By Marti Webb Slay

The shortage of resources for mental health patients is resulting in a problem for hospital emergency departments, which are seeing an increasing number of psychiatric patients.

“It’s a daily struggle,” said Elizabeth Caine, MSHA, MBA, associate vice president and administrator for UAB’s Center for Psychiatric Medicine. “It causes a backlog for patients seeking medical care and trauma care.”

By June 30, UAB had boarded psychiatric patients in the emergency department for more than 2,600 hours per month, on average. “We are delivering care, but it takes up space and prevents the emergency department from turning the beds over and seeing other patients who come in,” Caine said.

The problem of emergency department backlog isn’t unique to psychiatric patients. “Almost every emergency department in our state deals with boarding crises on a daily basis,” said Jeremy Rogers, MD, FACEP, associate medical director of the department of emergency medicine at Grandview Medical Center. “Many days, our Alabama hospitals have prolonged wait times when there are no inpatient beds available. This is not just a psychiatric care issue. It is a general situation hospitals find themselves in.

“Studies show that psychiatric patients are generally two times as likely to be admitted to the hospital as medical patients. And the need for access to mental health resources has significantly increased. A recent study showed that emergency department encounters with mental health patients have increased by 44 percent. From 2010 to 2016, there was a 13 percent decrease nationwide in inpatient psychiatric beds. So more patients are attempting to access mental health resources while there has been a contraction of resources.  This nationwide trend is also taking place in Alabama and certainly in Birmingham.”

Caine agreed. “It’s really a nationwide problem, specifically in urban areas, but also in rural areas where there is often not access to psychiatrists or outpatient psychiatry programs.”

“With beds closing and the lack of inpatient treatment options, we are seeing more return visits to the emergency department,” said Carrie Wynn, BSN, RN, service line director of emergency services at Decatur Morgan Hospital. “Some of the mental health patients stay in the ER for days. We had one patient for 20 days. So you have a treatment bed in your ER tied up for nearly a month, waiting for us to find them a bed to transfer to.

“In addition, if patients are at risk for suicide or a threat to others, regulations now require a one-to-one sitter while they are in the ED. You can imagine the impact that’s having on our healthcare staffing, especially with some of the long stays. And the ED is not a therapeutic environment for these patients. When you have a paranoid schizophrenic who is having auditory hallucinations in a noisy ED, that’s not beneficial for them. We offer care, but there’s a line between what an ER physician can do for them versus what a psychiatrist would do.

“This crisis is also causing problems with allocation of EMT resources. Because there are so few available beds in the state, we find one across the state, so we’re frequently sending our ambulance crews six hours away. If it’s a six-hour trip, that’s 12 hours the ambulance is out of service. It keeps a crew from answering 911 calls locally.”

All the providers say there are no simple solutions here. More beds are needed, as well as more caregivers. A better system for care before patients become emergent would result in less traffic in EDs. Better follow-up care would cut down on repeat visits. An automated system for tracking available beds would free up personnel who are currently searching for availability institution by institution. But these are all long-term answers that will require funding and a concerted effort by state leaders.

In the meantime, Rogers offers some suggestions for steps EDs can take to help manage the situation: Since routine is important for psychiatric patients, regular meals are important, and many need nicotine supplements. If restraints are needed, they should be discontinued as soon as possible. Hospitals should provide a dedicated space in order to consolidate resources and board psychiatric patients further away from the activity of the emergency department. Telehealth access to psychiatrists can help provide better care for hospitals that don’t have an inpatient psychiatric facility.

Rogers acknowledged the frustration of providing quality care to all patients in the ED under difficult conditions. “We want to take good care of our patients,” he said. “It’s frustrating when we are overburdened. This is a difficult and complicated issue.”