Hours and Miles: Patient and Health System Implications of Transfer for Psychiatric Bed Capacity

Abstract

IntroductionAn increasing number of behavioral health (BH) patients are presenting to the emergency department (ED) while BH resources continue to decline. This situation-may lead to more external transfers to find care.MethodsThis is a retrospective cohort study of consecutive patients presenting to a tertiary care academic ED from February 1, 2013, through January 31, 2014. Patients were identified through electronic health record documentation of psychiatric consultation during ED evaluation. We reviewed electronic health records for demographic characteristics, diagnoses, payer source, ED length of stay, ED disposition, arrival method, and distance traveled to an external facility for inpatient admission. Univariable and multivariable associations with transfer to an external facility in comparison with patients admitted internally were evaluated with logistic regression models and summarized with odds ratios (OR).ResultsWe identified 2,585 BH visits, of which 1,083 (41.9%) resulted in discharge. A total of 1,502 patient visits required inpatient psychiatric admission, and of these cases, 177 patients (11.8%; 95% CI = [10.2–13.5]) required transfer to an external facility. The median ED length of stay for transferred patients was 13.9 hours (interquartile range [IQR], 9.3–20.2 hours; range, 3.0–243.0 hours). The median distance for transport was 83 miles (IQR, 42–111 miles; range, 42–237 miles). In multivariable analysis, patients with suicidal or homicidal ideation had increased risk of transfer (odds ratio [OR] [95% CI], 1.93 [1.22–3.06]; P=0.005). Children younger than 18 years (OR [95% CI], 2.34 [1.60–3.40]; P<0.001) and adults older than 65 years (OR [95% CI], 3.46 [1.93–6.19]; P<0.001) were more likely to require transfer and travel farther to access care.ConclusionPatients requiring external transfer for inpatient psychiatric care were found to have prolonged ED lengths of stay. Patients with suicidal and homicidal ideation as well as children and adults older than 65 years are more likely to require transfer.

Substance Use, Homelessness, Mental Illness and Medicaid Coverage: A Set-up for High Emergency Department Utilization

“… 29 Despite evidence that integrated treatment is considered best practice, there are barriers to widespread adoption. 11 , 30 – 33 Given the high demand for mental healthcare and substance use treatment identified in this study of California, future research should assess availability and impact of integrated mental health/substance use treatment programs.…”

“… 6 , 7 Many patients continue to face significant barriers to consistent mental healthcare. 2 , 8 – 11 ED visits increase when mental health services are unavailable or uncoordinated. 12 – 14 Nationally, frequent ED users for all diagnoses account for 3–8% of all ED patients and 21–28% of all ED visits.…”

The differences between referred and non-referred patients to a psychiatric consultation-liaison service in a general hospital

“…Therefore, a smooth transfer of information and advises about psychological frailty and needs of patients to community services is of importance, not only for treatment adherence, but perhaps also for secondary and tertiary prevention, especially to general practitioners in charge of the patient, as already suggested in other investigations. 34–37…”

Assessing psychiatric safety in suicidal emergency department patients

“…Transferring psychiatric patients to other facilities to decrease the ED's burden should also be considered from the patient's point of view. Several studies demonstrate a much longer ED length of stay for patients transferred . Data obtained from the Healthcare Cost and Utilization Project 2010 Nationwide ED Sample indicate that transfers were more likely for uninsured psychiatric patients (odds ratio [OR] = 2.26) than for privately insured patients .…”

“…Several studies demonstrate a much longer ED length of stay for patients transferred. 65,66 Data obtained from the Healthcare Cost and Utilization Project 2010 Nationwide ED Sample indicate that transfers were more likely for uninsured psychiatric patients (odds ratio [OR] = 2.26) than for privately insured patients. 67 Transfers should be done in the context of usual referral patterns, which can vary depending on the site.…”