Longer Waits, More Transfers for Psychiatric Patients at EDs

PHILADELPHIA – Patients presenting to emergency departments with mental health issues wait longer than others and then, in many cases, are sent elsewhere for care, according to new research.

The study published in the journal Health Affairs blames cutbacks in capacity at state and county mental hospitals, forcing increasing numbers of psychiatric patients to seek treatment in EDs.

The Perelman School of Medicine at the University of Pennsylvania-led research reports that patients presenting with mental health emergencies wait nearly two hours longer on average and have a rate of transfer to another facility at six times the rate of those seeking care for physical health issues.

“Previous research shows that patients in the ER often experience lengthy wait times, but our new study shows that psychiatric patients wait disproportionately longer than other patients — sometimes for several hours — only to ultimately be discharged or transferred elsewhere," said lead author Jane M. Zhu, MD, MPP. "Overall, the study highlights the degree to which emergency departments struggle to meet the needs of mental health patients."

For the study, researchers examined length-of-stay data for more than 200,000 psychiatric and non-psychiatric ED visits during 2002-2011, using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), which is conducted annually by the national Centers for Disease Control and Prevention.

For the overwhelming majority of psychiatric patients, according to their analysis, the average length of stay was significantly longer than for non-psychiatric patients: 355 minutes vs. 279 minutes for patients admitted for observation, 312 minutes vs. 195 minutes for patients who were transferred to other facilities, and 189 minutes vs. 144 minutes for patients who were discharged.

For the 18% of psychiatric patients eventually admitted to the hospital, the average length of stay wasn't significantly different than for other patients, according to the report.

Over the study period, the annual number of visits to EDs by adults in the United States shot up by 30% — from 82.2 million to 106.8 million — with an even more dramatic increase, 55%, for psychiatric visits — from 4.4 million to 6.8 million. Increasing most were visits for alcohol-related disorders, according to the results.

At the same time, length of stay increased except when patients were admitted for observation. Study authors note that included just 2% of psychiatric visits, and that figures were variable, leading to an apparent close of the gap by 2011.

The largest underlying factor for longer lengths of stay and more transfers, according to the researchers, is a shortage of psychiatric inpatient beds. That is a result of the "de-institutionalization" of a large portion of the U.S. psychiatric inpatient population, which began in the late 1960s, they state.

Background information in the article notes that between 1970 and 2006, state and county psychiatric inpatient facilities in the country cut capacity from about 400,000 beds to fewer than 50,000.

"There has been progress made recently as the number of hospital-based psychiatric ER units has increased, along with regional psychiatric emergency care facilities that can quickly take in patients who visit local ERs," Zhu said. "However, these improvements have yet to offset the overall shortage of psychiatric inpatient resources."



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African-Americans Less Likely to Get ED Painkillers for Some Conditions

BOSTON – For certain “non-definitive” conditions, emergency clinicians are significantly less likely to prescribe opioids to African-American patients compared to white patients reporting the same pain levels.

That’s according to a new report, published by PLOS One.

The Boston University Henry M. Goldman School of Dental Medicine-led research discovered that black patients who visit EDs with back and abdominal pain are significantly less likely to receive painkiller prescriptions. Yet, that only occurred for conditions without clear clinical presentations and that are difficult to diagnose, study authors emphasize, and no differences were found for visits related to fractures, kidney stones, or toothaches.

Study authors suggest that pressure to be vigilant when prescribing opioids might increase the risk that physicians rely more on inappropriate subjective cues, such as race.

Researchers used the National Hospital Ambulatory Medical Care Survey (NHAMCS) to examine medications prescribed and administered in EDs during a five-year period from 2007 to 2011.

Results indicate that non-Hispanic black patients were less likely to receive opioid prescriptions at discharge during ED visits for back pain and abdominal pain but not for toothaches, fractures, and kidney stones, compared to non-Hispanic whites, with adjusted odds ratios that ranged from 0.56–0.67.

“Differential prescription of opioids by race-ethnicity could lead to widening of existing disparities in health, and may have implications for disproportionate burden of opioid abuse among whites,” study authors posit. “The findings have important implications for medical provider education to include sensitization exercises towards their inherent biases, to enable them to consciously avoid these biases from defining their practice behavior.”

