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Psychiatric Patients Often Warehoused in Emergency Departments for a Week or More

Psychiatric Patients Often Warehoused in Emergency Departments for a Week or More

Reduction in Mental Health Beds Prevents Timely Transfers

Deborah Brauser

is a freelance writer for Medscape.

January 24, 2011 — A lack of inpatient facilities means mental health patients are often left lingering in hospital emergency departments (EDs) for up to a week or more, according to a nationwide survey of ED administrator

Psychiatric Patients Often Warehoused in Emergency Departments for a Week or More

Reduction in Mental Health Beds Prevents Timely Transfers

Deborah Brauser

is a freelance writer for Medscape.

January 24, 2011 — A lack of inpatient facilities means mental health patients are often left lingering in hospital emergency departments (EDs) for up to a week or more, according to a nationwide survey of ED administrators.

In fact, 86% of the survey participants report their EDs were “sometimes” or “often” unable to transfer patients to an inpatient facility quickly, and 60% said these delays compromised patient care.

This problem is attributed to both a sharp decrease in beds at mental health facilities and an increased demand for mental health services, William Schumacher, MD, chief executive officer of Schumacher Group, the national ED management firm that conducted the survey and located in Lafayette, Louisiana, said in a release.

The mental health problem in America is being swept under the rug for hospital to deal with. We need a more proactive way to address this challenge.

“The mental health problem in America is being swept under the rug for hospital [EDs] to deal with. We need a more proactive way to address this challenge,” added Dr. Schumacher.

Anita Sowell, RN, MSN, CPHQ, chief of emergency services at Athens-Limestone Hospital in Athens, Alabama, and a participant in the survey, says the survey findings reflect her experience.

“Fortunately, we have not had to board mental health patients for a week, but we have had to board them for quite a while. It is a problem in this rural area as it is everywhere else in the country,” said Ms. Sowell.

The survey analyzed data on staffing and operational issues from 603 EDs across the country gathered via a mailed questionnaire.

According to background information in the survey, approximately 120 million patients visit US hospital EDs every year.

“By virtue of the Emergency Medical Treatment and Labor Act, the federal law obliging hospital personnel to see all patients who present to the [ED], hospital [EDs] are the de facto healthcare safety net for millions of patients throughout the country,” the survey states.

The results also showed the following:

More than 70% reported boarding mental/behavioral patients for 24 hours or longer;

41% reported boarding times up to 2 days or longer;

10% reported boarding times of a week or more; and

Only 29% reported boarding these patients for 12 hours or less.

“This poses risks to patients and underlines a growing crisis in mental healthcare in which hospital [EDs] must ‘house’ mental health patients who have few or no inpatient options. Long boarding times can lead to ED crowding, extended wait times, and hospital admission times for all patients,” the survey authors write.

Slowing the Flow

Ms. Sowell reported her facility is a small community hospital that does not have a psychiatrist on staff.

We’re unable to admit these patients because we can’t provide treatment. So we’re at the mercy of a larger facility to get to a bed as it becomes available.

“We’re unable to admit these patients here because we can’t provide the treatment. So we’re at the mercy of a larger facility to get to a bed as it becomes available.

“This is frustrating because when you have patients who have already been treated and a decision has been made about their disposition but you can’t move them out and that’s a bed that another patient waiting cannot take. And it slows down the flow,” she said.

She added that, depending on their mental state, some patients can be challenging to manage, which can be a concern to the staff and other ED patients.

Ms. Sowell reported that her department is currently set up just to make psychiatric patients comfortable until they can be transferred. But because of the need to board an increasing number of mental health patients, they are currently renovating one of the rooms in the ED to “make it safer for these patients so that they can’t injure themselves, and safer for our staff too.”

Dr. Steven Scholzman

“These findings were not a surprise to me, and I’m just glad people are noticing that this is a real problem,” Steven Schlozman, MD, director of medical student education in psychiatry at Harvard Medical School and associate director of residency training in child psychiatry at Massachusetts General Hospital in Boston, told Medscape Medical News when contacted for comment.

