Some psychiatric patients are more frequent users of hospital ERs

Long waits for care in overcrowded U.S. emergency departments (EDs) are stressful for patients and care providers and increase the risk of adverse events and the costs of care. ED patients with psychiatric conditions, in particular, have been found to commonly have ED lengths of stay that range from eight hours to more than a day. New research in General Hospital Psychiatry identifies key characteristics of ED users with mental health issues in order to help predict and possibly reduce the likelihood of future ED visits.

The study found that frequent ED users with a psychiatric illness tended to fit one of five predictor categories: being homeless, testing positive for cocaine use, enrollment in Medicare (but not Medicaid), having a personality disorder or having liver disease.

"Greater disease severity, poorer social support networks, and more limited access to outpatient service may be reasons that might lead Medicare patients to be at increased risk for frequent ED visits in this sample," said Grace Chang, MD, MPH, PhD, a professor of psychiatry at Harvard Medical School and lead author of the study.

Chang explained that 19 percent of patients – nearly one of every five – with a psychiatric illness who sought emergency care were considered to be frequent ED users. These patients sought emergency care an average of seven times in the previous year, compared to an average of one and a half visits among other patients.

"The possibility that some people may visit several EDs could lead to an underestimate of total ED use," she noted. "Additionally, we attempted to predict ED use in the month after the index visit, [but] there may have been more visits in the year afterward."

Researchers reviewed data for 863 adults with psychiatric illness. Most patients were between 40 and 60 years old; all had visited one of four general hospitals in the Boston area between June 2008 and May 2009.

"We hope that if this study's findings are validated in other studies or settings, it will be possible to identify those at highest risk for multiple visits and to offer proactive intervention – to anticipate, rather than react to, their needs," Chang said.

Philip R. Muskin, MD, a professor of psychiatry at New York-Presbyterian Hospital/Columbia University Medical Center, agreed with the study's findings. "These frequent ED visitors are psychiatric patients," he said, "not people with schizophrenia or psychotic disorders. Rather, they are patients who are typically disadvantaged because of their poor social services networks."

Muskin said identifying frequent ED users is a step in the right direction and could lead to a standardized tool for use in EDs.

"We need a standard intervention system in emergency departments that links frequent ED visitors – those who are living pretty awful lives – to community services," he said. "Knowing that a group of patients is likely to return to the ED in the near future, we should be able to say to these patients as they leave: 'This is an option we'd like to offer you.'"