Psychiatric Patients Get the Short End of the ER Stick

The hospital’s emergency room is filled with patients representing a range of urgent problems. The kid with a broken ankle, courtesy a bumpy slide at second base. The woman wearing dark sunglasses and cradling her migrained head. The guy pressing a towel into the web of his hand to stanch the blood from a knife meant to cut a bagel. The hyperactive, foot-tapping college student who alternates between nonstop chatter and low, howling moans, in the throes of an anxiety attack, schizophrenia or who knows what.

Who will be seen first, who will get treated quickly, how long will it take to admit someone who should be an inpatient?

This is a hypothetical example. But it’s pretty certain not to be the patient with the mental disorder. A study published in the Annals of Emergency Medicine showed people presenting at hospital emergency departments and trauma centers with psychiatric problems spent more than 11 hours in the ER, and that they wait even longer if they must be transferred for admission.

If the psych patient is older, intoxicated or uninsured, according the study, the wait is even longer. The time doubled if the patient was discharged not home but to an outside facility.

As reported on MedPageToday, the conclusions highlight how interrelated is mental health care, and how much room there is for improvement for to coordinate care.

This isn’t news. National Center for Health Statistics showed that the average wait for mental health services in an emergency department was 42 percent greater than the wait for other health issues.

In a survey by the American College of Emergency Physicians, 40 percent of emergency department medical directors said psychiatric patients waited more than eight hours from disposition decision to discharge from the ED. Only 7 percent of the directors said medical patients had to wait that long.

In addition to being inconvenient and distressing, waiting too long in an ER can be harmful. See our post, “ER delays cause patients to skip care.”

Some ERs are better able to process psych patients than others.

“Emergency departments (EDs) that are embedded within a larger system of care and have ready access to various levels of after care options,” the researchers wrote, “are likely to be better positioned to more rapidly transition patients through the ED.”

There’s still not much authoritative data about just how much psychiatric patients are penalized in the ER because their disorder isn’t visible or exciting or … what? So the latest research was aimed at identifying patient-related and clinical management factors associated with longer ED waits.

Psychiatric patients seeking emergency consultation at five urban hospitals-two academic and three community-were studied. More than 1,000 patients were included. The median age was 39, and the gender representation was equal. About 7 in 10 were non-Hispanic white; two-thirds had public insurance; 13 percent were homeless.

The most common complaints were depression or anxiety (37 percent) and suicidal thoughts or nonlethal self-harm (33 percent). One in 3 showed evidence of alcohol use, with or without other drugs.

On discharge, the most common diagnoses were mood disorder (69 percent) and substance use disorder (41 percent). Nearly 300 patients were discharged to home and nearly 600 were admitted to the hospital or transferred to a psychiatric unit.

The average wait times and average added times were:

  • transfer outside the care system, 15 hours;
  • transfer within the system, 12.9 hours;
  • transfer to psychiatric unit in hospital, 11 hours;
  • age: 12.6 hours for ages 60 and older, 11.9 hours for ages 41 to 59, 10.7 hours for ages 18 to 40;
  • positive screen for alcohol, more than 6.2 hours;
  • diagnostic imaging, more than 3.2 hours;
  • use of a restraint, more than 4.2 hours;
  • uninsured, more than 4 hours.

Being admitted or transferred resulted in an additional wait of 3.3 to 7.4 hours. The long wait after diagnosis and before admission/transfer, the researchers said, was the single biggest influence on how long a patient would be confined to care.

“Approximately two-thirds of all patients receiving emergency mental health care … were either admitted or transferred to a psychiatric unit. Although these hospitalized patients tended to be seen and assessed more quickly than patients discharged home, they had significantly longer overall length of stay because of the extended wait time between the decision to admit and the ED discharge.”

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