Many behavioral health patients boarded in emergency departments are discharged after an inpatient bed request has been made.
Behavioral health patients who are discharged from an emergency department after clinicians request an inpatient bed admission face high risk for return visits to the ED, recent research has found.
Boarding of mental health and substance abuse (MHSA) patients in emergency rooms is one of the most vexing challenges at hospitals across the country. With a shortage of behavioral health inpatient beds in hospitals and mental health facilities, patients can spend days or even weeks boarded in an ER awaiting placement in an inpatient setting.
"MHSA patients who were discharged from ED after bed requests were placed were at greater risk for return visits to the ED. This implicates that these patients require outpatient planning to prevent further avoidable healthcare utilization," researchers wrote this month in American Journal of Emergency Medicine.
The researchers examined post-discharge outcomes for 492 patients at University of Iowa Hospitals & Clinics, The Hawkeye State's only academic medical center.
"An ED revisit within 12 months was significantly higher among patients discharged who had a bed request in place prior to departure (54.0%), than those discharged from the ED (40.9%) or admitted to inpatient care (30.5%)," the researchers wrote.
The most common reason patients were discharged after bed requests was stabilized patient condition (85.1%). For 11.8% of patients, they became frustrated and the provider did not think hospitalization was mandatory. For 2.5% of patients, they left against medical advice.
Rising to the challenge
In addition to a shortage of beds, there are daunting obstacles to providing behavioral health patients with inpatient placement from the ED setting, the researchers wrote.
"As EDs often function as a last resort for psychiatric patients, providing effective psychiatric services are important to ensure patient safety. However, in the ED, the patients are often subject to the complex processes of the mental healthcare system, including medical clearance, insurance verifications, regulatory and institutional requirements, and patient disposition. The complex processes result in psychiatric boarding."
In the absence of increased access to inpatient beds for behavioral health patients, there are strategies to boost support for patients discharged from an ED after a bed request has been made, the researchers wrote.
"[A] recent ED-based study utilizing universal screening plus an intervention consisting of an expanded suicide screening and provision of a self-administered safety plan in the ED followed by a telephone-based intervention holds promise," they wrote.
Emergency psychiatry services, mental health social workers (MHSWs), and mobile crisis outreach (MCO) programs are valuable resources, the lead author of the American Journal of Emergency Medicine research told HealthLeaders.
"The utilization of emergency psychiatry service to reassess boarding patients is important when available. The use of MHSW and MCO is also an option," said Sangil Lee, MD, MS, of the Department of Emergency Medicine at the University of Iowa Carver College of Medicine.
Outpatient care is crucial, he said.
"In a resource-abundant region, these patients simply need to wait for their inpatient bed, but that does not work in most acute care settings in the U.S. When they are released, it is important for these patients to have outpatient resources available, such as an expedited psychiatry visit and follow up provided by an MCO."
Post-discharge outcomes
Compared to other MHSW patients treated in an ED, mortality 12 months after discharge is not higher for behavioral patients released following an inpatient bed request, the American Journal of Emergency Medicine researchers found.
However, patients discharged after an inpatient bed request were found at higher risk for other negative outcomes 12 months after discharge.
- For MHSW patients discharged after an inpatient bed request, 24.8% returned to the ED for psychiatric conditions and 16.8% returned for suicidal conditions
- For MHSW patients admitted to an inpatient bed, 14.4% returned to the ED with a psychiatric condition and 6.0% returned with a suicidal condition
- For MHSW patients who were discharged from the ED with no inpatient bed request, 14.0% returned to the ED with a psychiatric condition and 6.7% returned with a suicidal condition
Christopher Cheney is the CMO editor at HealthLeaders.
KEY TAKEAWAYS
Particularly in low-resource areas of the country, it is common for behavioral health patients to be boarded in emergency rooms for several days.
Complex healthcare processes contribute to the prevalence of boarding behavioral health patients in ERs, including medical clearance and insurance verifications.
For behavioral health patients discharged from an ER after an inpatient bed request has been made, more than half return to an ER within 12 months, recent research shows.