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About Mental Health

Not just the last but the only resort for too many

It is no surprise to anyone working in a hospital that emergency departments have become the de facto dumping ground for patients in psychiatric distress.

An online survey released this week of 1,716 emergency physicians from across the nation paints a grim scene of psychiatric patients waiting long hours, and even days, for an inpatient psychiatric bed.

The results of the poll were presented this week at the American College of Emergency Physicians’ annual meeting, ACEP16/Scientific Assembly in Las Vegas.

“Three-quarters of emergency physicians responding to our poll reported seeing patients every shift who required hospitalization for psychiatric treatment,” ACEP President Rebecca Parker, MD, said in a conference call with journalists on Monday. “The problem is that once the decision to admit is made, it can be nearly impossible to find an inpatient bed for these patients.”

Parker said that more than 10% of respondents to the polls reported that they had six to 10 ED patients waiting for inpatient psychiatric patients during their last shift.

“All of these patients require care and monitoring while they are in the emergency department, which keeps our physicians from treating new patients who come through the door. This ripple effect is real,” Parker said. “More alarming is that almost one-quarter of our poll responded that they have patients waiting two to five days for a psychiatric bed. Can you imagine waiting in the ED for a bed for days at a time! It’s awful! Yet, the inpatient beds for psyche patients just aren’t there.”

Two study abstracts by Suzanne Lippert, MD, presented at the conference support the poll findings. One, Mental Health Emergency Department Visits: 24 Hours and Counting, Characteristics Associated with Prolonged Length of Stay, shows that patients with bipolar disorder, psychosis, dual diagnosis, multiple psychiatric diagnoses and depression had increased odds of being in the emergency department for more than 24 hours.

A related study, Waiting for Care: Differences in Emergency Department Length of Stay and Disposition Between Medical and Psychiatric Patients, found that:

  • 21% of psychiatric patients versus 13.5% of medical patients required admission to the hospital
  • 11% of psychiatric patients versus 1.4% of medical patients were transferred to another hospital
  • 23% of psychiatric patients versus 10% of medical patients stayed in the ED more than 6 hours
  • 7% of psychiatric versus 2.3% of medical patients stayed in the ED for more than 12 hours

“We have a potential perfect storm,” said Lippert. “Decreasing psychiatric inpatient beds. Insufficient accessible outpatient psychiatric centers for crisis stabilization, and then increased emergency department crowding. We are really seeing the growing crisis of unmet psychiatric need.”

14-Hour Waits

Renee Hsia, MD, author of a recent study on the topic that appeared in Health Affairs, attended the ACEP teleconference and noted that “the absolute number of psychiatric visits increased by 55%, from 4.4 million to 6.8 million between 2002 and 2011, far outpacing the growth of non-psychiatric visits.”

“The disparities between [waits for] psychiatric and non-psychiatric patients are very stark. In 2011, the 90th percentile length of stay was 1,378 minutes for psychiatric patients, and 543 min for non-psychiatric patients, which amounts to a difference of almost 14 hours,” Hsia said. “This is especially disturbing when you realize that in 2002, psychiatric and non-psychiatric patients had virtually no difference in the length of stay for these patients.”

Why is this happening?

“It’s important to note that between 1970 and 2006 state and county psychiatric inpatient facilities went form around 400,000 beds to less than 50,000 beds,” Hsia said.

“Starting in the 1960s there was a large deinstitutionalization of mental healthcare from the inpatient to outpatient facilities. Unfortunately, they closed a lot of inpatient beds without shoring up the outpatient resources.”

This report is brought to you by:
John Commins
HealthLeaders Media