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A Quality Improvement Approach to Reducing Throughput Time for Pediatric Patients Presenting with a Chief Complaint of Mental Health to the Emergency Department
Emergency department encounters for mental health concerns have been steadily rising over the past decade. Children with autism spectrum disorders have higher rates of ED utilization compared to neuro-typical peers, and of those encounters, thirteen percent were for psychiatric problems for children with ASD, compared to two percent for children without ASD (Kalb, 2012). In September of 2017, the crisis center in Philadelphia was closed, and there was a corresponding increase in volume of encounters for children with a chief complaint of mental health at the Children’s Hospital of Philadelphia.
Objectives:
To demonstrate improvement in the system of care, specifically decreased length of stay in the emergency room of a large pediatric emergency department for patients being seen for a chief complaint related to mental health.
Methods: In collaboration with the triage team, the primary medical team, and social work, the psychiatry emergency department consult group undertook a quality improvement effort to identify redundant efforts and to streamline the process of care. The team identified the baseline process of triaging patients and requesting social work and psychiatry consults. Utilizing PDSA cycles, interventions for reducing the time to consult, and discharge were identified.
Results: Baseline data from 2017 showed an average length of time from triage to discharge of 391 minutes per patient presenting with a chief complaint of mental health among a total of 1,599 patient encounters. Based on the quality improvement efforts, the team identified duplication of efforts during the admitting process- patients were being seen by the triage team, the primary medical team, the social work team, and the psychiatry team. The psychiatry team was also duplicating efforts of the social work team in documentation. The team developed a mental health track board through which members of the social work team and psychiatry team could immediately be notified when a patient presented with a chief complaint of mental health, and could begin the evaluation process immediately. A process for streamlining documentation was also implemented to reduce duplication of efforts between the psychiatrist and social worker. These changes resulted in a 21% reduction in average time to discharge from 391 minutes in 2017 to an average of 308 minutes among 2,753 patient encounters in 2018. The reduction in median time was 30%, from a median time of 354 minutes per encounter to 250 minutes per encounter.
Conclusions:
Close collaboration among ED clinicians that reduce redundant processes can significantly decrease the time to discharge for patients presenting to the ED with mental health needs. This is particularly important for patients with ASD who are presenting more frequently to the ED, and are presenting more frequently for psychiatric emergencies, and for whom ED encounters are particularly challenging and stressful.