Just the Facts in Emergency Medicine 2001

David Marcozzi, MD, MHS-CL, FACEP

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While the importance of follow-up psychiatric treatment has been demonstrated, psychotherapy is recommended for fewer than half of adolescent suicidal patients evaluated in the ED Piacentini et al. Additionally, adolescents with somatic complaints are infrequently screened for depression Porter et al. ED providers often lack the training, skills, and resources to deal effectively with mentally ill patients. Standardized psychiatric training is not required of residents in emergency medicine and pediatric emergency medicine.

Fewer than one-quarter of emergency medicine residency programs provide formal psychiatric training for residents Santucci et al. Moreover, surveys of nurses—even those working in designated pediatric EDs—show that they are uncomfortable with pediatric psychiatric emergencies Fredrickson et al. ED physicians also may not have the time to perform a thorough mental health evaluation, and many rely on psychiatrists, psychologists, or social workers to perform such an evaluation.

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When that assistance is not available, patients may not receive an evaluation at all. The ED setting also makes it difficult to care for a mentally ill patient. The lack of privacy and the noisy, high-stimulus environment may make it uncomfortable for patients to participate in a mental health evaluation Hoyle and White, Patients with mental illness have an important impact on EDs. They tend to require resource-intensive care, and their admission rates are high— 22 percent in one study Larkin et al. Because hospital EDs often do not have specialized psychiatric facilities or psychiatric specialists available and find it difficult to place such patients—many of whom are indigent or uninsured—in outside facilities, ED staff spend more than twice as long seeking beds for these patients than for those without psychiatric problems.

According to the administrator of the Division of Mental Health and Developmental Services for the State of Nevada, the single overarching challenge facing the agency is the number of mentally ill patients who are crowding EDs in the southern part of the state. In , the state had an.

More recently, the average was 62 patients waiting an average of 93 hours for an inpatient bed Ryan, In a recent national survey, 6 in 10 emergency physicians said the increase in psychiatric patients seeking care at EDs is negatively affecting access to emergency care for all patients by generating longer waiting times and limiting the availability of ED staff and ED beds for other patients ACEP, The survey data also indicate that 8 percent of the U. Alcohol and other drug-related dependence is a pervasive problem in patients presenting to the ED.

Between and , approximately 8 percent of all ED visits each year were attributable to alcohol, and the total number of alcohol-related visits increased by 18 percent during that time McDonald et al. Despite this statistic, a much higher percentage of patients would test positive for alcohol use if screened. One study found that one-third of adolescent patients tested as a part of routine care were alcohol-positive, but were not necessarily given an alcohol-related diagnosis Barnett et al.

Associated Data

Of those visits, 33 percent were for an adverse reaction, 17 percent for overmedication, 10 percent for detoxification, and 6 percent for drug-related suicide attempts SAMHSA, Among drug-related visits in , 80 percent involved only seven categories: alcohol in combination with another drug 31 percent ; cocaine 30 percent ; marijuana 18 percent ; heroin 14 percent ; and benzodiazepines, antidepressants, and analgesics, which together accounted for 30 percent of such visits SAMHSA, Again, however, many more patients would likely test positive for drug use if screened.

In a study of alcohol and drug use in seven Tennessee general. Patients often present to the ED with acute or chronic manifestations of alcohol or drug problems. Chronic problems related to alcohol and other drug use include skin infections from drug injections, cirrhosis and its complications, and gastrointestinal disorders. Alcohol and other drug use often occurs in the presence of, or may lead to, physical illness and injury.

Among patients that present to the ED with injuries, those that report alcohol or drug use are significantly more likely to report violence associated with the episode Cunningham et al. Drug abuse can complicate the evaluation of the injured patient by masking signs and symptoms of injury Fabbri et al. Screening and on-site interventions and referrals for alcohol have been demonstrated in a variety of health care settings, including the ED, to reduce ED and hospital use and decrease the amount that patients drink Bernstein et al.

In one study of trauma patients admitted for alcohol-related injuries, those that received 30 minutes of counseling at the hospital experienced a 47 percent reduction in serious injuries requiring trauma center admission in the following 3 years and a 48 percent reduction in less serious injuries requiring ED care Gentilello et al.

Additionally, studies have shown that ED patients are often accepting of screening and brief interventions for alcohol problems Cherpitel et al.

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However, research has shown that ED physicians usually fail to identify those at risk for problems with alcohol or to provide such interventions Gentilello et al. Similar studies have found a high prevalence of undetected substance abuse and an unmet need for treatment among ED patients Bernstein et al. This situation has been demonstrated by a number of studies even though numerous federal and expert panels have recommended routine screening of injured patients in the ED for substance abuse and the provision of brief interventions for those that test positive Gentilello, According to a survey sponsored by the West Virginia Chapter of the American College of Emergency Physicians ACEP , barriers to screening include provider attitudes of disinterest, avoidance, disdain, and pessimism, as well as inadequate time, insufficient education, and a lack of resources.

