Emergency Department Use and Vulnerable Populations

In the United States, roughly 1 in 4 adults has a diagnosable mental disorder and between 5% and 7% of adults have severe mental illness.1 Among those with the most severe conditions, fewer than half received outpatient treatment, with the treatment rate dropping to less than one-third among those without health insurance.Without good access to healthcare, people resort to using the emergency department (ED) in community hospitals when care is needed.1

In 2007, for example, 12 million ED visits involved a diagnosis related to a mental health or substance abuse condition, accounting for 12.5% or 1 of every 8 ED visits. An impressive 41% of the ED-related visits resulted in hospitalization.3 Mood disorder was the most common mental health reason for an ED visit (42.7%), followed by anxiety (26.1%) and alcohol-related conditions (22.9%). The remaining were drug-related conditions, schizophrenia and other psychosis, and intentional self-harm.

Vulnerable Populations
Several studies have documented the use of hospital EDs by vulnerable populations.4-6 Vulnerable populations are social groups whose members have increased morbidity and mortality risks secondary to factors such as low socioeconomic status and lack of environmental resources.7

The Behavioral Model for Vulnerable Populations suggests that access to health (including healthcare use) and health outcomes are determined by a person’s predisposing, enabling and need factors.Predisposing factors include demographic characteristics, social structure (e.g., education and employment history), homelessness, and underlying mental health and substance abuse conditions. The enabling factors include personal resources such as insurance, income, presence or absence of a regular source of healthcare, and community resources. Need factors include self-perception of healthcare needs and comorbid illnesses.8

In a study by Small,9 researchers used the Behavioral Model of Vulnerable Populations to evaluate utilization of physician visits, ED services and hospitalizations for a 12-month period. The sample (n = 1,466) included patients with one or more vulnerable health issues such as substance disorders, homelessness and mental health problems, victims of violent crimes, people diagnosed with HIV/AIDS, and people receiving public health benefits. This study found that patients with enabling characteristics were more likely to utilize ED care and hospitalization, relative to those without vulnerable predisposing characteristics.

The findings suggest that vulnerable populations experience a multitude of barriers not faced by the general population and that these barriers lead to different patterns of healthcare utilization. These findings can be helpful to healthcare providers, policy makers and researchers, enabling them to better understand the motivations for healthcare use by this population.

SEE ALSO: Engineering ED Efficiency

Quality Care Issue
ED utilization by vulnerable populations has been identified as a quality-of-care issue.10 The Institute of Medicine (IOM) report “Crossing the Quality Chasm: Adaptation to mental health and addictive disorders,”11 and recently updated Joint Commission standards are two federal initiatives that address issues related to the management of patients with mental health and substance abuse conditions.12 Both publications focused on improving access and the overall quality of health and healthcare for patients with mental health and substance abuse conditions. The IOM initiative has focused on making healthcare more safe, effective, patient-centered, timely, efficient and equitable. The Joint Commission initiative includes standards that specifically address challenges facing patients with mental health and substance abuse conditions. This includes monitoring patient flow through the ED and leadership communication with behavioral health providers.10

Stigma is another quality-of-care issue and barrier for mental health patients seeking treatment. Stigma is defined as a “collection of negative attitudes, beliefs, thoughts and behaviors that influence the individual, or general public, to fear, reject, avoid, be prejudiced, and discriminate against people.”13 In ED settings, mental health issues are often not considered real emergencies. Trained staff members are not always able to identify or understand the needs of this population. Furthermore, negative attitudes about psychiatric patients in the ED can compromise the ED professional’s ability to properly evaluate and treat this population.14

Implications for Practice
The data reported here have important implications for improving the quality of healthcare for people with mental health and substance abuse conditions. To accomplish the IOM and Joint Commission mandates for safe, timely, effective, efficient and patient-centered care, monitoring of patient flow through the ED is needed, including the evaluation of risks related to boarding of patients and leadership communication with behavioral health providers.11,12

Furthermore, ED staff attitudes and concerns must be acknowledged with regard to ability to provide adequate care.12 Healthcare providers such as doctors of nursing practice are in key positions to not only provide direct care but also to evaluate and develop best practices to improve patient and healthcare outcomes. Through collaboration with other healthcare providers, a DNP can identify ED staff education needs, provide education and evaluate existing systems and tools utilized to manage patients with mental health and substance abuse conditions in the ED setting. For DNPs, this is consistent with American Association of Colleges of Nursing goals and recommendations.15 Doctoral level knowledge and skills in these areas are consistent with nursing and healthcare goals to eliminate health disparities and to promote patient safety and excellence in practice.15

Diane Crayton is a family nurse practitioner at California Psychiatric Specialists in Tustin, Calif.

