You asked several questions about the treatment of people with mental illness in hospital emergency departments (EDs). Specifically, you wanted to know (1) how many children and adults spend more than 23 hours in an ED, why, and what kinds of services they receive and (2) the costs of ED treatment compared to residential and outpatient treatment.

SUMMARY

Nationally, 0. 7% of all people who visited an ED in 2003 stayed more than 23 hours, according to the Centers for Disease Control. In Connecticut during 2004, 60,870 people presented a psychiatric condition at an acute care hospital ED without subsequently being admitted as inpatients while these hospitals admitted 23,744 people with a psychiatric diagnosis (although not all from an ED). Applying the national percentage to the Connecticut data suggests that, at a minimum, over 500 people presenting with mental illness stayed in a Connecticut ED for more than 23 hours during 2004, but this figure is conservative.

ED overcrowding, which is a national phenomenon, leads to extended ED stays. While no single factor explains why overcrowding occurs, the key factor is the inability to move people into hospital beds. This inability arises from (1) hospitals limiting the number of inpatient beds they staff, thus limiting their ability to respond to demand spikes; (2) competition for beds with scheduled surgical patients; and (3) increased demand due to reductions in regional bed capacity. Overcrowding also results from shortages of on-call physicians and inadequate availability of alternative care in the community. One Connecticut ED director believes the longest ED stays here result from the difficulty in placing ED patients in a state-run psychiatric facility.

Treatment for psychiatric patients in EDs is similar to other patients. An ED physician first makes sure they have no medical condition needing care then psychiatric staff evaluate the psychiatric disorder, try to stabilize it, and determine whether the person needs to be admitted to a facility or can be treated in the community. Patients who need to stay beyond 23 hours are usually confined to a psychiatric area where they are treated for the most part by ED behavioral health staff.

We could find no data on the cost of ED treatment. Medicaid fee-for-service rates for intensive outpatient services at mental health clinics are established for individual facilities and are not available; rates for individual services range from $ 30 for a half-hour of individual psychotherapy to $ 75 or $ 80 for testing and evaluation. Daily rates for residential treatment for children and adolescents average $ 175. We are waiting for more detailed information from various state agencies and will forward it to you.

LENGTH OF ED STAYS FOR PSYCHIATRIC PATIENTS

Nationally, 0. 7% of all people who visited an ED in 2003 stayed more than 23 hours (Centers for Disease Control, National Hospital Ambulatory Medical Care Survey: 2003 Emergency Department Summary, May 26, 2005). A 2004 survey by the American College of Emergency Physicians (ACEP) found that psychiatric patients “board” in EDs more than twice as long as other patients. We could find no length-of-stay data specifically for people with psychiatric conditions or for children.

We found no length-of-stay data for Connecticut, but we calculate conservatively that some 500 patients in the state’s acute care hospitals may have stayed in an ED for more than 23 hours in 2004. These hospitals had 60,870 ED visits in 2004 by people with mental disorders that did not result in hospital admission, according to Connecticut Hospital Association data. They admitted 23,744 people with a psychiatric diagnosis, approximately 70% of whom were diagnosed as psychotic. Sixty-seven percent (67%) of psychotic inpatients were admitted from the ED (CHIMEData Mental Illness Fact Sheet, October 2005).

Using this data, we calculate that about 12,355 psychotic patients were admitted from an ER (23,744 x 70% = 16,620 x 67% = 11,136). Adding this figure to the 60,870 non-admission visits yields at least 72,000 people with mental disorders visiting Connecticut’s EDs in 2004.

If we assume the national 0. 7% national figure for stays over 23 hours applies uniformly to all types of patients and apply it to the Connecticut ED data, the result suggests that at least 504 people who went to a Connecticut ED for psychiatric reasons stayed beyond 23 hours.

But this figure is conservative. It does not factor in (1) the approximately 7,125 people admitted to a hospital with a mental disorder other than psychosis, some of whom may have been admitted from an ED; (2) the 4,000 people admitted to state-operated psychiatric hospitals; and (3) the ACEP survey finding that psychiatric patients “board” in hospital EDs more than twice as long as other patients.

“Boarding” is the term used to describe people admitted to a hospital from an ER who must wait there until an inpatient bed is available. It apparently does not include people waiting in the ED for a bed in a residential or other treatment facility or services in the community. The ACEP report states that 70% of ED physicians report more people with mental illness “boarding” in their EDs and that 60% report that this increase causes longer waits for all, limits the availability of hospital staff, and reduces the number of available ED beds.

More data on ED visits, lengths-of-stay, and bed capacity specifically for Connecticut children may be forthcoming from a group the Office of Health Care Access (OHCA) has convened to study the state’s psychiatric bed capacity for children. PA 05-280 requires OHCA to convene this group, which is composed of hospital administrators, children’s mental health advocates, and state agency officials. John Blair, OHCA’s legislative liaison, reports that the group will be meeting on November 18 to receive data its members have collected, including ED data. OHCA must submit its findings and recommendations to the General Assembly by January 1, 2006.

REASONS FOR EXTENDED ED STAYS

ED Overcrowding

ED overcrowding is a national issue and is not limited to people with psychiatric disabilities. A 2003 General Accounting Office (GAO) report stated that most emergency departments across the country experienced some degree of crowding.

