The other night in the emergency room where I work, something surprisingly happened: a third of our patients needed “child care”. In other words, they had a behavioral or mental health problem that required another person to sit with them for their personal safety or the safety of staff and other patients.
This is probably shocking to some, but the need for guards is not new to our staff. What is new, however, is the increase in the number of patients seeking behavioral or mental health care in our emergency department – some of them emerging and others not.
Several factors are responsible for this increase in my department and others. Some say a lack of inpatient facilities and beds has caused a backlog in our emergency departments. Some attribute it to the added stress of the COVID-19 pandemic, which has also resulted in a loss of support networks and restricted access to primary and psychiatric care in person.
Data indicates that people with substance use disorders have been particularly affected during the pandemic, with many people starting or increasing substance use, and the United States is experiencing a record number of fatal overdoses. To compound the problem, local shelters in my area remain largely closed or at low capacity despite widespread vaccination efforts, pushing vulnerable patients onto the streets while alternative housing is organized.
The emergency department has long been viewed as the “safety net” of the medical system, including for people with mental health problems. But given the current overcrowding and boarding issues, administrators are looking at the contributors to this crisis. The rows of patients waiting with assistants by their side have become a constant, gnawing reminder of how we let down those who come to us for help. Not only are these patients not getting the help they need, they are also often worse off than when they first arrived, cut off from family, life and work. As one senior psychiatrist said in our recent conversation, “We have entered a new era.”
Based on what I have described, you might think our emergency service is under-resourced or mismanaged. It’s the opposite: we have more resources than most US emergency services. There are emergency psychiatrists, psychiatric residents, physician assistants, advanced practice nurses, social workers, and substance abuse and alcohol counselors. Our emergency department is a pioneer in drug and alcohol treatment, using the “right time” of an emergency room visit to give patients the help they need.
What we are seeing more and more now, however, is not the vulnerable and right time to learn, but rather a merry-go-round of chronic patients interspersed with new patients who are unable to get the help they need. in the community, and which overwhelms both our physical space and our capacity. The problem is not unique to our emergency department, or even to our city. This scenario played out across the country.
Those who come to us in time of need can now expect to wait days before a psychiatric or inpatient treatment bed can be found. These extended waits lead to worsening results as well as a reduced space in which we can see other patients with critical medical conditions. The problem for children in emergency departments is also severe, with children being held up and waiting for scarce beds in inpatient units where they can get the care and respite they and their families need.
What can be done? Cities need to make sure shelters are open, health systems need to improve outpatient treatment facilities, and administrators need to liberalize admissions processes in outpatient facilities. Behavioral therapists and psychiatrists also need to rethink the telehealth-only visits that evolved during the pandemic. Without a thoughtful deployment, the elderly and those without resources and capabilities may be left out as others go online for care, trapped on the wrong side of the ‘digital divide’.
At the same time, doctors and health care experts must lobby locally and nationally for funds to restore hospital capacity for those in need, including pediatric and adolescent patients. For those who are severely disabled, perhaps by rethinking and strengthening the deinstitutionalization process, we could more fully support patients in our communities. We need to provide more robust mental health and social services that recognize the challenges patients face when left on their own.
In short, the safety net must be rewoven to include more than the emergency department. While emergency departments frequently serve as a point of access in times of crisis, definitive care for behavioral and mental health problems can be found elsewhere. We are doing our patients a disservice to think or act otherwise.