1. Stone Ashley Rogers Debby Kruckenberg Sheree Lieser Alexis 2012 Impact of the mental healthcare delivery system on California emergency departments.Stone A, et al. Impact of the mental healthcare 2.delivery system on California emergency departments. West J Emerg Med. 2012;13(1):51-56.

2. Barrett B, Scott Y. Past-year acute behavioral healthcare utilization among individuals with mental health disorders. Results from the 2008 National Survey on Drug Use and Health. J Dual Diagnosis. 2012;8(1):19-27.

3. Owens LP, et al. Mental health and substance abuse-related emergency department visits among adults, 2007. Healthcare Cost and Utilization Project Statistical Brief No.92. AHRQ, http://www.hcup-us.ahrq.gov/reports/statbriefs/sb92.pdf

4. Baillargeon J Thomas C R Williams B Begley C E Sharma S Pollock B HRaimer B 2008 Medical emergency department utilization patterns among uninsured patients with psychiatric disorders.Baillargeon J, et al. Medical emergency department utilization patterns among uninsured patients with psychiatric disorders. Psychiatr Serv.2008;59(7):808-811.

5. Coffey R M Houchens R Chu B C Barrett M Owens P Stocks CBuck J 2010 Emergency department use of for mental and substance use disorders.Coffey RM., et al. Emergency department use for mental and substance use disorders. J Healthcare Research and Quality. 2010;1-43. http://www.hcup-us.ahrq.gov/reports/ED_Multivar_Rpt_Revision_Final072010.pdf 201305082348391457565546

6. Nicks BA, Manthey DB. The impact of psychiatric patient boarding in emergency departments. Emerg Med Int. 2012;2012:360308.

7. Nyamathi A, et al. Development of nursing theory and science in vulnerable populations. In:Fitzpatrick J J Nyamathi A Koniak-Griffin D 2007 Annual Review of Nursing research Vulnerable populationsNyamathi A, et Vulnerable PopulationsAnnual Review of Nursing Research. New York: Springer Publishing Company, LLC. 2007; 4.

8. Stein JA, et al. Applying the Gelberg-Anderson behavioral model for vulnerable populations to health services utilization in homeless women. J Health Psychol. 2007;12:791-794.King T E Wheeler M B Bindman A B Fernandez A Grumbach K Schillinger D Villella T J 2007 Medical mandagement of vulnerable and underserved patients; Principles, practice, and populationsStein JA, et al.

9. Small L F 2011 Determinants of physician utilization, emergency room use, and hospitalizations among populations with multiple health vulnerabilities.Small LF. Determinants of physician utilization, emergency room use, and hospitalizations among populations with multiple health vulnerabilities. Health. 2011;15(5):491-516.

10. New England Healthcare Institute. A matter of urgency: Reducing emergency department overuse. http://www.nehi.net/writable/publication_files/file/nehi_ed_overuse_issue_brief_032610finaledits.pdf

11. Institute of Medicine. Improving the Quality of Healthcare for Mental and Substance-Use Conditions. http://www.nap.edu/catalog/11470

12. Joint Commission On Accreditation Of Healthcare Organizations 2012 Approved: Standards revisions addressing patient flow through the emergency department.Joint Commission on Accreditation of Healthcare Organizations. Standards revisions addressing patient flow through the emergency department. Jt Comm Perspect. 2012;32(7):1-5.

13. Gary FA. Stigma: Barrier to mental healthcare among ethnic minorities. Issues Ment Health Nurs. 2005;26(10):979-999.

2013052714065675202870414. Zun LS. Pitfalls in the care of the psychiatric patient in the emergency department. J Emerg Med. 2012;43(5):829-835.

15. American Association of Colleges of Nursing. Essentials of Doctoral Education for Advanced Nursing Practice. http://www.aacn.nche.edu/publications/position/DNPEssentials.pdf

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