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
"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
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
"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
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,
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
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." ▪