title: Marked reduction in length of stay for patients with psychiatric emergencies after implementation of a comanagement model.
abstract: OBJECTIVE
  Patients with psychiatric emergencies often spend excessive time in an emergency department (ED) due to limited inpatient psychiatric bed capacity. The objective was to compare traditional resident consultation with a new model (comanagement) to reduce length of stay (LOS) for patients with psychiatric emergencies. The costs of this model were compared to those of standard care.
  
  
  METHODS
  This was a before-and-after study conducted in the ED of an urban academic medical center without an inpatient psychiatry unit from January 1, 2007, through December 31, 2009. Subjects were all adult patients seen by ED clinicians and determined to be a danger to self or others or gravely disabled. At baseline, psychiatry residents evaluated patients and made therapeutic recommendations after consultation with faculty. The comanagement model was fully implemented in September 2008. In this model, psychiatrists directly ordered pharmacotherapy, regularly monitored effects, and intensified efforts toward appropriate disposition. Additionally, increased attending-level involvement expedited focused evaluation and disposition of patients. An interrupted time series analysis was used to study the effects of this intervention on LOS for all psychiatric patients transferred for inpatient psychiatric care. Secondary outcomes included mean number of hours on ambulance diversion per month and the mean number of patients who left without being seen (LWBS) from the ED.
  
  
  RESULTS
  A total of 1,884 patient visits were considered. Compared to the preintervention phase, median LOS for patients transferred for inpatient psychiatric care decreased by about 22% (p < 0.0005, 95% confidence interval [CI] = 15% to 28%) in the postintervention phase. Ambulance diversion hours increased by about 40 hours per month (p = 0.008, 95% CI = 11 to 69 hours) and the mean number of patients who LWBS decreased by about 26 per month (p = 0.106; 95% CI = -60 to 5.9 visits per month) in the postintervention phase.
  
  
  CONCLUSIONS
  A comanagement model was associated with a marked reduction in the LOS for this patient population.
authors.affiliation: Department of Emergency Medicine , University of California, San Francisco, CA, USA. steve.polevoi@emergency.ucsf.edu
authors.forename: Steven K
authors.initials: SK
authors.lastname: Polevoi
authors.forename: J
authors.initials: J
authors.lastname: Jewel Shim
authors.forename: Charles E
authors.initials: CE
authors.lastname: McCulloch
authors.forename: Barbara
authors.initials: B
authors.lastname: Grimes
authors.forename: Prasanthi
authors.initials: P
authors.lastname: Govindarajan
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D004637:Emergency Services, Psychiatric / Q000458:organization & administration*; D005260:Female; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data*; D008297:Male; D001523:Mental Disorders / Q000175:diagnosis* / Q000628:therapy*; D008875:Middle Aged; D017146:Models, Organizational; D010346:Patient Care Management / Q000458:organization & administration*; D011446:Prospective Studies; D055815:Young Adult