Evaluating psychiatric readmissions in the emergency department of a large public hospital

Figures & data

Figure 1 Patient flow.

Note: Admissions to the emergency department of the Parkland Memorial Hospital with a psychiatric complaint ≥2 times within a 30-day period from September 2015 to August 2016.

Table 1 Demographics

	Days between admissions
	Total (n=202)	≤3 (n=93)	>3 (n=109)
Age, years (mean ± SD)	40.0 (11.9)	38.7 (10.3)	40.4 (12.9)
Education, years (mean ± SD)	11.1 (2.4)	11.0 (2.5)	11.3 (2.3)
Gender (male)	162 (80%)	76 (82%)	86 (79%)
Race
American Indian or Native Alaskan	14 (7%)	9 (10%)	5 (5%)
Asian	1 (1%)	0 (0%)	1 (1%)
Black or African American	91 (45%)	40 (43%)	51 (47%)
Native Hawaiian or other Pacific Islander	0 (0%)	0 (0%)	0 (0%)
White	87 (43%)	41 (44%)	46 (42%)
Other	8 (4%)	3 (3%)	5 (5%)
Ethnicity
Hispanic	20 (10%)	9 (10%)	11 (10%)
Non-Hispanic	182 (90%)	84 (90%)	98 (90%)
Employment status
Not employed	175 (87%)	81 (87%)	94 (86%)
Full-time employment	1 (1%)	0 (0%)	1 (1%)
Part-time employment	16 (8%)	6 (6%)	10 (9%)
Income source
No income source	93 (46%)	48 (52%)	45 (41%)
SSI/SSDI and other disability	72 (35%)	32 (34%)	40 (37%)
Family support	9 (4%)	2 (2%)	7 (6%)
Other	21 (10%)	7 (8%)	14 (13%)

Notes: Random sample of 30-day psychiatric patient readmissions in the emergency department over a 12-month period, September 2015 to August 2016. Patients may have multiple listings for race and income source. Employment status was not released by all the patients.

Abbreviations: SSDI, Social Security Disability Insurance; SSI, Supplemental Security Income.

Table 2 Treatment factors

	Days between admissions
	Total (n=202)	≤3 (n=93)	>3 (n=109)
aDays since last admission (mean ± SD)	8.2±8.6	1.5±0.8	13.9±8.1
Hospital visits in last 30 days (mean ± SD)	4.4±4.8	5.8±5.9	2.9±2.5
Readmission visit related to/or a continuation of an unresolved issue from the previous visit
Identical or very similar to previous visit	145 (72%)	67 (72%)	78 (72%)
Related but not identical	44 (22%)	21 (23%)	23 (21%)
Not related but could have been addressed	1 (1%)	1 (1%)	0 (0%)
Totally unrelated	8 (4%)	3 (3%)	5 (5%)
bContinuity of care: treatment recommendations provided at the previous visit followed
Fully	12 (6%)	4 (4%)	8 (7%)
Partially	72 (36%)	28 (30%)	44 (40%)
Not at all	115 (58%)	58 (62%)	57 (52%)
cContinuity of care: resources provided at the previous visit utilized
Fully	11 (5%)	5 (5%)	6 (6%)
Partially	72 (36%)	26 (28%)	46 (42%)
Not at all	118 (58%)	62 (67%)	56 (51%)

Notes: Random sample of 30-day psychiatric patient readmissions over a 12-month period, September 2015 to August 2016.

a Included for descriptive purposes. Information in the chart review indicated a problem in the continuity of care:

b treatment recommendations provided at discharge were not able to be followed;

c referrals and appointments for psychiatric and/or medical treatment were not able to be completed.

Table 3 Factors contributing to readmission

	Days between admissions
	Total (n=202)	≤3 (n=93)	>3 (n=109)
Outpatient follow-up	43%	41%	46%
Missed appointment	56 (26%)	23 (25%)	33 (30%)
Did not understand follow-up instructions	3 (1%)	1 (1%)	1 (2%)
Clinic unable to provide services	1 (1%)	1 (1%)	0 (0%)
Other problem	33 (16%)	18 (19%)	14 (13%)
Referrals	56%	63%	48%
Did not use referral	95 (46%)	51 (55%)	44 (40%)
Facility unable to provide services	4 (2%)	4 (4%)	0 (0%)
Referral not given	1 (1%)	1 (1%)	0 (0%)
Other problem	16 (8%)	8 (9%)	8 (7%)
Transportation	14%	13%	14%
Transportation not available for medical appointment	2 (1%)	0 (0%)	2 (2%)
Transportation not available for psychiatric appointment	5 (2%)	3 (3%)	2 (2%)
Transportation not available for substance treatment	4 (2%)	3 (3%)	1 (1%)
Other problem	17 (9%)	10 (11%)	7 (6%)
Housing	63%	72%	58%
Homeless	127 (63%)	64 (69%)	63 (58%)
Could not get into shelter	1 (1%)	1 (1%)	0 (0%)
Banned from shelter	1 (1%)	1 (1%)	0 (0%)
Asked to leave current housing	1 (1%)	1 (1%)	0 (0%)
No identification – required for shelter	4 (2%)	3 (3%)	1 (1%)
Does not want to return to current housing	1 (1%)	1 (1%)	0 (0%)
Other problem	4 (2%)	2 (2%)	2 (2%)
Medications	41%	40%	42%
Unable to fill prescription	9 (4%)	3 (3%)	6 (6%)
Did not go to pharmacy	38 (18%)	22 (24%)	16 (15%)
Declined by pharmacy	1 (1%)	1 (1%)	0 (0%)
Unable to afford prescription medications	1 (1%)	0 (0%)	1 (1%)
Lost prescription	9 (4%)	3 (3%)	6 (6%)
Unable to tolerate (side effects) medication	4 (2%)	1 (1%)	3 (3%)
Refused to take prescription medications	8 (4%)	4 (4%)	4 (4%)
Did not understand the need to take medications	1 (1%)	0 (0%)	1 (1%)
Forgot to take medication	1 (1%)	1 (1%)	0 (0%)
Afraid of medication	0 (0%)	0 (0%)	0 (0%)
Confused about how to take medication	2 (1%)	0 (0%)	2 (2%)
Other problem	21 (10%)	5 (5%)	16 (15%)

