Diminishing access to psychiatric beds and the resulting overcrowding of emergency departments is an urgent crisis and a national disgrace, said psychiatrists, emergency department specialists, and other physicians at the AMA's House of Delegates meeting last month in Chicago (see Psychiatry-Related Issues Prominent on AMA Agenda).

With virtually unanimous support, the AMA house called for efforts to facilitate access to both inpatient and outpatient psychiatric services and the continuum of care for mental illness and substance abuse as a means of relieving pressure on emergency departments (EDs) across the country that have been forced to board patients in crowded hallways—sometimes for days—before available beds can be found.

The recommendations were part of a report titled "Access to Psychiatric Beds and Impact on Emergency Medicine," prepared by the AMA's Council on Medical Service.

In a nod to the urgency of the problem of ED overcrowding, delegates also asked for a report back at next year's meeting on the effectiveness of local solutions that have been implemented around the country to mitigate boarding and crowding.

"This is a huge problem," said Nicholas Jouriles, M.D., president-elect of the American College of Emergency Physicians (ACEP)." We have places around the country where it takes two, three, or five days to find a bed upstairs. We know that people who are boarded are more likely to have morbidity and mortality, and if you are elderly you are four times more likely to go to a nursing home. If we don't fix the boarding problem, people will die."

Jouriles reported that an informal survey of 2,000 members of the 2,600-member ACEP found that 200 deaths were related to boarding." That's an epidemic that we need to stop," he said.

During reference committee hearings—which precede the meeting of the House of Delegates—and on the floor of the house, physicians from all specialties emphasized the scope of the problem and the fact that it is embedded in other, larger problems in American health care: the rising number of uninsured people, the closing of psychiatric units due to falling hospital revenues, the need for more psychiatrists, and on-call and duty-hour restrictions.

One physician at the meeting referred to the boarding and overcrowding issue as "the proverbial canary in the coal mine" of the American health care crisis.

At reference committee hearings on the report, psychiatrist and past APA Assembly Speaker Al Herzog, M.D., described a 14-year-old patient who had threatened to hang herself but for whom there was no inpatient bed immediately available.

"I ended up doing something I never in my life thought I would do," he told delegates. "The dad happened to work in my hospital, and he said to me, 'Don't send her to the ED. I know what the ED is like—all the psychiatry patients waiting for beds with no place to go.' I said to him, 'you're asking me to send home an actively suicidal teenager?' I told the parents the only way I would do that is if the two of them would watch her continuously until I find a bed. They said they would.

"So I sent home an actively suicidal teenager," Herzog said." But if she had shot herself and survived, I could have gotten her into an ICU. The insurance company would have paid $2,500 a day, no questions asked, as opposed to the $600 to $800 a day for psychiatric care"—the latter of which is decreasingly available because it loses money for the hospital.

"This is about larger issues," Herzog said. "This is about money."

The AMA council's report was the result of a resolution sponsored at last year's annual meeting by the Section Council on Psychiatry and others, including ACEP.

The chair of the section council, John McIntyre, M.D., who is also on AMA's Council on Medical Service, said there was solid support for the report from the entire house.

"There is recognition not only by ED physicians but by the rest of medicine of the importance of psychiatric services," he said. "And there is also a recognition that there has to be better reimbursement and support for increasing the psychiatric workforce."

During reference committee hearings, section council member Paul Wick, M.D., urged that advocacy for psychiatric services include not only inpatient and outpatient services, but the full continuum of care.

"If access is improved and funded to offer intermediary services between inpatient and outpatient care, it would alleviate the ED crisis," he said. "These services include day treatment, partial hospitalization, residential treatment, sober-living facilities, and therapeutic foster care for children."

The point was echoed by section council member Kenneth Certa, M.D." Having this continuum of services would absolutely avoid hospitalization," he said. "That is where the field is going. Most of our payers and state legislators don't want to see large state hospitals; we don't institutionalize people anymore, but treat them in the community. The reason people are showing up in the ED is in part because the full network of social supports isn't there. A lot of people in inpatient units in Philadelphia [where Certa works] could probably be treated in the community if there were adequate services available."

As a result of that testimony, the council report recommendations were amended to include advocacy for a full range of a continuum of services.

In comments to Psychiatric News after the meeting, Certa pointed out that psychiatric patients are an easy target on which hospitals can focus as they try to deal with overcrowded EDs.

"Many patients, not just those with mental illness, are often backed up in our emergency rooms," he said. "But hospitals often set aside beds for elective admissions of surgical patients. These are more lucrative, and it is in the hospitals' best financial interest to keep the surgeons happily operating. If an emergency room patient gets admitted to a bed that the hospital was counting on filling with a fresh post-op patient, the post-op patient has to hang out in the PACU [post-anesthesia care unit] until a bed becomes available.

"In the past, hospitals did not need to manage beds so tightly to stay financially sound," he said. "There were enough empty beds to admit ED patients, as well as have some available for post-op patients. This is no longer true. Psychiatric patients are only a part of the issue, but one that has captured a lot of attention. It is certainly true that the differential reimbursement for psychiatric services, compared to others, plays a role in hospital decisions about which units to close. But the decisions made to treat more patients in nonhospital settings have had many positive effects, which a rush to rehospitalization might lose. It is a very complicated picture, and I am glad the AMA plans a follow-up study."

Also added to the Council on Medical Service report was the recommendation for a report back next year to the house describing the effectiveness of local solutions around the country to the problem of boarding and overcrowding.

The motion received widespread support from physicians across specialties." The AMA needs to promote solutions that work," said Melissa Garritson, M.D., a pediatric emergency physician. "This is not an ED problem; this is a hospital-wide problem. The entire hospital needs to be involved."

Brian Johnston, M.D., an ED physician from Los Angeles, said, "This is a national scandal; we need a national response. We need to know if we are getting better or worse. Lives are on the line."

Also, Brooks Bock, M.D., of Detroit, said, "There is no question that we need to solve the problem of overcrowding and patients languishing. I can tell you what's going in Detroit [to address the problem], but I can't tell you what's going on elsewhere." ▪