Conference Coverage

Mental health visits, boarding continue to climb



– Between 2009 and 2015, the number of emergency department visits related to mental health increased 56% among children and 41% among adults, results from an analysis of national hospital data showed.

Dr. Genevieve Santillanes, University of Southern California, Los Angeles

Dr. Genevieve Santillanes

“The current mental health system is in crisis, and the impact on emergency departments continues to increase,” lead researcher Genevieve Santillanes, MD, said in an interview in advance of the annual meeting of the American College of Emergency Physicians. “We are seeing more patients with mental health disorders, and, when patients with mental health disorders require inpatient care, they board in the ED for long periods of time.”

According to Dr. Santillanes, an emergency medicine physician at the University of Southern California, Los Angeles, data from older studies and non–nationally representative studies have demonstrated that mental health–related ED visits have been increasing. “Emergency physicians know from experience that mental health–related ED visits are increasing and that patients are boarding in EDs longer, but there had not been recent nationally representative studies analyzing these trends in visits by pediatric and adult patients,” she said.

In an effort to describe recent trends in mental health–related ED visits for patients of different ages, Dr. Santillanes and her colleagues retrospectively analyzed data from the National Hospital Ambulatory Medical Care Survey, which generates nationally representative annual estimates of ambulatory care visits to general, nonfederal, short-stay U.S. hospitals. They calculated the proportion of ED visits during 2009-2015 in which one of the first three discharge diagnoses was a mental health or substance abuse diagnosis as defined by the Healthcare Cost and Utilization Project’s Clinical Classifications Software categorization scheme. They excluded patients diagnosed with developmental disorders, as well as those with a diagnosis of delirium, dementia, amnestic and other cognitive disorders, fetal/newborn complications of alcohol and substance abuse, and chronic medical complications of alcohol abuse. The researchers also calculated ED length of stay (LOS) and the proportion of mental health ED visits resulting in inpatient care in the form of admission, observation, or transfer and used linear regression models to examined time trends of the survey data estimates.

Dr. Santillanes and her associates found that mental health–related ED visits for children jumped from 699,677 visits in 2009 to 1,095,313 visits in 2015, an increase of 56%. Adult mental health–related ED visits rose from 7.1 million in 2009 to 10 million in 2015, an increase of 41%. The researchers also found that encounters with a mental health discharge diagnosis rose from 2.1% of pediatric ED visits in 2009 to 3.4% of visits in 2015 (P = .006). For adults, the proportion of ED visits with a mental health discharge diagnosis rose from 6.9% in 2009 to 9.9% in 2015 (P less than .001). In 2015, more than 10% of visits in patients aged 15-64 years and 8.9% of visits in children aged 10-14 years resulted in a mental health discharge diagnosis visits. During this period, the proportion of ED mental health visits that resulted in inpatient care declined from 29.8% to 20.4%, or an average of –2.3% per year; P = .004). At the same time, ED LOS for patients receiving inpatient care increased from 401 to 528 minutes (a 31.7% increase, or an average of 28.6 minutes per year; P = .006), while ED LOS for discharged patients averaged 259.5 minutes and did not significantly change over the study period (P = .660).

“The mean length of stay for these visits was 8.8 hours in 2015,” Dr. Santillanes said. “That represents more than a 30% increase in length of stay from 2009. When we board patients awaiting admission for other medical conditions, we treat their medical conditions while they wait for an inpatient bed. In most EDs, when patients board awaiting a psychiatric bed, they are not receiving treatment for their psychiatric condition. Besides adding to ED crowding, those prolonged boarding times result in patients who need intensive mental health treatment spending many hours in an ED without treatment for their mental health condition.”

Knowing that patients with mental health disorders represent a significant and increasing portion of the patients treated in our EDs, Dr. Santillanes continued, emergency physicians need to determine how to best treat patients with mental health emergencies. “We have dramatically improved the care we provide to patients with medical and surgical conditions,” she said. “We need to do the same for patients with mental health emergencies. Patients with mental health emergencies represent a large proportion of the patients we treat, so we need to be prepared to provide compassionate and evidence-based care for patients with mental health conditions. At the same time, we also need to continue to advocate for improved access to mental health care for all patients so that [they] do not have to rely on emergency departments to access care.”

The researchers reported having no financial disclosures.

SOURCE: Santillanes G et al. Ann Emerg Med. 2018 Oct. doi. 10.1016/j.annemergmed.2018.08.050.

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