If you’re having a psychiatric emergency, hang up and dial 911, or go to your nearest emergency room.” Most psychiatric patients are all too familiar with this voicemail message. And those who follow this advice, even calling 911, will still likely find themselves at the nearest emergency department (ED).
What many psychiatrists do not realize is that the majority of EDs in the US are inadequately equipped to treat psychiatric crises. As a result, many patients who seek emergency psychiatric care are mostly held for transfer to inpatient facilities. In fact, patients who present to the ED with mental health and substance abuse complaints are 2.5 times as likely to be admitted as those with purely physical problems.1
Unfortunately, the demand for inpatient psychiatric beds far exceeds supply. The Treatment Advocacy Center reported that the number of inpatient beds dropped by 95% from 1955 to 2005, going from 340 beds per 100,000 people to 17 beds per 100,000 people—and the number is still dropping.2 Because of this shortage, admitted patients must often wait many hours in the ED without treatment. This practice is known as psychiatric boarding.
The number of patients in the US presenting to the ED with psychiatric complaints has increased by more than 50% since 2006. One in eight ED visits now involves a psychiatric emergency.3 Meanwhile, the number of psychiatric inpatient beds continues to diminish.
A main driver of boarding is the belief that most patients experiencing psychiatric emergencies require inpatient admission. However, like physical complaints, mental health and substance abuse crises can often be stabilized in the ED. Imagine, for example, that we admitted everyone who presented to the ED with chest pain. If that were the case, we would be lamenting a national shortage of general hospital beds as well. (Fortunately, only 18% of chest pain patients are admitted from the ED to the hospital.4)
Research strongly suggests that if an appropriate treatment is started promptly, the majority of psychiatric emergencies can be resolved within 24 hours without inpatient hospitalization.5 To end boarding for this vulnerable population, we must implement effective ways to deliver timely psychiatric care in the ED.
Dr Zeller is Vice President of Acute Psychiatry at Vituity, a multispecialty partnership of physicians, advanced providers, and industry professionals, and is an Assistant Clinical Professor, University of California-Riverside. Dr Zeller reports reports no conflicts of interest concerning the subject matter of this article.
1. Owens PL, Mutter R, Stocks C. Mental Health and Substance Abuse-Related Emergency Department Visits Among Adults, 2007. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb92.pdf. Accessed July 5, 2016.
2. Torrey EF, Entsminger K, Geller J, et al: The Shortage of Public Hospital Beds for Mentally Ill Persons, 2008. http://www.treatmentadvocacycenter.org/storage/documents/the_shortage_of_publichospital_beds.pdf. Accessed July 5, 2018.
3. Weiss AJ, Barrett ML, Heslin KC, Stocks C. Trends in Emergency Department Visits Involving Mental and Substance Use Disorders, 2006-2013. 2016. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb216-Mental-Substance-Use-Disorder-ED-Visit-Trends.pdf Accessed July 5, 2018.
4. Venkatesh AK, Dai Y, Ross JS, et al. Variation in US hospital emergency department admission rates by clinical condition. Med Care. 2015;53:237-244.
5. Zeller SL. Treatment of psychiatric patients in emergency settings. Prim Psychiatry. 2010;17:35-41.
6. Waits for Care and Hospital Beds Growing Dramatically for Psychiatric Emergency Patients [press release]. Las Vegas, NV: American College of Emergency Physicians; October 17, 2016.
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8. Nicks BA, Manthey DM. The impact of psychiatric patient boarding in emergency departments. Emerg Med Int. 2012. https://doi.org/10.1155/2012/360308. Accessed July 5, 2018.
9. Zeller S, Calma D, Stone A. Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments. West J Emerg Med. 2014;15:1-6.
10. Conn J. Telehealth reduced readmissions, hospital days. Modern Healthcare. February 5, 2013. http://www.modernhealthcare.com/article/20130205/NEWS/302059954. Accessed July 5, 2018.