Hospital emergency departments are like home was to Robert Frost,"
the place where, when you have to go there, they have to take you
That isn't always so easy. Emergency department (ED) visits rose from 93
million in 1993 to 110 million in 2004, a 12 percent increase, said Scott
Zeller, M.D., chief of psychiatric services at Alameda County Medical Center
in Oakland, Calif. At the same time, the number of hospital EDs has dropped by
18 percent, so more patients have to be squeezed into fewer places.
Often patients get squeezed out instead. In 2004, there were 500,000"
diversions"—occasions in which ambulances had to be shunted
off from a filled ED to another that had open beds. Wait times to be treated
were up, and one survey found that each nurse was caring for 4.2 patients and
each doctor for 9.7 patients—simultaneously.
"All this leads to increased walkouts by frustrated patients, more
medical errors by stressed providers, more negligence claims, and compromised
patient care," said Zeller at APA's 2009 annual meeting in San Francisco
Psychiatric patients aren't the cause of this overload, but often add to
the burden, he said.
"ED staff spends twice the time looking for post-ED placements for
psych patients and retains them twice as long," he said. The
well-publicized reduction in the number of inpatient psychiatry beds, when
added to insurance company pressure to impose limits on reimbursable care,
leads to shorter lengths of stay, less likelihood of stabilization, and more
chance of a quick return to the ED, he said.
Joseph Parks, M.D.: "Everybody wants somebody else to take care of
psychiatric patients. The [emergency departments] think their job is not to do
mental health or substance abuse, but that's what they do, and as a result,
they do it badly."
Credit: David Hathcox
But in fact psychiatric patients aren't "clogging" space in the
ED, said Joseph Parks, M.D., director of the Division of Comprehensive
Psychiatric Services at Missouri's Department of Mental Health. In Missouri
total ED visits grew by 20 percent from 1997 to 2006 (measured in visits per
1,000 population). Mental health visits increased by 50 percent (from 7.0
visits to 10.5 visits/1,000 population), but the mental health portion of all
ED visits went up by only about 1 percent (from 1.87 percent to 2.95 percent),
suggesting that psychiatric patients alone were not creating the ED
The increase in ED visits related to mental health, Parks said, stems from
a series of policy decisions that have funneled psychiatric patients into EDs,
beginning with the elimination of state hospital beds from 1970 to 1990. In
addition, law-enforcement personnel wanted to avoid suicide risk from
arrestees jailed with psychiatric problems, so they sent these people to the
ED. Mental health crisis services were established apart from hospitals, and
states didn't require community mental health centers (CMHCs) and hospitals to
Finally, the Emergency Medical Treatment and Active Labor Act (sometimes
referred to as the "Patient Anti-Dumping Law") required that
hospital EDs accept, evaluate, and stabilize anyone who presents at their
"That makes emergency services an entitlement, unlike any other
mental health service," said Parks.
"Everybody wants somebody else to take care of psychiatric
patients," he said. "The EDs think their job is not to do mental
health or substance abuse, but that's what they do, and as a result, they do
Dealing with psychiatric patients in the ED is not just a matter of
numbers, said Parks. His analysis of ED crowding sounds more like a problem in
hydraulic engineering than health care. "You have to think about
capacity, inflow, processing time, and outflow," he said.
Part of the problem is the internal resistance to admitting psychiatric
patients, said Parks. "Hospitals chose to close their psychiatric units,
and then they wonder why those patients are showing up in the ED."
In Missouri, the legislature allocated funds to community hospitals to buy
services from CMHCs. Medicaid already permitted states to add payments for"
extraordinary" services, such as psychiatric ED services or
involuntary-commitment inpatient beds. Parks surveyed hospitals in Missouri to
see how they were using this option.
At least 43 community hospitals in Missouri have inpatient adult
psychiatric units, and 23 (with 688 beds) responded to Parks's survey. Of
those, 21 were set up to handle involuntary patients. Between 23 percent and
35 percent of the inpatient psychiatric beds were occupied by substance abuse
patients. Average occupancy was 75 percent, and the adult length of stay was
usually five or fewer days.
"Hospitals associated with CMHCs generally had better clinical and
financial outcomes," said Parks.
Hospitals could even make money by maintaining inpatient psychiatric units
and allying with (or buying) CMHCs where they can send patients once they are
discharged to the community, if the Missouri experience is any example. Twenty
of the 23 hospitals responding to the survey operated their psychiatric units
at a profit, charging an average rate of $919 per day. The survey provided
some insight into why they were able to do so.
First, the hospitals had to make the commitment to deliver the mental
health services the community needed, said Parks. They also needed to ensure
high occupancy rates by means of a no-reject policy that did not exclude
patients with substance abuse or those presenting involuntarily. Nonadmission
of a qualified patient resulted in a next-day conference to justify the
rejection. The hospitals had to hire qualified staff members who were employed
by the unit, not in private practice. They needed at least 20 beds and had to
keep them full.
The close connection with the CMHC is needed to ensure adequate follow-up
care for patients after they leave the inpatient unit.
Hospitals' reluctance to create space for psychiatric patients has not been
an accident but a matter of their own choice, said Parks. Hospitals buy
practices and facilities all the time, so they could do well by buying CMHCs,
if they chose, and could make money doing it, he said. ▪