July 1st, 2012

Psychiatric patients face lengthy ED waits

Psychiatric patients who visit an Emergency Department (ED) may face a lengthy wait.

A recent study of 1,092 patients seeking psychiatric help at five Boston-area hospital EDs showed an average wait of 11.5 hours (up to 15 for patients requiring outside hospitalization).

Psychologists cite a number of factors why psychiatric patients may be facing such lengthy waits.

Psychologist Elena J. Eisman, Ed.D., ABPP (who is executive director/director of professional affairs for the Massachusetts Psychological Association), says there are still hurdles to be jumped over to achieve parity. Eisman has independently been working in a coalition of behavioral health providers looking at parity, and in one meeting, a physician discussed an ED study. “What they found is that if you look at who is in the waiting room – the people on the bottom are always behavioral health people,” Eisman says. “They have been waiting the longest.”

Lisa Rocchio, Ph.D., who owns an interdisciplinary mental health practice (and is president of the Rhode Island Psychological Association), cited a Rhode Island study of people who presented for ED care, but gave up waiting and left before receiving treatment. Psychiatric patients left to a higher degree than those seeking general medical care, she says.

Rocchio says overall ED use among all patients has increased in recent years – even more so for mental health-related visits.

“EDs are more crowded generally, but I do believe that a big reason for that is, more and more patients with mental health issues are presenting in ED for care,” Rocchio says. “And I think part of that is attributable to the fact that patients with psychiatric difficulties also often have chronic and serious medical conditions and there are barriers specifically for psychiatric patients when it comes to receiving treatment for both their medical and psychiatric needs.”

Rocchio says funding for community supports and comprehensive outpatient treatment has dried up and copayments and deductibles have increased. “So patients who are more vulnerable and needy have a harder time accessing care.”

“I think there’s a real shortage of accessible psychiatric care, especially for children,” she says. “So when you’re not getting routine comprehensive care on an outpatient basis, you’re more likely to run into difficultly and end up in an ED.”

She notes greater access to funds for home-based and outpatient care services is needed to help reduce barriers to outpatient mental health services and increase access to community supports.

Lisa Uebelacker, Ph.D., staff psychologist at Butler Hospital and assistant professor (research) at Brown University in Rhode Island, says in her experience with one ED, lack of resources – specifically a shortage of psychiatric beds to transfer patients to – was a major barrier.

“Insurance plays into that, too, because it’s easier to get a bed if you have better insurance – or insurance, period,” she says.

If an ED determines a patient needs a psychiatric bed, and there isn’t one available, “they end up being boarded in the ER, which is not really good for anyone,” she says.

While some EDs are better than others, most don’t have the resources or room to treat patients with serious mental health conditions, according to Uebelacker. “It’s not like we just need to train emergency department staff and everything will get better. It’s a health care system issue.”

“We don’t want to leave these folks who are suffering to sit in an emergency department when they could be in a place getting treatment specifically designed for what they need. If somebody is at the point where they really need help and they are willing to ask for it, you want the process to go as smoothly as possible so if they need help again they are willing to ask for it again,” she adds.

Rhode Island will soon see an addition of beds, as Butler recently broke ground on a patient care center – scheduled to open in summer 2013 – to include a new 26-bed adult inpatient unit and an expanded patient assessment services center.

In addition to the need for outside hospitalization, the Boston area study cited older age, being uninsured, restraint use, the completion of diagnostic imaging and a positive toxicology screen result for alcohol as contributing to a longer wait.

“The biggest takeaway for me was really working hard to figure out alternatives to hospitalization or advocate for greater capacity for hospitalization, because ultimately these folks are coming in and they are vulnerable and they need help, and there are often times not many places to put them,” says lead author Anthony P. Weiss, M.D., of Harvard and Massachusetts General Hospital.

“I think it’s important for practitioners to realize that as they are sending someone to the ED, understanding what they are sending them into,” Weiss says. “And that for many patients that experience is not a positive one, although we didn’t specifically look at patient experience in this data. But it’s 11.5 hours in an emergency room. So not to dissuade clinicians if they think it’s medically necessary, but to have them understand that if it’s possible to avoid the ED visit, that might be something of value.”

By Pamela Berard

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