Psychiatric Emergency Department Presentations Requiring Intensive Care Unit Hospitalization

Title: Psychiatric Emergency Department Presentations Requiring Intensive Care Unit Hospitalization

 

Background: Medical and surgical intensive care unit (ICU) hospitalizations represent a high intensity and costly form of intervention, usually reserved for patients with serious and potentially life-threatening conditions. There is a dearth of information on Emergency Department (ED) presentations for psychiatric indications that result in ICU hospitalization.

 

Methods: This was a pilot study conducted as part of a wider quality improvement initiative. We sought to characterize presentations for which psychiatry was consulted while patient was in the ED, and that resulted in direct ED to ICU hospitalization. We conducted a retrospective chart review of ED presentations to the Massachusetts General Hospital. All ED visits between 9/30/2016 and 10/1/2018 were included, with these dates determined by a dataset that had already been developed for a separate study (1). Demographic and clinical variables were collected, including age, gender, race, indication for ICU admission, medical and psychiatric clinical impressions, and discharge disposition. Statistical analyses were performed in SPSS version 28.

 

Results: 195,092 unique patient encounters were identified, of which 4,582 (2.35%) resulted in ED-to-ICU admission. Of these, 36 visits (0.02%) had psychiatry consulted in the ED. When compared with all ED to ICU hospitalizations (N=,4582), patients who had an ED psychiatry consult (N=36) were younger (mean age 40 vs. 61), stayed longer in the ED (mean 16 hrs vs 4hrs), publicly insured or uninsured (61.1% vs 21.4%), homeless (22.2% vs 1.4%), and more frequently required use of restraints in the ED (27.8% vs 6%). For the 36 with a psychiatry consult in the ED, prescription medication overdose was the main indication for ICU hospitalization (9 visits), and 9 out of 15 medications identified in the overdoses were non-psychiatric. At the end of the hospital stay, 16 (44%) of the 36 patients were discharged to in-patient psychiatric care, and 15 (42%) discharged to home, with no in-hospital deaths.

Discussion: Findings from this pilot study highlight unique demographic and clinical features of patients who present to the ED and are directly hospitalized to the ICU, and for whom psychiatric consultation is sought in the ED. These include overrepresentation of younger patients, non-psychiatric prescription medication overdoses, and adverse social circumstances such as being homeless or uninsured. This study was limited as only cases for which psychiatry was consulted in the ED were included. We hope to expound on these findings in a comprehensive follow-up study. 

 

Reference:

1. Schnitzer K, Merideth F, Macias-Konstantopoulos W, Hayden D, Shtasel D, Bird S. Disparities in Care: The Role of Race on the Utilization of Physical Restraints in the Emergency Setting. Acad Emerg Med. 2020;27(10):943-50.