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

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Reducing the Number of Frequent Revisits in the Emergency Department Melissa Alm, BSN, RN, CEN, PMH-DNP Student, Deborah Morgan, DNP, PMHNP-BC & Christy Hopkins, MD Key Findings: This needs assessment investigated the incidence of frequent emergency department (ED) revisits by frequent ED utilizers. Of the 259 patients who had 5 or more visits to this ED within a 6-month period; 63% had a psychiatric diagnosis, 78% had health insurance and these 259 patients accounted for 2,751 individual visits within this timeframe. Background • 136 million visits to EDs in the USA in 2014 • $32 billion could be reduced in healthcare spending in the US each year if inappropriate ED use and revisits could be eliminated Demographic Information of Frequent ED Utilizers from Chart Review Do frequent ED utilizers have health insurance? 6% ACCESS TO OUTPATIENT… 16% ACCESS TO OUTPATIENT… HAS A NAMED PCP IN EMR 0 78% Yes No Yes • PMHNP intervention showed a significant reduction in ED nursing and medical staff workload, plus prompt, effective access to mental health care for “undifferentiated health problems” Methods • Conducted a retroactive chart review of 259 frequent ED utilizers (5 or more ED visits within 6 months) • Identified provider perspectives on this population, precipitating factors and solutions by creating an online survey • Incorporated stakeholder feedback data into a behavioral change model to identify enablers and obstacles to intervention implementation No 163 96 132 PSYCHIATRIC SYMPTOMS WERE CHARTED IN ED 0 Yes 50 127 100 150 200 250 300 No Data collected from a 6-month retroactive medical chart review of frequent ED utilizers (Jan 1st, 2019 to Jun 30th, 2019) Survey Question Answered by ED Providers and ED Nurses What Factors Most Significantly Contribute to Frequent ED Revisits? Medically Complex Patients 23% 22% 35% • ED providers and nurses viewed the most significant precipitating factor of frequent ED revisits as being patients having “unstable psychiatric symptoms” • ED providers and nurses associated the most effective interventions in reducing frequent ED revisits with outpatient services, not interventions performed within the ED Frequent ED Utilizers with Psychiatric Diagnoses or Presenting with Psychiatric Symptoms in the ED 20% • Presented the study findings to ED leadership stakeholders, along with the recommended intervention, to embed a PMHNP role within the ED team to reduce frequent ED visits 50 100 150 200 250 300 Emergency Coverage Only HAS A PSYCHIATRIC DIAGNOSIS • In six months, 259 frequent ED utilizers at an urban medical academic center ED accounted for 2751 individual ED visits • More than half of these patients had one or more psychiatric diagnoses charted (163, 62.9%) HAS A CASE MANAGER • 65% of the 2456 frequent ED utilizers in one US hospital had mental health symptoms • 60% less frequent ED utilizer visits were recorded over 2 years at a US academic medical center following the introduction psychiatric services within the ED team Access to Oupatient Services & Care Management for Frequent ED Utilizers Results Unstable Psychiatric Symptoms No Other Access to Outpatient Healthcare Insecure Housing & Social Determinants of Health Data from the survey completed by Hospital ER providers and ER nurses (Dec 2019) • ED Leadership stakeholders agreed the greatest obstacle to adding a PMHNP role within the ED team was funding this new position Conclusions • Most of the ED personnel surveyed preferred for this patient population to be provided better access to effective care in outpatient care • Most frequent ED utilizers have some form of health insurance but still struggle to stabilize symptoms in an outpatient setting • A PMHNP role embedded in the ED could provide initial mental health services to these patients, help manage their current crisis and work with them to prevent the next crisis • Obstacles to implementing were lack of funding for this position and the requirement of a paradigm shift of ED culture regarding its role in patient care COLLEGE OF NURSING