The Consequences of Inappropriate Admissions and Automatic Hospitalization in Acute Psychiatric Care: A Call for Reform and a More Nuanced Approach

By Lauro Amezcua-Patino, MD, FAPA

The mental healthcare system faces significant challenges in providing appropriate and efficient care to patients in acute psychiatric settings. This opinion article explores two interconnected issues: the admission of patients who do not meet the necessary criteria to acute psychiatric hospital beds and the automatic hospitalization of suicidal patients from emergency rooms (ERs).

Acute psychiatric care plays a crucial role in the mental healthcare system, providing intensive treatment to patients with severe mental health conditions.

However, the efficiency and effectiveness of this care are compromised by two concerning trends: the admission of patients who do not meet the necessary criteria to acute psychiatric hospital beds and the automatic hospitalization of suicidal patients from ERs. This article aims to shed light on the factors driving these practices, their consequences, and the need for reforms that prioritize patient well-being, resource optimization, and evidence-based care.

Personal Experience:

In the last 35 years, I have been on both sides of the admissions process, approving admissions and receiving admissions, performing utilization review, quality assurance, and advocating for adequate patient care. This extensive experience has provided me with a unique perspective on the challenges and complexities of the acute psychiatric care system. I have witnessed firsthand the consequences of inappropriate admissions and automatic hospitalization, as well as the potential for positive change when evidence-based practices and patient-centered approaches are prioritized.

Factors Contributing to Inappropriate Admissions and Automatic Hospitalization:

Several factors contribute to the admission of patients who do not meet the necessary criteria to acute psychiatric hospital beds and the automatic hospitalization of suicidal patients from the ERs:

1. Liability concerns: Healthcare providers and institutions may feel pressure to take a more conservative approach to avoid potential legal liabilities, leading to a lower threshold for admission and hospitalization.

2. Resource constraints: ERs and psychiatric hospitals often face time and resource limitations, making it challenging to conduct thorough assessments and develop individualized treatment plans. This can result in a default to hospitalization as a perceived safe and efficient option.

3. Lack of community resources: The scarcity of accessible and effective community-based mental health services may contribute to the perception that hospitalization is the only viable option for ensuring patient safety and providing necessary care.

4. Stigma and misconceptions: Stigma surrounding mental health and a lack of understanding about the spectrum of suicidal behavior may lead to an overemphasis on risk and a belief that all suicidal patients require inpatient treatment.

5. Influence of for-profit companies: For-profit psychiatric hospitals may have financial incentives to admit patients who do not meet criteria, as higher occupancy rates and longer lengths of stay can generate more revenue.

The Consequences of Inappropriate Admissions and Automatic Hospitalization:

The admission of patients who do not meet the criteria for acute psychiatric hospitalization and the automatic hospitalization of suicidal patients in ERs can lead to:

1. Unnecessary financial costs: These practices often result in unnecessary treatment expenses, prolonged lengths of stay, and the diversion of resources away from critical areas, such as community-based mental health services and preventive care.

2. Misallocation of resources: Inappropriate admissions and automatic hospitalization can strain already limited resources, leading to bed shortages and potentially compromising the quality of care for patients who truly require intensive intervention.

3. Iatrogenic effects: The experience of being hospitalized, particularly involuntarily, can be traumatic for some patients and may discourage them from seeking help in the future. It can also disrupt social support systems and lead to feelings of stigmatization.

4. Missed opportunities for early intervention: By defaulting to hospitalization, ERs and psychiatric hospitals may miss opportunities to provide early intervention, crisis stabilization, and connection to community-based services that could effectively manage risk while preserving the patient's autonomy and social functioning.

The Need for Reform and a More Nuanced Approach:

To address the consequences of inappropriate admissions and automatic hospitalization, healthcare systems and policymakers must prioritize:

1. Clear admission guidelines and regulatory oversight: Developing and enforcing evidence-based criteria for admission to acute psychiatric hospital beds can help ensure that patients receive the most appropriate level of care based on their clinical needs.

2. Expansion of community-based mental health services: Investing in and strengthening alternative community-based resources, such as crisis stabilization units, mobile crisis teams, and intensive outpatient programs, can provide more suitable and cost-effective options for patients who do not require inpatient care.

3. Comprehensive risk assessments and collaborative safety planning: ERs and psychiatric hospitals should adopt a more nuanced and individualized approach to assessing and managing suicidal patients. This involves conducting thorough evaluations that consider the patient's specific risk factors, protective factors, and overall psychosocial context, as well as engaging patients and their support systems in developing personalized safety plans.

4. Enhanced training for healthcare personnel: Providing education and training to help ER and psychiatric hospital staff better understand mental health conditions, conduct comprehensive assessments, and implement evidence-based interventions can improve the quality of care provided and reduce the reliance on automatic hospitalization.

The current practices of admitting patients without meeting criteria to acute psychiatric hospital beds and automatically hospitalizing suicidal patients in ERs have significant consequences for both patients and healthcare systems. These practices, driven by various factors such as liability concerns, resource constraints, lack of community resources, stigma, and the influence of for-profit companies, can lead to unnecessary financial costs, misallocation of resources, iatrogenic effects, and missed opportunities for early intervention.

To address these issues, a comprehensive reform of the admissions process, the development of alternative community-based mental health services, and the adoption of a more nuanced approach to assessing and managing suicidal patients are essential. By ensuring that patients receive the most appropriate level of care based on their clinical needs, promoting evidence-based practices, and prioritizing patient well-being, we can improve outcomes, optimize resource utilization, and create a more sustainable and effective mental healthcare system.

In light of these challenges and the need for change, the new division of Metropolitan Consulting (MQAS- Metropolitan Quality Assurance Services) is well-positioned to facilitate this process. With their expertise in healthcare systems, evidence-based practices, and patient-centered care, Metropolitan Consulting can provide valuable guidance and support to hospitals, ERs, and community-based mental health services.