Overutilization of Emergency Departments

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In my 25 years as an emergency room (ER) psychiatrist, I have observed a significant number of patients referred to the ER for non-emergent reasons. This observation led me to investigate the data on the subject, which, to my surprise, was quite limited. However, a few studies provided valuable insights into the overutilization of emergency departments (EDs), particularly in the context of psychiatric referrals and the potential for alternative care models such as mobile mental health clinics and patient navigation programs.

Vigiser and colleagues¹ evaluated 177 consecutive referrals to the psychiatrist in the ED over a 2-month period. They found that only one-third of these referrals met their criteria of justifiability, with the general practitioner (GP) being the referral source in only 29% of justified cases. This overutilization was attributed to a combination of poor understanding by the GP of when to refer urgently, efforts by the GP to bypass clinic waiting lists, and a lack of alternative community facilities.¹

Ellison and colleagues² further explored the issue of repeat visitors to psychiatric emergency services, constituting 7 to 18 percent of total patients and accounting for up to a third of the visits. Their review revealed that repeat visitors are more likely to lack social supports, to be currently in psychiatric treatment, and to have a chronic illness, suggesting a need for alternative care models for these patients.²

Weissinger and colleagues³ conducted a study to determine whether psychiatric patients have a significant reduction in ED visits after admission to a mobile mental health clinic. Their findings demonstrated that patients admitted to the clinic had a significant reduction in ED utilization, suggesting that psychiatric care provided directly in the home can promote health and prevent destabilization.³

Kelley and colleagues⁴ conducted a randomized controlled trial to determine whether an ED-initiated patient navigation program designed to improve health care access for Medicaid-insured frequent ED users could decrease ED visits, hospitalizations, and costs. Their findings showed that participants in ED-initiated patient navigation programs had a significant reduction in ED visits and hospitalizations during the 12-month evaluation period compared with usual care, averaging 1.4 fewer ED visits per patient and 1.0 fewer hospitalizations per patient.⁴

These studies highlight the need for a reevaluation of the current approach to psychiatric referrals in the ED and the potential benefits of alternative care models like mobile mental health clinics and ED-initiated patient navigation programs. Further research is needed to explore these alternatives and their potential to reduce ED overutilization, thereby decreasing health care costs and improving patient outcomes.

Dr Ajluni is an assistant professor of psychiatry at Wayne State University in Livonia, Michigan.

During the preparation of this work, the author used ChatGBT in order to synthesize and summarize information based on my ideas, input, and conclusions. After using this tool/service, the author reviewed and edited the content as needed and takes full responsibility for the content of the publication.

References

1. Vigiser D, Apter A, Aviram U, Maoz B. Overutilization of the general hospital emergency room for psychiatric referrals in an Israeli hospital. Am J Public Health. 1984;74(1):73-75.

2. Ellison JM, Blum N, Barsky AJ. Repeat visitors in the psychiatric emergency service: a critical review of the data. Hosp Community Psychiatry. 1986;37(1):37-41.

3. Weissinger AC, Burns R, Campbell NJ. Evaluating emergency department utilization for mobile mental health patients: a correlational retrospective analysis. J Am Psychiatr Nurses Assoc. 2021;27(5):383-389.

4. Kelley L, Capp R, Carmona JF, et al. Patient navigation to reduce emergency department (ED) utilization among Medicaid insured, frequent ED users: a randomized controlled trial. J Emerg Med. 2020;58(6):967-977.