RESEARCH WEEKLY: Emergency in the ER

(Feb. 16, 2016) The findings of a recent survey of emergency room physicians will come as no surprise to anyone who has been or accompanied someone in psychiatric crisis to an emergency room.

More than 8 in 10 emergency room physicians surveyed by the American College of Emergency Physicians (ACEP) in 2015 said the mental health care system was not working for the patients in their region, leading to more psychiatric patients in hospital ERs waiting longer to see doctors.

90% of ERs are boarding patients
According to ACEP:

• “Nearly 9 in 10 emergency physicians reported psych patients were being ‘held’ in their emergency departments” – a practice known as “boarding.”
• 91% of the responding doctors reported the practice led to “distracted staff, bed shortages or violent behavior by distressed psychiatric patients, all of which may harm patients or health care staff or both.”
• Long waits in hospital ERs “do not help patients in psychiatric crisis and sometimes actually exacerbate the problem.”

ACEP reports that 4% of all visits to emergency rooms each year are made by people in psychiatric crisis because of insufficient mental health resources in communities, particularly hospital beds. “Psychiatric patients may wait DAYS in an emergency department until a psych bed becomes available,” ACEP said in a statement. In a 2014 review of the literature on psychiatric patient care in the ED, the organization reported “one study has demonstrated that 70% of institutions have to board psychiatric patients for more than 24 hours and 10% for a week or more.”

More Psych Patients with Worse Symptoms
Arica C. Jesper et al. set out to quantify these impacts by examining the emergency department of an academic university hospital in Sacramento, California, when the county eliminated 50 of the 100 beds in a public inpatient facility and closed the facility’s outpatient unit. The results starkly illustrate what the emergency physician survey responses.

Comparing ER use at the university hospital in the eight months before the beds and outpatient facilities were closed and the eight months following, the researchers found:

• The number of ER visits requiring psychiatric consultation tripled after the county cut its inpatient bed numbers in half.
• The average time psychiatric patients spent waiting to be seen by a psychiatric clinician increased from an average of 14 hours to nearly 22 hours.
• The average number of psychiatric patients held in the ER longer than 24 hours skyrocketed from 28 patients in the eight months before the county closures to 322 in the eight months afterward.
• The number of psychiatric consultations when the most serious symptoms of psychiatric crisis – assaultive or suicidal behavior – were the chief complaint ballooned from 58 to 283. The number of patients presenting with hallucinations shot from 18 to 79.
• A smaller percentage of the patients – who now included more severely ill patients – were ultimately transferred to hospital beds; more were discharged home instead.
• The number of hours per day that psychiatric patients occupied bed space in the ER rose from approximately 18 hours to 97 hours, substantially affecting the flow of other patients through the ER. Care for as many as 13-20 non-psychiatric patients may have been delayed or “displaced” as a result.

Toward Better Practices
“With the unique responsibility to care for every patient and serve as a safety net, the ED is particularly influenced by changes in community resources,” the authors wrote. The paper noted that the Washington State Supreme Court already has found the boarding of psychiatric patients in the ED to be unconstitutional and projected that legal action elsewhere “will likely have an important influence on the care of psychiatric patients in the ED” going forward.

“Boarding is a significant problem in emergency medicine,” the emergency physicians group summarized in its 2014 literature review. “For psychiatric patients, the problem is significantly worse, with psychiatric patients remaining in the ED far longer than medical patients. Research indicates that boarding negatively affects patient quality of care, hospital operations and the system’s finances.

Labeling the situation a “national disconnect,” Elizabeth M. La et al. from Duke University in December 2015 proposed an evidence-based computer model for calculating the supply of hospital beds needed to reduce ER stays in one region of North Carolina. ACEP advanced eight best practices for reducing the number of psychiatric patients presenting in emergency rooms, including the use of “psychiatry ED observation” units where patients in mental health crisis may be kept “in a quiet environment separate from the chaotic environment of the main ED.” Any number of practices exist to reduce the emergency in America’s emergency rooms. What is lacking is implementation.

References:
American College of Emergency Physicians. (15 December 2015). Survey: 8 in 10 ER docs say mental health system is not working for patients. Retrieved 5 February 2016 from PR Newswire.
American College of Emergency Physicians. (undated). Psychiatric emergencies.
Nesper, A.C., et al. (13 November 2015). Effect of decreasing county mental health services on the emergency department. Annals of Emergency Medicine.
La, E. M., et al. (1 December 2015). Increasing access to state psychiatric hospital beds:supply-side solutions. Psychiatric Services.
American College of Emergency Physicians. (October 2014). Care of the psychiatric patient in the emergency department – A review of the literature.