The survey found that a minority of ED physicians routinely screen and council ED patients on alcohol abuse Williams et al. Another important barrier to screening of patients for alcohol or drug abuse by ED staff is that the care provided may not be reimbursed if the screen is positive. In some states, laws permit insurance companies to refuse payment for injuries sustained if the patient is found to be under the influence of alcohol or drugs. The intent of these laws is to punish drunk drivers, thereby reducing the cost of insurance for others Gentilello, However, physicians may be reluctant to screen patients for alcohol or drugs because of the potential financial impact on patients, the hospital, and themselves.

Like mental health patients, those with identified substance-abuse problems tend to be a resource-intensive group. In a statewide study, ED patients with unmet substance-abuse treatment needs generated much higher hospital and ED charges than other patients Rockett et al. Not only do substance-abuse patients require extra time and effort on the part of ED staff, but drug-related ED visits have become a major cause of violence in the ED Anonymous, For example, a patient who is primarily seeking drugs may turn violent if not able to obtain them van Steenburgh, The types of patient presentations most associated with violence are intoxicant use, states of withdrawal from drugs, delirium, head injury, psychiatric problems, and social factors Lavoie et al.

According to the U. Census Bureau , more than 59 million people, or 21 percent of the total U. Rural EDs face a number of problems that differ from those of urban hospitals, including limited availability of hospitals and equipment, an inadequate supply of qualified staff, an unfavorable payer mix, and long distances and emergency response times.

There are nearly 2, rural community hospitals in the United States, representing 44 percent of all community hospitals AHA, a. Between and , more than rural hospitals closed. Rural hospitals are smaller than their urban counterparts, with a median of 58 beds compared with for urban hospitals The Lewin Group, Smaller hospitals tend to have lower margins than larger ones; more than 50 percent of hospitals with fewer than 25 beds have negative margins, versus only 13 percent of those with or more The Lewin Group and AHA, The modest size of rural hospitals and their correspondingly small capital and financial assets make them less able to survive significant changes in financial performance; when the financial survival of a hospital is at stake, investments in the latest technologies and recruitment of highly qualified personnel are assigned low priority.

Given the high cost of maintaining trauma centers and the difficulty of maintaining them even in busy urban areas Taheri et al. Rural EDs also lack many of the newer diagnostic modalities. Such shortages impair the establishment of definitive diagnoses, as well as the application of the latest potential improvements in emergency practice. For example, acute stroke treatment with tissue plasminogen activator TPA requires immediate access to a computed tomography CT scanner and a fast accurate reading, neither of which may be available at most rural EDs Drummond, The population served by rural hospitals tends to be poorer, to be uninsured, and to make greater use of various forms of public health insurance.

While 72 percent of urban residents had private insurance coverage in , this was the case for only 60 percent of those living in remote rural areas. Rural workers tend to be self-employed, to work for smaller companies, and to earn lower wages.

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These factors compromise access to private health insurance. The impingement of private health insurance and managed care, public and private, is a major factor determining the financial environment in which rural hospitals are situated Kaiser Commission on Medicaid and the Uninsured, In , over 7 million people living in rural areas were uninsured, including 24 percent of those living in remote rural areas, defined as rural counties nonadjacent to a county with an urban center.

This high level of uninsured is compounded by the fact that the rural uninsured tend to lack. They are also older, and their self-reported health is poorer. One-quarter of rural uninsured are aged 45—64, and 42 percent of rural uninsured residents report less than very good health, compared with 38 percent of urban uninsured residents Kaiser Commission on Medicaid and the Uninsured, The large numbers of uninsured in rural areas can have spillover effects on the community, reducing access to emergency services, trauma care, specialists, and hospital-based services Kellermann and Snyder, Unreimbursed care for emergency physicians and hospitals can result in cutbacks, closure, or relocation of services Irvin et al.

The low levels of private insurance and low incomes in rural America contribute to the important role played by Medicaid and other forms of public insurance in these areas. Public programs insure 16 percent of those in rural areas, compared with 10 percent in urban settings. Therefore, rural hospitals are much more dependent on these programs for their existence.

The BBRA preferentially reinstated cost-based reimbursement to rural hospitals for some services and included higher payments to Medicare-dependent hospitals. Yet the impact on rural hospitals remains tremendous, as these acts have projected Medicare margins in rural hospitals to decrease by 3. Particularly hard hit are outpatient services, expected to decrease by 20—28 percent IOM, A CAH is exempt from the prospective payment system for both inpatient and outpatient care. Instead, hospitals that receive this designation bill Medicare on a fee-for-service basis.

Medicare reimburses at a rate of — percent of reasonable and customary charges. A hospital can be designated as a CAH. It is still too early to assess whether the CAH program has been successful in increasing access to emergency care. More research is needed to determine whether new capacity is being built, or hospitals are changing to qualify for the CAH program. For example, a hospital may have to reduce its number of acute care beds to be designated as a CAH.

Others hospitals may add hour care, which in turn increases the existing ED capacity. The limited supply of medical workers in rural areas affects many aspects of medicine, not just emergency care. The most difficult aspect of rural emergency care is finding qualified emergency physicians, specialists to provide on-call services, and ancillary staff. Many rural EDs have only parttime physicians on staff and are often not available 24 hours a day.

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