Shortfalls in Emergency Psychiatric Care Persist, Study Finds

People who visit the emergency department (ED) for mental health care are transferred to another facility at a rate 6 times higher than people who visit EDs for non-psychiatric conditions, and they wait hours longer, as well, according to a new study by Jane M. Zhu, MD, MPP, and colleagues at the University of Pennsylvania Perelman School of Medicine finds. The study appears in the September 2016 issue of Health Affairs.

The new study is not the first to show that ED patients often experience lengthy wait times but it does show that psychiatric patients wait disproportionately longer than other patients, sometimes for several hours, only to ultimately be discharged or transferred elsewhere, said Zhu.

“Overall the study highlights the degree to which emergency departments struggle to meet the need of mental health patients,” she said in a statement.

The study analyzed data on length of stay—a standard measure of ED crowding and access to services—for more than 200,000 psychiatric and non-psychiatric ED visits during the study period (2002-2011). The nationally representative data were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from the CDC. The authors noted that during this period of study, the annual number of visits to the ED by US adults rose by 30%, but psychiatric visits increased more—by 55%.

The researchers found that for the great majority of psychiatric patients, average length-of-stay was significantly longer than for non-psychiatric patients. For patients admitted for observation, the difference was 355 minutes for psychiatric patients versus 279 minutes for non-psychiatric patients; 312 minutes versus 195 minutes for patients who were transferred to other facilities, and 189 versus 144 minutes for patients who were discharged. Overall, the differences in ED length-of-stay between psychiatric and non-psychiatric patients did not narrow over time.

For many people, the ED has become a gateway to mental health, the authors noted.

“Although one-eighth of all ED visits are for mental health diagnoses, the majority of EDs still have no psychiatric services available,” they wrote.

Eighty percent of EDs “board” psychiatric patients (keep them in the ED while waiting for a bed to become available or for transfer to another facility), and one-third of EDs board psychiatric patients for longer than 8 hours after the disposition of their cases is decided upon.

“Boarding affects the care received by other patients because boarded patients reduce ED capacity and increase pressure on staff and resources,” the researchers explained.

The largest factor underlying the deficiency in ED capacity for psychiatric care is the shortage of psychiatric inpatient beds that began in the late 1960s with deinstitutionalization of a large portion of the US psychiatric inpatient population. The number of state and county psychiatric inpatient facilities around the nation has been slashed from approximately 500,000 in the 1970s to 113,569 in 2010, forcing many psychiatric patients to end up in EDs seeking care.

The authors also note that the shortage of outpatient mental health facilities and substance abuse treatment programs exacerbates the situation. In addition to more inpatient beds or better access to existing beds, the authors suggest increased use of dedicated psychiatric EDs and regional psychiatric emergency services to shift care for psychiatric patients from the general ED setting to an organized group of psychiatric providers, along with longer-term improvements in both reimbursement and capacity and quality of psychiatric care to strengthen care for patients with mental illness.