The situation wasn’t unusual for Stanford, Calif., emergency physician Suzanne Lippert: The patient before her was a woman in her 60s suffering from severe depression, who said she had a plan to take her own life. The problem for Lippert: No inpatient bed was immediately available, so the woman would have to temporarily wait in the Stanford Hospital emergency room as a “boarder.”
Three days later, the woman was still there. Six days later, the same.
“I thought this had to be an extraordinary case,” Lippert said during a call with reporters. “I found out it’s not.”
Lippert and others are presenting data on the issue at this week’s annual conference of the American College of Emergency Physicians. Some of their research on the worsening problem of mental health emergencies and hospitals is based on a recent online survey of more than 1,700 ER doctors. Among the findings:
- 3 out of 4 emergency physicians see at least one psychiatric patient who requires hospitalization every shift.
- More than 7 in 10 emergency physicians report that on their last shift, psychiatric patients were waiting for inpatient beds.
- Of those doctors, more than a third say the psychiatric patients had to wait at least two days for a bed to become available.
“ERs are the de facto dumping grounds for these patients,” said Renee Hsia, director of health policy studies in the Department of Emergency Medicine at the University of California at San Francisco, and “our ER departments are at their breaking points.”
Hsia and colleagues used a decade of data from a National Hospital Ambulatory Medical Care Survey to track ER visits. During that time, the absolute number of psychiatric visits to hospital emergency rooms rose 55 percent, from 4.4 million in 2002 to 6.8 million in 2011.
The same increase did not occur with medical visits to the ER, according to their study, which was published recently in the journal Health Affairs. The result was that more than twice as many psychiatric patients as medical patients were stuck in hospital emergency rooms for longer than six hours. More than three times as many of these “boarders” remained in the ER for longer than 12 hours, the study found.
The nation’s lack of inpatient psychiatric beds is not a new issue. The deinstitutionalization of psychiatric patients that began in the 1960s was not followed by an increase in group homes and halfway houses. In 1955, there were 558,922 state psychiatric beds in the United States. Today there are 37,679, and nearly half of those beds are available only for forensic cases — meaning patients who are also criminal suspects in jails or prison inmates, according to a June study by the national nonprofit Treatment Advocacy Center.
These changes have made the hospital emergency room the triage of last resort for an ever-growing number of people with severe mental illness.
Along with the plummeting number of inpatient psychiatric beds, the number of hospital-based psychiatrists has dropped sharply. Less than 17 percent of the 1,700 ER physicians who were surveyed said their hospital had a psychiatrist on call to respond to psychiatric emergencies in the ER.
“There is not a requirement [for hospital ERs] to have a psychiatrist, or any specialist, on call,” Hsia said.
Overcrowding in hospital emergency departments has been on the rise since the 1980s, experts say, and the central cause is boarders — people waiting more than two hours for an inpatient bed. Psychiatric boarders generally wait the longest.
“There are spillover effects on all [ER] patients because of these longer stays,” said Rebecca Parker, president of the American College of Emergency Physicians.
Many studies over the past decade have shown that ER overcrowding results in higher mortality rates of ER patients, higher costs and higher stress levels for medical professionals.
That overcrowding won’t end anytime soon, Parker said, unless access to outpatient treatment centers expands. But in the latest survey, more than half of the ER physicians said mental health resources in their communities had declined in the past year.
The paradox at the heart of the problem is almost beyond comprehension, in Lippert’s view.
“Nowhere else in medicine,” she said, “do we have our most severely ill patients staying the longest.”