Predictors of Prolonged Length of Stay Among Young Adults Presenting to the Emergency Department with Psychosis

Elijah E. Boliver MPH (2), Brittany Gouse MD MPH (1,2), Tithi D. Baul, MPH (1-3), Luisa Camacho MPH (2), Jennifer Lancet, (MBA, MS, CPS2), Temitope Ogundare MD (1,2), Nandini Agarwal MPH (1,3), Hannah Brown MD (1,2)

1: Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
2: Wellness & Recovery After Psychosis Program, Boston Medical Center, Boston, MA
3. Evaluation Research Center, Department of Psychiatry, Boston Medical Center, Boston, MA

Abstract

Introduction: The emergency department (ED) is a common pathway to treatment for individuals experiencing psychosis. Prolonged ED length of stay (LOS) is associated with significant declines in quality and timeliness of care. We examined factors associated with prolonged LOS within an urban, safety-net hospital among young-adult patients experiencing psychosis.
Methods: We analyzed ED visits among young adults, age 18-30 with a schizophrenia spectrum disorder billing code between 03/01/2019-02/28/2021. We conducted bivariate analyses to determine associations between demographic characteristics and prolonged LOS (defined as ED LOS > 24 hours). We conducted multivariable regression analyses to measure the association between prolonged LOS and markers for acuity (physical restraint, parenteral medication, inpatient hospitalization, and substance use screening).
Results: Among 637 patients, 69.9% were male, mean age of 26-years (SD=3.1). There was a significant association between race/ethnicity and prolonged LOS (p=0.027); a higher proportion of non-Hispanic Black patients (67.5%) had prolonged LOS compared to non-Hispanic white patients (6.7%). Multivariable regression analyses showed that compared to patients without prolonged LOS, patients with prolonged LOS had higher odds of being physically restrained (aOR: 4.79; 95%CI: [2.45, 9.37]; p<0.001) and receive parenteral medication (aOR: 1.88; 95%CI: [1.02, 3.46]; p=0.044).
Conclusions: ED LOS > 24-hours may represent a risk factor for iatrogenic trauma early in the course of psychosis due to increased possibility of physical restraint use and parenteral medication. Early negative experiences with the mental health system may increase duration of untreated psychosis. Further work is critically needed to better understand driving factors for prolonged LOS in Massachusetts to inform policy changes such as increased funding for inpatient psychiatric services.