and prevalence of psychiatric and substance use disorders all have the potential to affect the outcomes we measured. No randomization occurred in our interventions. Once a change was implemented, all patients received care under that model. Our methodology does not elucidate what aspects of co-management have the greatest impact on improving outcomes. This is an important area for future exploration, which will be informed by our results.

Conclusions/Implications:

Innovations in approaching psychiatric consultation are vital for determining which models are most effective in improving clinical and resource utilization outcomes. The results can inform the implementation of co-management models at other hospitals by describing how such a model affected our measured outcomes. Future areas for research include looking at how co-management models may affect overall cost of care, staffing needs, and additional clinical outcomes such as suicide prevention.

References:

Oldham MA, Lang VJ, Hopkin JL, Maeng DD. Proactive Integration of Mental Health Care in Hospital Medicine: PRIME Medicine. J Acad Consult Liaison Psychiatry. 2021 Nov-Dec;62(6):606-616. doi: 10.1016/j.jaclp.2021.06.005. Epub 2021 Jul 3. PMID: 34229093.

Polevoi SK, Jewel Shim J, McCulloch CE, Grimes B, Govindarajan P. Marked reduction in length of stay for patients with psychiatric emergencies after implementation of a comanagement model. Acad Emerg Med. 2013 Apr;20(4):338-43. doi: 10.1111/acem.12105. PMID: 23701340; PMCID: PMC3671493.

Presentation Eligibility: Not previously published or presented

Diversity, Equity, and Inclusion: UC Irvine Medical Center is the only academic medical center in Orange County, where minority ethnic groups comprise a majority of the overall population. Reflecting this diversity, our study's patient cohort includes substantial representation from Asian and Hispanic backgrounds. Several of our outcomes, including rate of emergency medication administration and frequency of discharge with appropriate psychiatric prescriptions, hold particular relevance for minority and low-income patients. Our authorship is multidisciplinary, with contributors from both the Emergency Medicine and Psychiatry departments of our institution. It is trainee-led, with psychiatry residents, including the presenting author, collaborating with emergency medicine and consultation-liaison psychiatry faculty.