# Improving Emergency Department Throughput in a Community Psychiatric Hospital Using a Structured Quality-Improvement Framework

## TL;DR

This study examines how psychiatric screening processes impact emergency department wait times in a community hospital and finds that these processes account for most of the delays.

## Contribution

The study quantifies the impact of mandated psychiatric screening processes on emergency department throughput in a community psychiatric hospital.

## Key findings

- PESS evaluation time accounted for nearly 60% of total emergency department length of stay.
- Mean emergency department length of stay was 22.41 hours for encounters requiring PESS evaluation.
- Variability in PESS workflow components suggests opportunities for system-level improvements.

## Abstract

Background

Emergency department (ED) overcrowding and prolonged length of stay (LOS) are pertinent challenges in psychiatric emergency care that have significant implications for patient safety, staff workload, and hospital efficiency. In particular, psychiatric emergency departments experience extended throughput delays due to limited inpatient capacity and external regulatory processes. In New Jersey, the Psychiatric Emergency Screening Services (PESS) is a mandated evaluation process that may contribute substantially to ED LOS, yet its quantitative impact has not been well characterized. This study aimed to quantify the contribution of PESS-related processes to emergency department LOS in a community psychiatric hospital.

Methods

This retrospective observational quality-improvement study analyzed consecutive psychiatric emergency department encounters at Bergen New Bridge Medical Center, a community psychiatric hospital, between April 2022 and March 2023. De-identified operational and electronic medical record data were used to evaluate trends in ED LOS and to assess the contribution of PESS-related processes to overall throughput delays. Quantitative analyses included descriptive statistics and regression-based trend analysis to examine changes in LOS over time and the proportion of LOS that is attributable to PESS intervals.

Results

Across the April 2022-March 2023 study period, emergency department length of stay (LOS) demonstrated substantial variability across encounters. When LOS was aggregated into five-day intervals, linear regression analysis showed a moderate negative association between calendar time and emergency department LOS (r=-0.713, p=1.47 × 10⁻¹²), although notable dispersion persisted throughout the observation period.

Among 118 psychiatric emergency department encounters requiring Psychiatric Emergency Screening Services (PESS) evaluation, the mean emergency department LOS was 22.41 hours (SD 4.90), with a median of 22.42 hours (IQR 19.38-24.94). Mean total PESS evaluation time was 13.38 hours (SD 4.68), accounting for 59.7% of mean total LOS, whereas non-PESS emergency department time accounted for a mean of 9.03 hours (SD 5.85).

Examination of PESS workflow components revealed marked variability within screening-related intervals. Time from PESS order to arrival demonstrated greater dispersion than time from PESS arrival to emergency department departure, contributing substantially to overall variation in total PESS evaluation time.

Conclusion

In this single-center quality-improvement study, externally mandated psychiatric screening processes accounted for a substantial proportion of emergency department length of stay, limiting the effectiveness of hospital-based throughput interventions. These findings suggest that meaningful reductions in psychiatric ED LOS may require system-level policy modifications in addition to internal operational improvements. Quantifying regulatory contributors to throughput delays provides an important framework for future quality-improvement efforts and policy discussions aimed at improving psychiatric emergency care delivery.