Editorial: A Wintry Mix of Patients, Redux



The unconscionable extended ED boarding of acutely ill psychiatric patients in need of inpatient care was the subject of one of the most requested recent EM editorials. Tragically, in the 2 years since “A Wintry Mix of Patients” first appeared (March 2013), little has changed.

An August 7, 2014 Washington State Supreme Court decision prohibiting the use of EDs to board acutely ill psychiatric patients may be one step in the right direction. But it offers no alternatives for actually providing the care. A week after the ruling, ACEP’s president expressed concern that EPs could be caught in the middle of conflicting federal and state mandates, and medical liability risks.

Throughout the United States this winter, admitted patients and their families waited hours to days in emergency departments for inpatient beds. Few waited longer or suffered more than those waiting for a psychiatric bed. The number of patients needing hospitalization for acute psychiatric conditions and behavioral disturbances frequently exceeds the capacity of psychiatric services to admit them and increasingly exceeds the capacity of psychiatric EDs to provide continued care until beds become available. When psychiatric patients are boarded in surrounding medical EDs that were never designed for this purpose, emergency physicians, nurses, and security officers must try to provide a safe and secure environment of care for both the displaced psychiatric patients and nearby medical and surgical patients.

In a January 22, 2013, article, Washington Post reporter Olga Khazan describes the plight of a 15-year-old girl with Asperger’s syndrome and an anxiety disorder who spent 2 days on stretchers in two EDs waiting for an inpatient bed. The article attributes the nationwide bed shortage to cutbacks after “28 states and the District [of Columbia] reduced their mental health funding by a total of $1.6 billion” between 2009 and 2012.

Similarly, in a July 2012 report, “No Room at the Inn: Trends and Consequences of Closing Public Psychiatric Hospitals,” the nonprofit Treatment Advocacy Center (TAC) points out that the total number of state psychiatric beds in this country decreased by 14% from 2005 to 2010, dropping the per-capita bed ratio to the same level it was in 1850, the year that our country began to provide more humane care by hospitalizing the most severely mentally ill patients. The TAC report also notes that, in the absence of needed psychiatric treatment and care, people in acute or chronic crises gravitate to hospital EDs, jails, prisons, or the streets, and are partly responsible for higher rates of violent crimes.

At the same time that state-supported psychiatric beds are disappearing at an alarming rate, a desperate need for more med/surg beds is leading many general hospitals to convert psychiatric beds to nonpsychiatric beds. But a lack of inpatient beds is not the only factor responsible for this crisis in care. Health insurance providers are much more selective with respect to which inpatient psychiatric services they will pay for, and often will not cover an available inpatient bed nearby. Why is there a difference between psychiatric and nonpsychiatric inpatient coverage, and why do states permit the difference? This practice adds to the misery and delays the care of all patients, as emergency psychiatrists and social workers must spend hours or days arranging for covered inpatient stays.

All inpatient care, including psychiatric care, can be expensive, but how much money does the elimination of psychiatric services really save if you add in the cost of extra prison capacity, the loss of income by family members waiting in the ED with an ill relative, or the loss of productivity by victims of violent crimes committed by nonhospitalized mentally ill patients? Psychiatrists utilizing potent modern medications have made incredible strides in treatment, but treating an illness is not the same as curing it, and patients who stop taking their medications after their prescriptions run out often end up back in the ED—sometimes repeatedly. Such episodic ED care also adds to the overall costs and, more important, hurts many people in the process.

For more than 150 years, states have assumed major responsibility for providing a safe therapeutic environment for those suffering from severe mental illness. Now is not the time to abandon this responsibility. As a nation, if we cannot recognize the seriousness of this problem and if we do nothing to fix it immediately, lack of beds is not the only lack of capacity from which we suffer.

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