Reducing the Length of Time Psychiatric Patients Who Are Assessed as Requiring an Adult Mental Health Inpatient Bed Spend in the Emergency Department; a Systemic Quality Improvement Journey.

Abstract

Presenting problem: There are significant pressures on Adult Mental Health Crisis and Inpatient Services, which is a complex and fragile system. This has led to psychiatric patients spending protracted waits in emergency departments (ED) for access to a mental health inpatient bed. This paper describes a large-scale improvement project that adopts a systemic approach to understanding the problem and testing change ideas generated by staff to bring about improvement. The SQUIRE guidelines were followed in writing this paper.

Tests of change: The change ideas tested were: Testing of a 7 Day Assessment Centre to provide an alternative pathway for low risk patients waiting in ED. This facilitates a longer period of assessment for the patient and enables the provision of short-term intervention, stabilising the patient and decreasing the reliance on an inpatient admission. Testing of the Side by Side Model, which promotes joint assessment and care planning for mental health patients presenting in the ED experiencing a crisis. Adult Mental Health and ED professionals work collaboratively, thereby reducing the length of time the patient is waiting in ED to determine an assessment outcome and to find the right care pathway. Improved Interface working between Inpatient and Community Services to facilitate timely discharge and address the delayed discharge position, improving overall flow in the system.

Outcomes: Quality improvement methodologies were adopted to engage staff in the process and to measure the impact of change ideas. There has been evidence of improvement in the system with regards to: a reduction in the length of time that psychiatric patients are waiting in ED to complete their assessment and determine the right care pathway, a reduction in admissions to our adult mental health inpatient wards and reduced bed occupancy, an increase in patients discharged on a community pathway, a reduction in the number of patients waiting in ED, a reduction in the delayed discharge position and the number of patients becoming delayed in adult mental health inpatient wards through better interface working. This has led to overall decreased pressures on the ED system, better utilisation of resources and improved staff and patient experience. This quality improvement journey has given staff an opportunity to build confidence in the use of QI methodology and tools, to test ideas that they believe will and have made a difference, to give them a voice in the process, to inspire hope around what the future service might look like, to celebrate success in their achievements and to allow them to express what matters to them. All of this has contributed to fostering an improvement culture across adult mental health services and re-energised staff working in really challenging and pressurised environments.

Relevance statement: This paper discusses change ideas that front line staff working within Adult Mental Health Services have tested to reduce the length of time that psychiatric patients are waiting in Emergency Departments to access the most appropriate care and support. In this process staff were acknowledged and recognised as subject experts in their field and given autonomy to test their own ideas that may lead to better patient outcomes and improved experience. Quality Improvement tools and methodologies were used to help staff to understand the complexities of the system that they work within and to measure the impact of their change ideas. This work provides some useful insights and learning that would benefit the wider system where sustained pressures exist due to reduced bed capacity and flow, leading to protracted waits for psychiatric patients in Emergency Departments.