The availability of inpatient psychiatric care has worsened significantly and progressively over the past four years on state and national levels. As inpatient psychiatric beds have become increasingly scarce, the number of patients seeking or requiring psychiatric assistance has also increased. These patients are spending increased time “boarding” in emergency departments, and with beds scarce and increasingly far afield, many require transfer to facilities many miles away. In the meantime, emergency physicians and other emergency department personnel must dedicate significant time and resources to not only searching for placement, but also attending to patients’ needs while ensuring the safety of both patients and departmental staff for the duration of patients’ ED stays. This leads to increased throughput times for other patients, a frightening environment for delivering care, patient safety issues, and decreased satisfaction for patients and providers.

A brief review of the literature and national statistics on mental health care confirms what most of us already know from experience: the number of inpatient psychiatric beds nationally falls woefully short of what is necessary to meet current demand. The Treatment Advocacy Center recommends that each state should have 50 public inpatient psychiatric beds for every 100,000 people in a state’s population.¹ According to the ACEP 2014 State-by-State Report Card, only three states (Mississippi, Missouri, and Arkansas) hit this target number, while 31 states had 50 percent or fewer of the target number of beds.² Unfortunately, there is little hope for improvement in these numbers as state budgets continue to cut billions of dollars from public mental health spending.

The problem of the inadequate supply of inpatient psychiatric beds affects both psychiatric patients and emergency providers. The external stimuli associated with the busy emergency department environment have been shown to increase patient anxiety and agitation, leading to increased risk of symptom exacerbation or elopement of patients seeking treatment for mental health or substance abuse issues, which poses a danger to patients and staff.³ Elopement before screening and treatment is dangerous and leads to increased risk of self-harm and suicide.⁴

Furthermore, the need for increased security and additional ancillary staff to monitor and protect these patients, emergency department staff, and other patients leads to increased labor costs.³ Additionally, the significant number of resources and personnel required to provide adequate care for these patients for extended periods may lead to delays in care of other ED patients. Poor clinical outcomes and increased morbidity and mortality have been directly linked to ED overcrowding and a lack of available ED beds.^5,6

The financial impact of boarding these patients is profound. A recent study at Wake Forest University Health Sciences Center found admitted psychiatric patients are associated with a 40 percent decrease in average physician reimbursement as compared to nonpsychiatric patients. Furthermore, the increased length of stay for each of these patients was determined to prevent the ED from caring for an additional 2.2 patients, leading to an overall financial loss to the system of approximately $2,400 per boarded psychiatric patient.³

The effects of budget cuts to public mental health care can be felt at the ground level in many emergency departments across the nation. Per the ACEP State-by-State Report Card, Iowa ranks 16th in the nation in number of psychiatric inpatient at 28 beds per 100,000 population. Although I work at the state’s only tertiary referral hospital, we lack sufficient psychiatric beds for our needs and are frequently forced to transfer patients to other facilities. We recently conducted a review of patient records for all psychiatric patients transferred out of the University of Iowa Hospitals and Clinics (UIHC) for 2010–2013. The average length of stay for psychiatric patients requiring transfer out of our ED more than doubled in that time (from 5.6 hours in 2010 to 13.8 hours in 2013). It is not unusual for patients to wait more than 24 hours in the ED while providers attempt to locate an available psychiatric bed.

The primary problem is inadequate funding. The recent economic downturn forced states to cut approximately $4.35 billion in public mental health spending in the period between 2009–2012, the largest reduction since deinstitutionalization in the 1960s.⁷ According to Steve Blanchard, the department administrator of UIHC Psychiatry, most hospitals run their inpatient psychiatric units at a deficit. Due to the chronic, disabling nature of mental illness, many patients seek care with coverage through government payers, which generally pay below cost. Duration of stay in an acute inpatient setting may be lengthened due to the inadequacy of outpatient community resources. In Iowa, the supply of inpatient psychiatric beds has continued to decline as inpatient facilities close due to lack of funding and retirement or exodus of Iowa psychiatrists to states with better reimbursement and more support staff. The problem of the inadequate supply of beds is exacerbated by the poor distribution of beds; many rural areas have no access to services. UIHC recently had a patient remain on one of the acute inpatient psychiatric units for 442 days because it was nearly impossible to locate a community-based option that could accept the patient, despite contacting more than 100 facilities.

In the absence of the promises for increased funding for mental health from state or federal sources, alternative solutions should be pursued.

While some of these problems may be specific to Iowa, they are symptomatic of the larger national crisis of lack of adequate mental health care. In the absence of promises for increased funding for mental health from state or federal sources, alternative solutions should be pursued. For example, telepsych, or the remote psychiatric evaluation, is one alternative being piloted at UIHC. Additionally, low-cost collaboration between EDs and community outpatient alternatives has been shown to decrease emergency department boarding.⁸ This collaboration could include using mental health clinicians to train ED staff in the management and care of patients with serious mental illnesses or having a social worker in the ED who can connect patients with community services at the time of discharge. The involvement of law enforcement may help. Federal grants of up to $250,000 over two years are available for the planning, implementation, or expansion of collaborative programs between criminal justice and mental health partners, including specialized training of law enforcement officers.

As emergency care providers, whether in rural Iowa or inner-city New York, we are all impacted by the shortage of inpatient psychiatric beds. Cost, quality of care, ED throughput, and patient safety are all negatively impacted by this crisis. Solutions,such as collaborating with community mental health services, educating ED staff about the management of the boarding mental health patient, and using telemedicine are all viable strategies that will protect a subset of ED patients who often cannot advocate for themselves.

Dr. Kitchen is an emergency physician resident R2 at the University of Iowa Hospital and Clinics in Iowa City.

References

1. Torrey EF, Entsminger K, Geller J, et al. The shortage of public hospital beds for mentally ill persons. Arlington, Va: Treatment Advocacy Center; 2008.
2. ACEP. America’s emergency care environment: A state-by-state report card 2014.
3. Nicks BA, Manthey DM. The impact of psychiatric patient boarding in emergency departments. Emerg Med Int. 2012;2012:360306.
4. Hickey L, Hawton K, Fagg J, Weitzel H. Deliberate self-harm patients who leave the accident and emergency department without a psychiatric assessment: a neglected population at risk of suicide. J Psychosomatic Res. 2001:50(2):87-93
5. Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust. 2006:184(5):213-216.
6. Sprivulis PC, Da Silva JA, Jacobs IG, et al. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust. 2006:184(5):208-212.
7. Glover RW, Miller J, Sadowski S. Proceedings on the state budget crisis and behavioral health treatment gap: The impact of public substance abuse and mental health treatment systems. Special Congressional Briefing; March 22, 2012.
8. Alakeson V, Pande N, Ludwig M. A plan to reduce emergency room ‘boarding’ of psychiatric patients. Health Affairs. 2010; 29(9): 1637-1642.