Wait times in the emergency department for patients with mental illness

Background:

It has been suggested that patients with mental illness wait longer for care than other patients in the emergency department. We determined wait times for patients with and without mental health diagnoses during crowded and noncrowded periods in the emergency department.

Methods:

We conducted a population-based retrospective cohort analysis of adults seen in 155 emergency departments in Ontario between April 2007 and March 2009. We compared wait times and triage scores for patients with mental illness to those for all other patients who presented to the emergency department during the study period.

Results:

The patients with mental illness (n = 51 381) received higher priority triage scores than other patients, regardless of crowding. The time to assessment by a physician was longer overall for patients with mental illness than for other patients (median 82, interquartile range [IQR] 41–147 min v. median 75 [IQR 36–140] min; p < 0.001). The median time from the decision to admit the patient to hospital to ward transfer was markedly shorter for patients with mental illness than for other patients (median 74 [IQR 15–215] min v. median 152 [IQR 45–605] min; p < 0.001). After adjustment for other variables, patients with mental illness waited 10 minutes longer to see a physician compared with other patients during noncrowded periods (95% confidence interval [CI] 8 to 11), but they waited significantly less time than other patients as crowding increased (mild crowding: −14 [95% CI −12 to −15] min; moderate crowding: −38 [95% CI −35 to −42] min; severe crowding: −48 [95% CI −39 to −56] min; p < 0.001).

Interpretation:

Patients with mental illness were triaged appropriately in Ontario’s emergency departments. These patients waited less time than other patients to see a physician under crowded conditions and only slightly longer under noncrowded conditions.In a 2008 report, the Schizophrenia Society of Ontario recommended adding a psychiatric wait times component to the Ontario government’s Emergency Room Wait Times Strategy.¹ They suggested that patients who present to the emergency department in psychiatric distress wait longer for care than other patients and that they are given a low priority triage score² (all patients are assigned a triage score when they first arrive at the emergency department, which may determine when and where they are seen by a physician).³ The Kirby Report, a senate report on mental illness and addiction in Canada, also decried differential emergency care for patients with mental illness.⁴A recent study found that patients with acute myocardial infarction are given lower priority care in the emergency department if they have a charted history of depression.⁵ However, whether patients who present to the emergency department for mental illness receive slower care than other patients is not known. In this study, we compared the emergency department wait times and triage scores for patients with affective and psychotic disorders to those for other patients, both in noncrowded conditions and during periods of crowding. Because we believe that triage nurses apply triage principles consistently to all emergency patients while physicians may be less likely to adhere to the guidelines, we hypothesized that there would be no “down-triage” (assigning a lower priority triage score) of these patients, but that patients with mental illness would have longer delays to see a physician, relative to other patients.     

Three Infectious Viral Species Lying in Wait in the Banana Genome

Plant pararetroviruses integrate serendipitously into their host genomes. The banana genome harbors integrated copies of banana streak virus (BSV) named endogenous BSV (eBSV) that are able to release infectious pararetrovirus. In this investigation, we characterized integrants of three BSV species—Goldfinger (eBSGFV), Imove (eBSImV), and Obino l''Ewai (eBSOLV)—in the seedy Musa balbisiana Pisang klutuk wulung (PKW) by studying their molecular structure, genomic organization, genomic landscape, and infectious capacity. All eBSVs exhibit extensive viral genome duplications and rearrangements. eBSV segregation analysis on an F1 population of PKW combined with fluorescent in situ hybridization analysis showed that eBSImV, eBSOLV, and eBSGFV are each present at a single locus. eBSOLV and eBSGFV contain two distinct alleles, whereas eBSImV has two structurally identical alleles. Genotyping of both eBSV and viral particles expressed in the progeny demonstrated that only one allele for each species is infectious. The infectious allele of eBSImV could not be identified since the two alleles are identical. Finally, we demonstrate that eBSGFV and eBSOLV are located on chromosome 1 and eBSImV is located on chromosome 2 of the reference Musa genome published recently. The structure and evolution of eBSVs suggest sequential integration into the plant genome, and haplotype divergence analysis confirms that the three loci display differential evolution. Based on our data, we propose a model for BSV integration and eBSV evolution in the Musa balbisiana genome. The mutual benefits of this unique host-pathogen association are also discussed.     

Multidimensional Measures of Impulsivity in Obsessive-Compulsive Disorder: Cannot Wait and Stop

Objective

Although the relationship between obsessive compulsive disorder (OCD) and impulsivity has long been debated, impulsivity has not been systematically examined in clinical samples of OCD. Meanwhile, recent findings suggest that impulsivity is multi-dimensional construct that can be examined through several constructs. Therefore, this study is aimed to evaluate multiple facets of impulsivity in OCD.

Method

The recruitment includes 80 OCD and 76 healthy control participants. Participants completed a test battery comprising three behavioral tasks of stop signal task (SST), delay discounting task (DDT) and balloon analog risk test (BART), and one self-report measure of the Barratt Impulsiveness scale (BIS-11).

Results

OCD subjects showed significantly lower stop signal reaction time of SST reflecting higher action impulsivity and higher delay discounting parameter of DDT suggesting increased choice impulsivity but significantly lower adjusted mean pump of BART implying lower risk taking propensity of BART than healthy control.

Conclusion

Increased Action and choice impulsivity, and decreased risk taking propensities were found in OCD. These findings seem to be consistent with clinical characteristics of OCD such as greater preference for or avoid risky situations (avoidance), inability to wait tension relief may provoke safety behaviors (compulsion) and inability to stop already started behaviors (repetition).