Emergency Department

Psychiatric Surge

No matter what your political leanings, one thing we can all agree on is that the United States does not have enough inpatient psychiatric beds. De-institutionization of patients with psychiatric disease in the 1970’s has overall been a good thing for most patients with psychiatric disease but the consequence is that there are many patients living in the community with inadequate mental health resources. That coupled with changes in reimbursement for psychiatric disease has resulted in more patients needing acute psychiatric care than can be accommodated in existing psychiatric hospitals. Between 2009 and 2016, Franklin County (the county that Columbus is in) saw a 157% increase in the number of patients presenting to the emergency departments in the county’s hospitals that needed inpatient psychiatric care.

As a result, psychiatric patients with no place to go fill up emergency room beds. A recent study from Wake Forrest University determined that psychiatric patients wait 3.2 times longer in the emergency room for admission compared to non-psychiatric patients (1,089 minutes versus 340 minutes). As mentioned in a previous blog post, room turnover rates are a key metric in emergency department efficiency and this increase in ED length of stay by the psychiatric “boarders” resulted in a loss of 2.2 room turnovers which equates to a loss of $2,264 to the hospital per psychiatric patient.

At our medical center, Assistant Professor of Psychiatry, Dr. Natalie Lester has a real passion for acute care psychiatry in the emergency department and she has turned that passion into some very tangible improvements in throughput of patients with psychiatric disease in our hospital’s emergency department. In 2013, telepsychiatry was introduced in the ED resulting in a drop in ED arrival time to psychiatric consultation from 14.9 hours to 7.7 hours! This translated to a drop in total ED length of stay from 25.6 hours to 21.8 hours.

In 2014, the Department of Psychiatry opened an 8-bed psychiatric observation unit at our medical center in close proximity to the University Hospital ED (on campus – about 8 miles from our hospital, University Hospital East). That resulted in a temporary reduction of ED psychiatric length of stay by one-third. Since then, however, the length of stay has gone up as the increasing demand for inpatient psychiatric care continues to outstrip supply.

In Central Ohio, there have been new psychiatric hospitals built but they limit their admissions to patients with commercial insurance with the result that there have been essentially no new beds available for patients with Medicaid. This is an enormous problem at our hospital because 65% of our emergency department’s psychiatric patients have Medicaid but only about 13% have commercial insurance. Furthermore, most free-standing psychiatric hospitals do not have the resources to manage patients with concurrent complex medical illness and those that require electroconvulsive therapy, etc.

Dr. Lester found that currently, 10% of the total number of patient care hours in our emergency department was spent managing patients with psychiatric disease. At the current rate of increase of emergency department utilization, by 2019, she projects that 22% of all emergency department hours will be used for care of psychiatric patients. We define the emergency department as being on “psych surg” if > 15% of the ED beds are occupied by psychiatric patients. Between the 2 emergency departments at our medical center, 56% of the hours of the year, one of the EDs is on psych surg. Clearly this is not sustainable nor is our situation unique compared to most other hospitals in the United States. So what can a hospital medical director do?

  1. Advocate for a move away from a traditional model of the ED consulting psychiatry and then admitting for treatment to a model where treatment is started in the ED in order to possibly avoid admission altogether. Larger hospitals should consider creating psychiatric observation units that can specialize in this type of care.
  2. Advocate for our communities to expand the number of inpatient psychiatric hospital beds.
  3. Change reimbursement for inpatient (and outpatient) psychiatric care to expand availability of services.
  4. Consider creation of psychiatric emergency departments in larger communities that can serve as a destination for emergency squads, police-delivered patients, as well as walk-ins thus off-loading regular emergency rooms to focus on medical/surgical problems.
  5. Adopt telepsychiatry programs, especially in smaller hospitals that do not have full-time on-site psychiatry services.

These are very real problems and very real costs that all hospitals and all communities face. We must start planning now for the increase in psychiatric emergency care that is anticipated to affect all of us in the near future.

August 3, 2016

By James Allen, MD

I am a Professor Emeritus of Internal Medicine at the Ohio State University and former Medical Director of Ohio State University East Hospital

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