The availability of inpatient psychiatric care has worsened significantly and progressively over the past four years on state and national levels. As inpatient psychiatric beds have become increasingly scarce, the number of patients seeking or requiring psychiatric assistance has also increased. These patients are spending increased time “boarding” in emergency departments, and with beds scarce and increasingly far afield, many require transfer to facilities many miles away. In the meantime, emergency physicians and other emergency department personnel must dedicate significant time and resources to not only searching for placement, but also attending to patients’ needs while ensuring the safety of both patients and departmental staff for the duration of patients’ ED stays. This leads to increased throughput times for other patients, a frightening environment for delivering care, patient safety issues, and decreased satisfaction for patients and providers.
Explore This IssueACEP Now: Vol 33 – No 06 – June 2014
A brief review of the literature and national statistics on mental health care confirms what most of us already know from experience: the number of inpatient psychiatric beds nationally falls woefully short of what is necessary to meet current demand. The Treatment Advocacy Center recommends that each state should have 50 public inpatient psychiatric beds for every 100,000 people in a state’s population.1 According to the ACEP 2014 State-by-State Report Card, only three states (Mississippi, Missouri, and Arkansas) hit this target number, while 31 states had 50 percent or fewer of the target number of beds.2 Unfortunately, there is little hope for improvement in these numbers as state budgets continue to cut billions of dollars from public mental health spending.
The problem of the inadequate supply of inpatient psychiatric beds affects both psychiatric patients and emergency providers. The external stimuli associated with the busy emergency department environment have been shown to increase patient anxiety and agitation, leading to increased risk of symptom exacerbation or elopement of patients seeking treatment for mental health or substance abuse issues, which poses a danger to patients and staff.3 Elopement before screening and treatment is dangerous and leads to increased risk of self-harm and suicide.4
Furthermore, the need for increased security and additional ancillary staff to monitor and protect these patients, emergency department staff, and other patients leads to increased labor costs.3 Additionally, the significant number of resources and personnel required to provide adequate care for these patients for extended periods may lead to delays in care of other ED patients. Poor clinical outcomes and increased morbidity and mortality have been directly linked to ED overcrowding and a lack of available ED beds.5,6