"Access to healthcare and pain management decisions should be made without regards to patients' race-ethnicity,” added lead author Astha Singhal, DMD, PhD. “Healthcare providers need to be sensitized to their inherent biases, so that they can consciously avoid these biases from affecting their practice behavior.”


Decompressive Craniectomy Saves Lives But Linked to More Disability

TR-hzCAMBRIDGE, UK – Decompressive craniectomy in patients with traumatic brain injury (TBI) and increased intracranial pressure definitely saves lives, according to a new study. But at what cost?

A report published recently in the New England Journal of Medicine points out that patients saved with the procedure also had high rates of vegetative state and severe disability.

The study team, which was led by researchers at the University of Cambridge and based at Addenbrooke's Hospital, recruited more than 400 TBI patients over a decade from the United Kingdom and 19 other countries. Participants were randomly assigned to one of two treatment groups: craniectomy or medical management.

Six months after the head injury, results indicate that just more than one in four patients (27%) who received a craniectomy had died compared to just less than half (49%) of patients who received medical management. Yet, patients who survived after a craniectomy were much more likely to be dependent on others for care — 30.4% compared to 16.5%, according to the results.

Patients who survived following a craniectomy continued improving from six to 12 months after injury, however, and study authors report that, by a year, nearly half of the patients whose skulls were opened were at least independent at home, 45.4%, as compared with one-third of patients in the medical group, 32.4%.

"Traumatic brain injury is an incredibly serious and life-threatening condition. From our study, we estimate that craniectomies can almost halve the risk of death for patients with a severe traumatic brain injury and significant swelling,” explained lead author Peter J. Hutchinson, PhD, FRCS. “Importantly, this is the first high-quality clinical trial in severe head injury to show a major difference in outcome. However, we need to be really conscious of the quality of life of patients following this operation, which ranged from vegetative state through varying states of disability to good recovery."

Background information in the article notes that decompressive craniectomy is a surgical procedure in which a large section of the skull is removed and the underlying dura mater is opened.

"Doctors and families will need to be aware of the wide range of possible long-term outcomes when faced with the difficult decision as to whether to subject someone to what is a major operation,” added co-author Angelos G. Kolias, PhD, MRCS. “Our next step is to look in more detail at factors that predict outcome and at ways to reduce any potential adverse effects following surgery. We are planning to hold a consensus meeting in Cambridge next year to discuss these issues."



Pediatric Burn Patients Not Transferred from EDs as Often as Recommended

COLUMBUS, OH – Despite recommendations that children with significant burns be transferred to a specialized center for evaluation and care, that usually doesn’t happen at most low-volume emergency departments.

That’s according to a new study published in the journal Burns. In low-volume hospitals, 90.3% of patients were treated and released from the ED, 4% were admitted to that same hospital without transfer, and 5.6% were transferred to another hospital, according to the report.

Background information in the study led by researchers from the Center for Pediatric Trauma Research and the Center for Injury Research and Policy at Nationwide Children's Hospital points out that nearly 127,000 children in the United States had burn injuries in 2012. More than half of those, 69,000, suffered burns considered significant injuries by the American Burn Association (ABA).

The ABA recommends that a child with a significant burn be referred for evaluation and care at a burn center, which must meet rigorous standards for personnel expertise, facility resources, and medical services. In addition, the specialized centers also must treat sufficient numbers of patients to demonstrate that expertise.

Yet, the researchers found that wasn’t occurring very often. Results indicate that 83.2% of the pediatric burn visits to EDs were at low-volume hospitals, and that only 8.2% of patients meeting criteria were transferred.

"While the majority of children treated without being transferred are likely receiving adequate burn care in the emergency department or possibly with outpatient follow-up care, ABA guidelines do not specify when outpatient follow-up is appropriate," said senior author Krista Wheeler. "The ABA could lessen this room for error by clarifying their guidance."

In fact, the ABA referral criteria might be too broad and would possibly benefit from urgency specifications regarding care, added co-author Jonathan Groner, MD, pediatric burn surgeon, and medical director of the Center for Pediatric Trauma Research. While some of the pediatric burn patients receiving care in low-volume hospitals could have improved clinical outcomes if they were transferred upon presentation, Groner suggested, others might need only outpatient follow-up at a burn center.

For the study, researchers used data from the 2012 Nationwide Emergency Department Sample (NEDS), the largest all-payer emergency department database in the United States.