Imamu Baraka came to the aide of a woman discharged on Jan. 9 from a Baltimore hospital wearing only a gown and socks. Baraka recorded video of the incident. (Facebook.com/imamu.baraka)
(12-3-19) Nothing illustrates “patient dumping” better than the viral video of 22-year-old Rebecca Hall being tossed out of the University of Maryland Medical Center into the freezing cold in January 2018 wearing little more than a hospital gown.
Delayed and Deteriorating: Serious Mental Illness and Psychiatric Boarding in Emergency Departments, a recent study released by the Treatment Advocacy Center, warns that Americans who visit emergency rooms with psychiatric problems have a higher rate of being dumped or being “boarded” than those without mental illnesses.
Psychiatric boarding is defined differently but most hospital administrators say having to wait six hours or more after being diagnosed in an emergency room awaiting treatment constitutes “boarding.” A 2016 survey by the American College of Emergency Physicians, found that more than 90% of emergency physicians say psychiatric patients board in their emergency room.
The average emergency room wait in Georgia for psychiatric patients requiring an inpatient bed is a whopping 34 hours, according to the TAC study authored by Elizabeth Sinclair Hancq, Jessica Walthall and John Snook. Psychiatric patients who required admission to a hospital or transfer to a bed in a psychiatric facility in Massachusetts waited in emergency rooms from 16.5 to 21.5 hours compared to 3.9 hours to 4.2 hours for medical or surgical patients needing beds.
A lack of inpatient beds is the primary reason for both patient dumping and boarding. The report noted that the 2.2 million patients with a serious mental illness visit emergency rooms each year where they often find “nowhere to go and sometimes no treatment” available.
Some key takeaways from the TAC report:
Insurance rates and reimbursement rates contribute to long wait times in emergency rooms while staffs frantically try to find a facility willing to accept a psychiatric patient. Reimbursement rates were 40% less for psychiatric patients than non-psychiatric patients in one area, the study noted. Consequently, many hospitals accept only a limited number of psychiatric patients for financial reasons. In 2018, 13% of individuals with serious mental illness were uninsured and 47% were covered by public insurance programs.
“Data suggest that individuals covered by plans such as Medicare or Medicaid tend to experience longer waits and an increased likelihood of boarding.”
Getting out of an emergency room can be difficult. Those in need of inpatient beds will find the transfer process problematic involving “several steps, including medical clearance, psychiatric screening and evaluation, insurance authorization…and arranging for transportation, some of which are unique to psychiatric patients.” It is tougher to get a public inpatient bed as opposed to a private one, which tends to be more expensive. Different and confusing admission standards cause “shotgun referrals” where “an individual is referred by emergency department staff to multiple facilities all at the same time” in an attempt to find someone willing to take a patient.
A “scarcity of psychiatric professionals” in emergency departments contributes to both over sedation and over admitting patients to inpatient facilities. Emergency rooms are not designed for care and management of chronic conditions such as a serious mental illness so they must pass off patients who need longer term care. Because these departments do not have psychiatrists or other well-trained mental health professionals on staff, a common response is to immediately sedate patients or decide a patient needs an inpatient bed to avoid discharging someone who might experience a subsequent crisis.
“This type of decision making can lead to patients waiting hours or days for a psychiatric bed, only to find that inpatient treatment is not appropriate once they are evaluated by a mental health professional.”
Even when a psychiatric patient is discharged from an emergency room, TAC found “they were still more likely to spend more than 24 hours in the emergency department compared to patients without a severe mental illness.”
Patient dumping. The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law that requires stabilization and treatment of all people presenting to an emergency department, regardless of their insurance status or ability to pay. It also says patients must be transferred to an appropriate facility for stabilization if such services cannot be adequately provided at an admitting emergency room. Sounds great, but…
“The process of patient dumping, sometimes referred to as ‘streeting,’ or discharging psychiatric patients who have not yet received appropriate treatment, still occurs as a mechanism to prevent boarding of psychiatric patients who have no appropriate options for timely placement.
Possible solutions. Both obvious. Better community services to avoid emergency room visits and increasing the number of inpatient beds in communities.
Sadly, most states in recent years have reducing community mental health care spending.
TAC has always pushed for ending the Institutions for Mental Diseases (IMD) exclusion that prevents Medicaid reimbursement for the care of most patients with mental illnesses in facilities with more than 16 total beds. Eliminating the IMD exclusion would help end patient boarding by creating more beds. However there’s been little interest among Democrats and civil rights groups to repeal the IMD exclusion. The Trump Administration has offered states waivers that would allow them to ignore the IMD exclusion. But few states have applied.
“A patient in the midst of a heart attack would not be left to languish because treatment is unavailable or inconvenient. The notion that such an individual could be set aside, and his or her condition allowed to deteriorate to the point that recovery is less attainable, would be unthinkable. However for people with mental illness society and systems have made the unthinkable a reality.”
How long have you waited in an emergency room for help? Do you know of an instance of patient dumping? Do you have ideas about how to end patient boarding? Please share your stories on my Facebook page and help call attention to this national scandal.
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