The other night, in the emergency department where I work, something happened that may come as a surprise: One-third of our patients required a “sitter.” In other words, they had a behavioral or mental health problem that necessitated another person sitting with them to assure their personal safety, or the safety of staff and other patients.
This is likely shocking to some, but the need for sitters is nothing new to our staff. What is new, however, is the increase in the volume of patients seeking behavioral or mental health care in our emergency department – some of them emergent and some of them not.
Multiple factors are behind this increase at 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 stresses of the COVID-19 pandemic, which also led to a loss of support networks and curbed access to in-person primary and psychiatric care.
Data indicates those with substance use disorders have been particularly affected during the pandemic, with many people starting or increasing substance use and with the U.S. experiencing a record number of fatal drug overdoses. Compounding the problem, local shelters in my area remain largely closed or at lower capacity despite widespread vaccination efforts, pushing vulnerable patients onto the streets while alternative housing is arranged.
The emergency department has long been seen as the “safety net” for the medical system, including for those with mental health problems. But given the current issues with crowding and boarding, administrators are examining contributors to this crisis. The rows of patients waiting with sitters by their sides have become a constant and gnawing reminder of how we are failing those who come to us for help. Not only are these patients not getting the help they need, but they are also often worse off than when they came in, cut off from their families, lives and work. As one seasoned psychiatrist pronounced during our recent conversation, “We’ve entered a new era.”
Given what I’ve described, you might think that our emergency department is under-resourced or poorly managed. It’s the opposite: We have more resources than most American emergency departments. There are emergency psychiatrists, psychiatry residents, physician assistants, advanced practice nurses, social workers, and drug and alcohol counselors. Our ED is a pioneer in drug and alcohol treatment, using the “teachable moment” of an emergency department visit to get patients the help they need.
What we see more of now, however, is not the vulnerable, teachable moment, but instead a merry-go-round of chronic patients interspersed with new patients who are unable to get the help they need in the community, and who are overwhelming both our physical space and our capacity. The problem is not particular to our emergency department, or even to our city. This scenario has been playing out across the country.
Those who come to us in a time of need can now expect to wait days before an inpatient psychiatry or treatment bed can be secured. These prolonged waits lead to worsened outcomes as well as less space in which we can see other patients with critical medical issues. The problem for children in emergency departments is also dire, with kids being restrained and waiting for scarce beds in inpatient units where they can get the care and respite that they and their families need.
What can be done? Cities need to ensure shelters are open, health systems need to improve outpatient treatment facilities and administrators need to liberalize intake processes at outpatient facilities. Behavioral therapists and psychiatrists also need to rethink the telehealth-only visits that have evolved during the pandemic. Without thoughtful deployment, older adults and those without resources and capacity can be excluded as others log on for care, trapped on the wrong side of the “digital divide.”
At the same time, physicians and health care experts need to lobby locally and nationally for funding to restore inpatient capacity for those who need it, including pediatric and adolescent patients. For those who are gravely disabled, perhaps by rethinking and strengthening the deinstitutionalization process, we could more fully support patients in our communities. We need to provide more robust social and mental health services that recognize the difficulties patients encounter when left to navigate on their own.
In short, the safety net must be rewoven so it includes more than just the emergency department. Although emergency departments frequently serve as the access point in a crisis, definitive care for behavioral and mental health issues lies elsewhere. We are doing our patients a disservice to think or act otherwise.