Notes: Random sample of 30-day psychiatric patient readmissions over a 12-month period, September 2015 to August 2016; includes homelessness as well as other concerns such as does not like, or cannot tolerate, current housing, could not get into shelter, banned from shelter, and asked to leave current housing.

Table 4 Presenting complaint

	Days between admissions
	Total (n=202)	≤3 (n=93)	>3 (n=109)
Psychiatric symptoms (% of patients)	52%	49%	53%
Symptoms of anxiety	13	5	8
Symptoms of confusion (delirium and dementia)	2	1	1
Symptoms of mania/hypomania	8	3	5
Symptoms of depression	34	18	16
Symptoms of psychosis (ie, paranoia, disorganized thought process, and hallucinations)	47	19	28
Substance use*	36%	45%	28%
Substance use issue (withdrawal/requesting referral)	55	31	24
Intoxication primary issue (violent or disorganized behavior included if secondary to intoxication)	17	11	6
Violent/suicidal ideation and behavior	52%	48%	55%
Violence: self-directed (suicidal ideation, behavior, and post-suicide attempt)	84	34	50
Violence: directed toward others (homicidal, aggressive, assaultive, and intending to harm others)	21	11	10
aPrimary medical complaint*	13%	10%	16%
bNonacute psychiatric complaint	6%	6%	6%
Social factors leading to psychosocial stress (ie, shelter, food, and respite)	2	0	2
Psychiatric medications refill	11	6	5

Notes: Random sample of 30-day psychiatric patient readmissions in the emergency department over a 12-month period, September 2015 to August 2016. Patients may have presented with multiple psychiatric complaints (psychiatric symptoms, substance use disorders, and violent/suicidal ideation and behavior).

a Patients who presented for the treatment of a medical condition and were later found to have a comorbid psychiatric complaint.

b Patients who did not present for or require acute psychiatric care.

* p<0.05 (Yates corrected χ²=6.06, p=0.014).

Table 5 Diagnosis

	Days between admissions
	Total (n=202)	≤3 n=93	>3 (n=109)
No diagnosis	0%	0%	0%
Anxiety disorders	2%	2%	1%
Mood disorders	36%	32%	39%
Bipolar disorder	24	7	18
Depressive disorder	48	23	25
Psychotic disorders	26%	26%	25%
Schizophrenia/schizoaffective	40	19	21
Psychosis disorder other or unspecified	13	5	8
Substance use disorders (including withdrawal)	51%	57%	45%
Other disorders	17%	20%	16%

Notes: Random sample of 30-day psychiatric patient readmissions over a 12-month period, September 2015 to August 2016. Anxiety disorders include panic disorder, obsessive–compulsive disorder, posttraumatic stress disorder, anxiety disorder not otherwise specified, and anxiety disorder.

Table 6 Quality improvement opportunities

	Days between admissions
	Total (n=202)	≤3 (n=93)	>3 (n=109)
Support and education for filling prescriptions	37%	30%	43%
Assistance with transportation	26%	29%	31%
Increased communication with follow-up providers	50%	40%	58%
Increased communication with family or other caretaker such as case worker	46%	38%	53%
Increased drugs/ETOH resources within PMH	65%	65%	63%
Increased drugs/ETOH resources outside PMH	65%	67%	62%
Establishing intensive case management	65%	62%	65%
Connecting with existing intensive case management	38%	33%	41%
Short-term housing solutions (overnight stay)	39%	43%	35%
Long-term housing solutions	50%	53%	45%

Note: Random sample of 30-day psychiatric patient readmissions over a 12-month period, September 2015 to August 2016.

Abbreviations: ETOH, ethyl alcohol; PMH, Parkland Memorial Hospital.