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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."