Marlene Busko

October 28, 2016

LAS VEGAS – Dwindling mental health resources are turning the nation's emergency departments (EDs) into a "dumping ground" for psychiatric emergencies, including those involving children.

Results of a poll of more than 1700 emergency physicians conducted by the American College of Emergency Physicians (ACEP) reveals that almost one quarter of ED physicians (21%) reported they have psychiatric patients waiting in the ED for 2 to 5 days for in-patient beds.

In addition, more than half (52%) of respondents reported that the mental health system in their communities had worsened during the past year.

These "extremely troubling" findings reflect the experience of Rebecca Parker, MD, an emergency physician at West Suburban Medical Center in Oak Park, Illinois, who is the incoming president of the ACEP.

"Psychiatric patients wait in the emergency department for hours and even days for a bed, which delays the psychiatric care they so desperately need. It also leads to delays in care and diminished resources for other emergency patients. The emergency department has become the dumping ground for these vulnerable patients who have been abandoned by every other part of the healthcare system," Dr Parker said in a press release.

"State and national policy makers need to make it a priority to address this," Dr Parker told reporters attending a press briefing here at the ACEP 2016 Scientific Assembly, where the poll results were released.

The results, she said, reveal a "desperate situation." When patients in crisis come to the ED for help, "the beds are simply not there," said Dr Parker. This is particularly true for pediatric psychiatric emergencies, a situation that she described as "truly heartbreaking."

The poll results also showed the following:

  • Almost half (48%) of respondents reported that psychiatric patients are held (or are "boarded") in their emergency department while waiting for an in-patient bed one or more times a day.

  • More than half (57%) of respondents reported increased wait times and boarding for children with psychiatric illnesses.

  • Only 16.9% reported having a psychiatrist on call to respond to psychiatric emergencies in the emergency department.

  • More than 11% reported having no one on call to respond to psychiatric emergencies.

  • More than 10% reported having six to 10 patients waiting for inpatient psychiatric beds on their last shift.

To improve patient care, Dr Parker called on emergency physicians to become politically active in ACEP.

Longer Waits for Psych Patients

Suzanne C. Lippert, MD, an emergency physician at Stanford University, California, presented results from two studies investigating ED wait times for patients with medical illnesses in comparison with those with psychiatric illnesses.

The research was prompted by a case involving a severely depressed woman who waited in the ED for 6 days, she said. Initially, Dr Lippert thought this was an extraordinary case, but she soon discovered that it was not unusual.

Dr Lippert and colleagues performed a retrospective analysis of ED visits from 2001 to 2011 based on data from the National Hospital Ambulatory Medical Care Survey.

They found that more than 65 million visits to the ED (about 6% of all visits) were for psychiatric illnesses. On average, psychiatric patients waited longer for treatment than medical patients (3.2 hours vs 2.3 hours, P < .01) and were more likely to be admitted to hospital (21% vs 13.5%) or transferred to an acute care facility (11% vs 1.4%).

In a second study, the researchers found that the most common psychiatric illnesses were drug and alcohol abuse (41%), depression (23%), and anxiety (26%), followed by severe disease (bipolar disorder, self-harm, or psychotic disorder); 10% of patients had multiple psychiatric diagnoses, and 9% had a dual diagnosis (substance abuse plus a psychiatric diagnosis).

Patients with bipolar disorder, psychosis, dual diagnosis, multiple psychiatric diagnoses, and depression were two to four times more likely to stay in the ED for more than a day; those with the more severe diagnoses stayed the longest.

EDs are "loud and chaotic, 24 hours a day. We don't know the clinical outcomes of psychiatric patients who spend hours and days there waiting for treatment," said Dr Lippert.

Renée Y. Hsia, MD, an emergency physician and professor at the University of California, San Francisco, said results of a recent study published in Health Affairs paint a similar picture.

Dr Hsia and colleagues analyzed data from a national US Centers for Disease Control and Prevention hospital survey of more than 200,000 patients. They found that the number of ED visits for psychiatric illness increased by 55% (from 4.4 million to 6.8 million) from 2002 and 2011 – a far greater increase than for medical illnesses, she said.

Moreover, in 2002, the length of stay in the ED was virtually identical for patients with psychiatric or medical illness. However, in 2011, there was a surprisingly large disparity – 10% of patients with medical illness stayed in the ED for more than 9 hours, but 10% of patients with a psychiatric illness stayed there for more than 22.9 hours.

The results of this research, she said, may help inform decision making by policy makers.

American College of Emergency Physicians (ACEP) 2016 Scientific Assembly. Abstracts 142 and 249. Presented October 17, 2016.

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