Dr. Walkeris an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (www.mdcalc.com), a medical calculator for clinical scores, equations, and risk stratifications, and The NNT (www.thennt.com), a number-needed-to-treat tool to communicate benefit and harm. Follow him @grahamwalker, and read his past columns athttp://bit.ly/WalkerEmergentology.
We are the elevator music while you are on hold. We are the line at Disney World. We are the bigger waiting room next to the real waiting room.
We are purgatory.
We are the emergency department.
Lately, emergency medicine has been doing a lot more babysitting and a lot less emergency-ing. And it's coming from all angles. But, today, let's talk about psychiatric boarders.
Most of us are the most familiar with the psychiatric patient awaiting placement. Waiting and waiting and waiting. These patients are usually suicidal in my experience, sometimes with concomitant substance-use problems. (I seem to specialize in “I'm drunk, and now I want to die” or “I ran out of crack, and now I'm feeling suicidal.”) Many fewer are gravely disabled (floridly manic or psychotic), but it happens. Homicidal seems to be the least common reason for a mental health involuntary hold.
Depending on the day, week, and insurance status, psychiatric patients are usually boarded for at least one full shift (eight hours), occasionally two or three. Sometimes even days; it's rare, but it certainly happens. Many of these patients (maybe a third?) are frequent psychiatric fliers: They are “chronically suicidal,” or they visit the ED for a clear-as-mud mixture of psychiatric and substance use problems. Not surprisingly, they also tend to have a number of social issues as well (homelessness, poor social support, weak coping mechanisms, etc.).
These patients create problems for the emergency department. First and most importantly, they almost never receive the appropriate, intensive psychiatric care that they need beyond “take this pill” or “you're going to get a shot in your arm.” I hope we'd all agree that the goal of the emergency department is to provide high-quality, effective, timely care to our patients (imagine an appy not going to the OR for three days or a STEMI not going to cath for six hours), and we're not able to provide this care to these patients.
Boarding patients often creates bed issues for the rest of the emergency department, taking up space that could be used for a new patient evaluation and instead are just in a holding pattern awaiting a bed somewhere else. Psychiatric patients' behaviors can often escalate, causing safety issues for themselves, other patients, and staff, not to mention making the chaotic environment of the ED even louder and more stressful.
And what do the data say? After the deinstitutionalization of state mental hospitals (think, One Flew Over the Cuckoo's Nest), state spending for mental health plummeted (and also transitioned to federal spending). The country had 400,000 inpatient psychiatric beds in the 1970s. Now, 85 percent of those beds are gone, despite an increasing number of psychiatric diagnoses and visits to emergency departments for psychiatric complaints and substance abuse (more than double in the past 15 years). In fact, in California where I practice, almost half of the counties have zero inpatient psychiatric beds, and 80 percent of them have zero child or adolescent psychiatric beds. All of the counties with inpatient psychiatric beds are grouped around the Bay Area and the Los Angeles/San Diego area.
Look no further than the prison population if you want some really depressing statistics. Our society is so thinly stretched for mental health support and coverage that we're probably just locking up the mentally ill: The number of incarcerated mentally ill quadrupled from 1998 to 2006. I can't imagine a worse place for patients with mental illness besides a prison.
There's plenty of blame to throw around, besides the budgetary changes:
- A highly litigious society where a zero misidentification rate is the standard of care for psychiatry and seemingly every other specialty.
- Lack of access for patients with mental illness and the increasingly common reliance on the emergency department for all diseases — medical and psychiatric. You know the line: “If you're having an emergency, call 911 or go to your nearest ED.”
- Lack of alternative options besides the ED for mental health crises. Community crisis centers do exist, but are rare in many communities and over-run in others.
- The malingering patient or patient with secondary gain who knows the system, and is aware that saying the magic words (“I'm suicidal”) gets them an extended stay in a warm bed with three meals.
Usually I try to end these columns with a solution, not just have them be sarcasm and venting, and I genuinely try not to complain unless I can at least think of a fix. (Favorite chemistry joke: If you're not part of the solution, you're part of the precipitate). But this really does seem, first and foremost, to be a resources issue.
We've slashed and burned our mental health system for four decades. The fat has been trimmed (and probably a lot of the muscle). Our problem now, just like in slash-and-burn farming, is that we have nothing left. If we don't restore these resources — and respect the need for them — we'll only be babysitting for longer, with the overflow sadly and apparently going to prisons instead.
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