Crowding is a complex issue, the GAO said, and no single factor explains why it occurs. The key factor, though, is the inability to move people into hospital beds. Intensive care, critical care, and instrument-monitored beds seemed to be in shortest supply. Hospitals in areas with the highest demand for inpatient beds had the greatest overcrowding problem. GAO also found that ED overcrowding resulted from:

1. hospitals’ decisions to staff only that number of inpatient beds that will nearly always be full, which limits their ability to respond to spikes in demand (on average, Connecticut hospitals staff about 78% of their licensed beds according to OHCA);

2. competition for beds with patients scheduled for admission for surgery;

3. increased demand due to closures of nearby hospitals or reductions in their bed capacity; and

4. inadequate availability of physicians and other providers in the community. The GAO report is available at http: //www. gao. gov/new. items/d03460. pdf.

Lack of treatment space in EDs, boarding, and shortages of on-call physicians and ED staff were other causes for ED overcrowding, according to a 2003 ACEP survey. The survey found that in nearly half of all ERs reporting (1) patients received care in hallways and non-clinical spaces such as offices and storage rooms and (2) nurses cared for more than four patients each (national standards call for one nurse for each critical care bed and one for every four routine beds).

Extended Stays and Mental Illness

ACEP’s 2004 survey of psychiatric patients in EDs suggests that reductions in community psychiatric beds have led to more psychiatric patients in EDs and increased levels of boarding. Mental health advocates cited in the report suggest that Medicaid cuts may be responsible for the reduction in psychiatric beds.

Connecticut acute care hospitals added 21 psychiatric beds between July 1999 and June 2002 according the OHCA. But this total increase masks an 11-bed reduction in small

urban and community hospitals; large urban hospitals (Bridgeport, Hartford, New Haven) added 30 beds while medium urban hospitals added two. OHCA suggests that low reimbursement rates were a cause of bed reductions (Connecticut Acute Care Hospitals’ Psychiatric Discharges and Clinical Encounters, SFY 2000-2002).

Department of Children and Families data indicate that between September 30, 2002 and June 30, 2005, the state lost 58 licensed residential mental health treatment beds for children and adolescents. At the same time, it gained 11 substance abuse treatment beds.

The CHIME data indicates that most ED visits for psychiatric disorders were due to alcohol abuse. Chronic inebriates, it says, often use emergency services because they lack other resources or access to primary care. And, “because of their complicated medical needs, which are often exacerbated by acute intoxication and related illness or injury, a relatively small number of acutely intoxicated chronic inebriates can stretch ED resources and contribute to ED overcrowding. ” (The national data indicates that alcohol and substance abuse was a factor in 5. 5% of injury cases. )

TREATMENT IN THE ED

The treatment psychiatric patients receive when they go to an ED, varies depending on the hospital, particularly when they stay there for an extended period, according to Dr. Steven Wolf, director of St. Francis Hospital’s ED. Typically, an ED physician first evaluates a patient. Once the doctor determines the patient does not have a medical condition that needs treatment (i. e. , “medically clears” the patient), a psychiatric social worker or advanced practice registered nurse (APRN) with a psychiatric specialty evaluates the individual’s mental health status and tries to contact his caregivers in the community for more information.

Based on this evaluation and other information he receives, this clinician makes a preliminary decision about ED care and whether the person needs an inpatient treatment bed or outpatient care. Inpatient treatment could be either in that hospital, another private facility, or a state facility. At this point in larger hospitals, Wolf says, a psychiatrist on rounds would be consulted to confirm the approach and develop an initial treatment plan. This consultation could also take place by telephone, which is the typical pattern at smaller hospitals.

In Wolf’s experience, “boarding” patients are confined to a designated psychiatric area. They receive medication and talk to the psychiatric social worker or APRN and occasionally a psychiatrist as available. Children sometimes have access to television or videotapes, and other ED staff occasionally has time to sit with them.

At least one Connecticut hospital, Middlesex, has created an area specifically for psychiatric patients as a sub-unit of its ED, according to an American Hospital Association report. The five-bed emergency crisis area was built to accommodate these patient’s needs and designed to improve their and the staff’s safety. The area is staffed by two psychiatrists (one weekdays, one on weekends), psychiatric nurses, and other behavioral health clinicians. Patients also receive services, as needed, from ED physicians and nurses. Psychiatric nurses, APRNs, social workers, and clinical psychologists meet daily to determine patients’ treatment and help find placements. About half the patients are stable enough to go home after their ED stay.

RELATIVE COST OF ED TREATMENT

We could find no data on the cost of ED treatment and little data on the costs of outpatient mental health or residential care. Connecticut’s Medicaid fee-for-service rates for individual mental health services provided through a clinic range from about $ 75 for a diagnostic interview to $ 30 for a half-hour of individual psychotherapy. Rates for intensive outpatient services (at least three hours a day three days a week) are negotiated with each mental health clinic. One source suggests that an in-state residential treatment facility for children and adolescents costs about $ 175 per day (Connecticut Mental Health Cabinet Report, 2005).

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