“We have this problem routinely because there are all kinds of implicit and explicit barriers to admission, to getting patients hospitalized. This includes possible insurance issues, that hospitals remain full for a long time, and that there are very limited step-down options,” said Dr. Schlozman.

“Hospitals remain full because they don’t know what to do with [psychiatric patients] who are now well enough to not be an inpatient but not so well that they can go straight back home. This is a big concern here in Boston, and I’ve heard it’s even worse in the rural areas of the country.”

The survey also showed that 74% of the ED administrators reported that a lack of available specialists posed at least a moderate risk to ED patients, and 38% said it posed a “significant” or “very significant” risk.

It is noteworthy, said Dr. Schlozman, that psychiatrists were not listed in the “specialists most missed” section of the survey.

ED doctors must feel that they have the competency necessary to triage, take care of, and decide whether or not to keep or send home these patients. As psychiatrist, I’m not entirely comfortable with that. A lot of time really needs to be devoted to psychiatric triage.

“To me, this means the [ED] doctors must feel that they have the competency necessary to triage, take care of, and decide whether or not to keep or send home these patients. As a psychiatrist, I’m not entirely comfortable with that. A lot of time really needs to be devoted to psychiatric triage.

“I think the bottom line is that there is a huge demand [for psychiatrists] that is not being met and that’s a really complicated issue. There’s debate and dissent within the field right now as to what psychiatry ought to be and how one ought to practice,” added Dr. Schlozman.

Psychiatrist Shortage

Adding to the problem is a shortage of psychiatrists that experts warn is on the verge of becoming a full-blown crisis. A second national survey, 2010 Review of Physician Recruiting Incentives, showed requests for psychiatrists increased 47% during a 1-year period and 121% during the previous 3 years.

“When the economy goes down, mental health problems tend to go up. But there is more to the rising demand for psychiatrists than the recession. A combination of factors is driving a psychiatrist shortage that could soon reach crisis level,” said Mark Smith, president of Merritt Hawkins, the company that conducted the survey.

He noted that half of all psychiatrists are older than 55 years and nearing retirement age, and interest in psychiatry is decreasing for many medical school graduates.

At the same time “population growth, population aging, economic challenges, and 2 wars are driving demand for mental health services higher,” said Mr. Smith.

“There’s a general sense in medical schools in the United States and other countries that this is not as legitimate a field of medicine [as other specialties]. There are people who receive direct and indirect advice from their mentors not to pursue psychiatry even if it’s something they’re interested in. So you have this shortage that gets perpetuated as a function of stigma,” explained Dr. Schlozman.

A member of the American Psychiatric Association Council on Medical Education and Lifelong Learning and on their Executive Committee of the American Association of Directors of Psychiatric Residency Training, Mr. Smith cited a Canadian study that looked at satisfaction among psychiatry residents.

“It turned out that it wasn’t so much that they minded the number of hours they worked or even the number of patients. What was hard for them was the lack of appreciation for the level of expertise that was needed in taking care of these patients.

“To fix this, I think you have to attack this stigma about the field within medical schools, and it has to be from the top down. And we need some very active recruiting. In addition, I think other fields need more psychiatric training, such as pediatrics, primary care, and family medicine,” said Mr. Smith.

In the current economy there are increasing numbers of patients who stop taking their medications and/or stop their in-office visits because of cost concerns, said Dr. Schlozman. Consequently, he said, it is important for clinicians to tell all patients about services that are available to help with medical expenses.

“You have people who, by virtue of their illness, have the hardest time reaching out for care, and then you make it hard for them to access care due to insurance push-backs, add to that a shortage of psychiatrists, and you have a recipe for a rapidly growing epidemic of people getting sicker.

“People are often proud and don’t want to acknowledge these challenges, so I would make this something you [routinely] ask about. There are mechanisms in place in every state to help cover these costs. Also, when patients stop showing up for visits, call and find out why. Don’t let them fall through the cracks,” said Dr. Schlozman.

Deborah Brauser has disclosed no relevant financial relationships

The Emergency Department Challenges and Trends: 2010 Survey is available online.

The 2010 Review of Physician Recruiting Incentives is available online.

Medscape Medical News © 2011 WebMD, LLC

Medscape Medical News © 2011 WebMD, LLC

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