February 9, 2001

ER psych patient flow improved

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Country music artist Skip Ewing embraces his daughter, Rebecca, after their run in the celebrity ski race. Rebecca not only beat her dad but had a time of 19 seconds – better than many adults in the contest. (photo by Cynthia Manley)

ER psych patient flow improved

Vanderbilt University Medical Center has deployed a new patient flow process that improves care for the approximately 150 psychiatric patients who are seen each month in the Vanderbilt University Hospital emergency room.

Under a previous setup, after medical evaluation, emergency psychiatric patients were transferred to the on-call psychiatric resident’s office just outside the ER. The resident on call either completed the release of the patient or arranged admission to a psychiatric facility. (There’s no psychiatric unit at VUH.)

Under managed care, arranging a psychiatric admission is an increasingly complex undertaking. Payers apply stringent criteria, and often they limit patients’ choices of facilities. At Vanderbilt, psychiatric residents were left to learn the managed care system from scratch, and their on-call rotation concluded by the time they developed proficiency at arranging admission. High patient volumes created yet more difficulty. “Increasing numbers of psychiatric patients see VUH as the psychiatric emergency center,” said Dr. Corey Slovis, chair of Emergency Medicine.

Psychiatric patients and their families became dissatisfied by the length of stay in the ER and by lack of communication regarding delays. ER physicians and staff were in turn frustrated.

Two psychiatrists-in-training dropped their Vanderbilt residency, noting they had no skills for patient disposition and citing the ER on-call rotation as among their biggest discontents.

ER leaders Sue Erickson and Lisa Mandeville spearheaded the search for a solution, first arranging meetings with representatives from Psychiatry, Emergency Medicine, Security and the Center for Clinical Improvement.

One idea was to create emergency psychiatric services at the Psychiatric Hospital at Vanderbilt (PHV). The cost was deemed prohibitive, however, and any medically compromised patients would still need emergency medicine services at VUH.

The group ultimately decided to place a PHV nurse or psychiatric social worker in the ER around the clock. The position is funded jointly by VUH and PHV. “This turned out to be the better solution from a clinical point of view,” said Laurel Roberts, who at the time was director of the Vanderbilt Respond Service, PHV’s program for patient intake (Roberts has since left Vanderbilt).

Doris Quinn, director of Improvement Education and Measurement with the Center for Clinical Improvement, led the group to create a flowchart for evaluation and disposition of emergency psychiatric patients. “I have never had a group so engaged around a flowchart,” Quinn said. This work provided the basis for new policies and procedures put in practice in July 1999.


The ER’s revamped psychiatric patient flow process of course starts with medical evaluation and, if necessary, medical stabilization. Then the PHV Respond nurse/social worker stationed in the ER does a psychiatric assessment, and in straightforward cases the ED attending and Respond worker together determine patient disposition.

More complex cases tend to raise liability issues for ED doctors, who may become accountable if a discharged patient were to commit a harmful act. The process in complex cases is first to consult the on-call psychiatric resident. Slovis estimates that assistance from a psychiatric resident is required less than once each week. If the ED attending and the resident cannot agree about patient disposition, they’re to phone a psychiatric attending, and if the ED attending and the attending cannot agree, the attending comes to examine the patient and becomes the patient’s attending physician.

Once disposition is decided, it’s handled by the PHV Respond nurse/social worker, including giving patients names and numbers for outpatient treatment, working out insurance precertification for admission, and arranging admission at PHV and other facilities.

“I am overwhelmed by how unbelievably well Respond is accomplishing this work,” Slovis said. “From the first day, they took ownership of the problem and became part of the team in the ER.”

The ER has added two examination rooms for psychiatric patients, and Respond workers are collecting data on ER wait times. Roberts said length of stay has been reduced and satisfaction has improved among patients, doctors and staff. “The main thing is that the quality of care for these patients has improved.”

In October, a VUH group began looking at admission of medical patients with psychiatric problems. While it is generally manageable to accommodate these patients in intensive care areas, as they improve medically and advance toward general acute care areas it may require additional arrangements to provide adequate attention to psychiatric problems. The group includes representatives from Nursing, Psychiatry, Legal, Security and the Center for Clinical Improvement.