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Abstract
We sincerely appreciate the thoughtful discussion of our study from Drs. Moulin and
Jones. However, we would like to provide clarification on several of the points they
raised.
As Moulin and Jones correctly indicate, there is no delineation of the relative acuity
of the study patients to those seen in other emergency settings in California. However,
we are unaware of any established metric to provide such a comparison for this patient
population, and no such categorization was noted in any of the other boarding time
studies cited in the article.
And while Alameda County does have an elevated number of involuntary psychiatric holds,
the county also has a disproportionate share of California’s chronic and persistently
mentally ill residents – out of which arise a significant percentage of the psychiatric
emergencies. This might be attributable to the agreeable local climate and the tolerance
of Berkeley and Oakland for those with alternative and transient lifestyles. But also,
the county has a great number of psychiatric boarding homes and nursing facilities
into which other Bay Area counties place many of their most severely psychiatrically
disabled. We postulate that it is these population factors, along with persisting
inner-city dilemmas like crack cocaine and concentrated poverty (which are less an
issue in most other parts of the state), that lead to the increased involuntary detentions.
Further, the greatest percentage of the patients brought to the study site are detained
by police in Oakland, a city recently described as the second most-dangerous in the
United States (U.S.), due to its high incidence of violent crimes.1 Yet Oakland has
a police officer to population ratio less than half of the nation’s most dangerous
city, Detroit.1 The idea that the relatively overwhelmed Oakland police would be taking
time away from intervening in violent crimes, to instead detain sub-acute psychiatric
patients that other counties would not find in need of treatment, seems contrary to
common sense.
The Federal Demonstration Project allowing more psychiatric hospitals to accept Medicaid
has two major shortcomings which we propose may limit its impact on boarding. For
one, it fails to recognize that many of these hospitals may already be at or near
capacity with otherwise-insured patients, and would be unlikely to suddenly accept
large numbers of low-reimbursement Medicaid instead. Secondly, this approach would
still only be continuing the status quo of shunting patients directly from EDs to
inpatient psychiatric beds, rather than attempting outpatient-level stabilization.
A medical analogy to this would be skipping ED interventions in patients with asthma
attacks, admitting to the inpatient floor instead, and only then beginning inhaler
treatment – hardly the most efficient paradigm.
We suggest the most impactful way to reduce ED boarding of psychiatric patients would
be to facilitate treatment alternatives which lower demand for scarce inpatient beds;
one possible such design is described in our study. There is nothing magic or extraordinary
about the methods used at the study site, nor are its percentages of patients discharged
within 24 hours unusual for crisis stabilization programs across the U.S. The important
factor is that with prompt treatment, the majority of psychiatric emergencies can
be stabilized in less than a day, often in less time than patients currently spend
boarding in EDs awaiting hospitalization. Just as surgeries which formerly required
hospitalization are now done in ambulatory centers, and uncomplicated childbirth can
have discharges the following morning rather than after several days, so too can acute
psychiatric treatment be converted from the tradition of days to hours. This redefinition
could lead to improved access to appropriate, timely care, while greatly reducing
costs and unnecessary hospitalizations -- all consistent with the goals of healthcare
reform.
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