NUBE 2024

Background:  Psychiatric emergency department visits are often associated with long wait times. This leads to agitation and dissatisfaction among patients, delay in care, patients leaving without receiving care, staff frustration, and increased costs. Prior publications indicate that triage guidelines correlate with wait times and patient satisfaction. Atrium Behavioral Health Charlotte is a dedicated psychiatric emergency department in the southeast region that treats all ages, populations, and psychiatric diagnoses. The ED patient volume has risen yearly from 2020 to 2023 leading to overcrowding and long wait times.

Method: The triage process was modified and implemented with Plan-Do-Study-Act (PDSA) cycles that involved provider and triage nurses. Pre and post surveys were administered to clinicians to evaluate perceptions of the triage process before and after the implementation. The triage process was redesigned to improve workflow and reduce redundancy of treatment. A sorting/lead registered nurse role was created to navigate the triage process with a patient and establish the level of acuity. Focused assessments were instituted as it was determined a full assessment was not needed to determine disposition for all patients. Patients could be quickly triaged by a nurse to assess patient safety and determine the need for immediate intervention or treatment. Provider (Advanced Practice Provider or physician) assessment now occurred in triage. We evaluated 5,249 ED visits between 9/22 and 4/23 before implementing the modified triage process and we assessed 4,202 ED visits between 7/23 and 2/24 after the implementation. The Wilcoxon test for unpaired samples was used to assess differences ED times. Time differences include Arrival to Triage, Triage end to Provider, Roomed to Provider, Provider to Disposition, Disposition to Depart, and Total length of stay.

Results: Prior to the triage change, 747 patients left the ED after check-in without being seen and the median time for patients’ length of stay from door to discharge was 287 minutes. The median total length of stay was reduced by 110 minutes leading to a 38% reduction (p<0.001). The median time from being roomed to seeing a provider has been reduced from 98 to 43 minutes (56% reduction; p<0.001). The median time from arrival to the ED until seen by a provider has been cut in half to 76 minutes (52% reduction; p<0.001). The percent of patients who left the ED before starting treatment has been reduced from 10.5% to 6.3% (40% reduction; p<0.001).

Conclusion: Implementation of the modified triage process reduced redundancy in assessments, which helped to have patients assessed by a provider quicker with decreased wait times at various touchpoints in the ED encounter. The data show that this new process led to significant decreases in left without being seen (LWBS) rates. Decrease in LWBS rates helped this psychiatric ED recapture lost revenue from patients that normally would have left without being seen due to long ED wait times. This process also helped eliminate redundancy of psychiatric assessments which freed up a social worker for disposition planning. This process also improved interdisciplinary communication.

Learning Objectives:

Explain the components of an optimized behavioral health triage protocol.

Show psychiatric emergency department wait times before and after the implementation of a modified triage protocol.

Describe the dissemination methods and uptake of a triage protocol in psychiatric emergency care settings.