Background: Healthcare workers in the emergency department (ED) are the most vulnerable to be physically or verbally assaulted (Roppolo et al., 2020). Care delivery in the ED is complex given that decisions are often made under pressure, with limited information, and frequent interruptions (Wong et al. 2022). Evans et al (2019) identified that an embedded psychiatric provider in the ED most significantly augmented metrics such as wait times, provider satisfaction and number of inpatient admissions. Prior to implementation of the embedded Psychiatric Nurse Practitioner Team in the ED, it was estimated that 2000 behavioral health patients were seen annually at UCSF ED. The average length of stay (aLOS) for behavioral health patients was 26 hours. In 2023, over 160 patients with psychiatry consult were admitted to inpatient medical teams, often because no psychiatric beds were available. These patients had inpatient aLOS of 12.4 days. Significant safety concerns plague ED staff with an average of 10 workplace violence events per year, 4 of which are considered severe.
Initial goals post implementation of the PMHNP team include:
- Average Length of Stay reduction of 25-50%.
- Decreased LOS would essentially create addition 1.5-3 additional bed capacity per day
- Decrease avoidable admissions to medicine by 10%
- Save 200 Inpatient bed days annually
- Reduce severe workplace violence injuries by 50%
Methods: Review of pre and post implementation data.
Results: The PMHNP model met or exceeded each goal. Overall, aLOS for psychiatric consult patients decreased from 22.8 to 17.2 hours, a 25% reduction. Saving 5.6 hours per patient, equivalent to building 1.2 staffed ED beds. There was a 40% reduction in aLOS for patients discharged to the community. Compared to 2023, admissions to medicine decreased 20%. Over one year, 32 admissions may be prevented, saving 397 inpatient bed days, almost twice the goal of 200 beds. This is equivalent to building 1.1 staffed inpatient beds. No severe ED workplace violence injuries have occurred in the 6 months since implementation of PMHNP compared to 4 total in 2023.
Lessons learned: Investment in an embedded PMHNP team had additional resource savings in avoided consults, 5150 holds and transfers. With responsive, timely consult available around the clock, ED providers were 32% more likely to forgo psychiatric consult after placing a patient on an ED hold. When consulted, the PMHNPs were 22% less likely to place patients on a 5150 than previous psychiatric staffing structure. Even when patients were placed on a 5150, reassessments happened around the clock. Psychiatric consult patients were over three times more likely to be discharged from 10pm to 9am. Transfer to inpatient psychiatric facility decreased by 8% and discharges to community increased by 16%. Patients placed on a 5150 who were ultimately discharged after serial exams had aLOS reduced by 11.4 hours.
Learning Objectives
To explore the role of the PMHNP in emergency psychiatric care.
Identify barriers to psychiatric care in the emergency department
Discuss the post-implementation outcomes of the embedded ED PMHNP Team
