What Patients Want From Emergency Care

As the Rolling Stones said so wisely many years ago, "You can't always get what you want."

This appears especially true if you are a psychiatric patient presenting in an emergency room, said panelists at APA's annual meeting in Honolulu in May.

"People think the hospital has unlimited resources," said Kenneth Certa, M.D., an associate professor of psychiatry and human behavior and director of the residency training program at Thomas Jefferson University Hospital in Philadelphia.

They see a pathway to hospitalization, of course, but sometimes also to food, shelter, clothing, social services, and social contact, said Certa.

However, emergency rooms are overcrowded, and sometimes beds are scarce, he said.

Certa has developed a rule of thumb about these patients' demands: "The more the patient wants to stay in the hospital, the less likely he needs to, and the more he wants to leave, the more likely he needs to stay."

Credit: David Hathcox

To document just how closely patient requests lined up with outcomes, Ellen Gluzman, M.D., a PGY-4 resident at the hospital, reviewed charts of 68 patients seen in the emergency department from April 2010 through June 2010.

Demographically, the average age of these patients was 38, 56 percent were male, 38 percent were white, 56 percent were African American, and 43 percent were homeless.

Overall, these patients' requests were met only 50 percent of the time by emergency department staff, said Gluzman.

The most common request from patients at admission was for inpatient treatment (70 percent), but those were frequently denied, she said. Only 34 percent were admitted.

Moreover, while only 7 percent of patients asked to be discharged, ultimately 64 percent were discharged with an outpatient referral.

Patients who were older, male, African American and homeless and had a substance use diagnosis were more likely to be denied their requests, said Gluzman.

However, diagnoses of mood disorder, psychotic disorder, and cluster B personality disorder had no significant effects on the relationship between request and outcome.

Much more still needs to be learned about the outcomes of patients who don't get what they want, said Gluzman.