A Quality Improvement Initiative: Reducing the Number of Frequent Revisits in the Emergency Department

Background:Inappropriate use of the emergency department (ED) is a persistent and costly problem in the United States (US) healthcare system. More than 136 million ED visits were recorded in the US in 2014 and studies show 50-65% of this patient population have mental health problems. The introduction of a psychiatric mental health nurse practitioner (PMHNP) role within the ED has been shown to reduce ED revisits and improve patient outcomes.Methods: A quality improvement initiative was developed to reduce frequent ED revisits. A literature review, a retroactive chart review of patients with frequent ED revisits, and an online survey that gathered information from ED providers on perceptions of frequent ED revisits were conducted. The data were synthesized into a needs assessment presentation that was disseminated to ED leadership stakeholders, who then provided implementation feedback. Results: Post chart review and survey data showed that 259 patients who had five or more visits to the University of Utah ED over a six-month period, were found to account for 2,751 individual ED visits. More than half of these patients had one or more psychiatric diagnoses (163, 62.9%), and 78% (202) had some form of health insurance. Of the surveyed ED providers, 84.9% (62) responders viewed that the most significant precipitating factor was patients having unstable psychiatric symptoms. Most survey participants (63.8%) identified improved access to outpatient services as preferred interventions to reduce frequent ED revisits and the least favorite intervention was providing a mental health consultation within the ED (7.3%).Conclusions: The earliest a PMHNP role could be embedded within the ED was determined to be 1.5 years (75%, 3) or 1 year (25%, 1). ED stakeholders identified the ED staff's knowledge, skills, understanding of the need and value for this role, as well as senior staff support as enabling qualities to implement this intervention. However, one stakeholder viewed ED staff perception of this role's relevance and value, as well as lack of support from ED senior staff for this intervention as obstacles to implementation. ED providers perceived the referral of patients to accessible outpatient care as the most effective way to reduce frequent ED revisits and were least fond of providing non-emergent mental health services within the ED to reduce this problem. Obstacles to adding a PMHNP role to the ED team were identified primarily as securing funding for this position and the requirement of a paradigm shift of ED culture regarding its role in patient care.