The borders separating emergency department ED and inpatient care are blurred

The borders separating emergency department ed and

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The borders separating emergency department (ED) and inpatient care are blurred. As inpatient stays become shorter and holding beds make ED stays longer, the treatment and discharge plan- ning functions of each confront the same set of issues. Despite these commonalities, patients are admitted to psychiatric inpatient units because more extended evaluations and more intensive treatments are recommended. When patients are at acute risk for suicide, some have to be admit- ted involuntarily. Even in this protected environment, suicide and suicide attempts are all too com- mon. What is more, there is no evidence that psychiatric hospitalization prevents suicide during the inpatient stay or in the immediate period after discharge. Hereafter, these issues will be exam- ined in more detail. In the final analysis, inpatient units appear to be safe places for the vast bulk of patients. 249 However, not everyone can be protected fully, even in the very best inpatient units. Should more be expected?
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Continuity of Care for Suicide Prevention and Research 42 The Collapse of the State Mental Hospital System and the Consequences of Reduced Overall Bed Capacity for the Mentally I ll By historical standards, 50 years is a short time; yet, between 1955 and 2005 there has been a pre- cipitous drop in the number of state mental hospital beds. 250 In 1955, there were 559,000 patients hospitalized in America’s state mental hospitals. By 2005, there were only 47,000 state mental hospital beds in the country. 250, 251 Since 2000, there has been a decline, albeit slower, of inpatient capacity in nearly all mental health organizations (Figure 3). 252 However, data from 2002 and 2005 indicate a reversal in these long-term trends. During the 2002 to 2005 interval there was a 21 percent increase in admissions to state psychiatric hospitals, but the number of residents increased by a meager 1 percent. 251 In response to these data, state mental health department personnel attributed these increases to one factor—an increase in the number of forensic admissions and residents and a corresponding increase in state hospitals constructed solely for residents needing both forensic evaluations and mental health care. 251 All of these changes have had profound societal implications; one of these appears to be increased homelessness. 253-257 Often having no place else to go, EDs have become the default option for individuals with all forms of suicide behaviors and with severe and persistent mental illness. 134, 253 In turn, many of these individuals are admitted to what few psychiatric beds there are. It is worrisome that patients at significant risk for suicide may be denied inpatient beds because there are fewer and fewer of them. To be sure, with the relative absence of state psychiatric beds, general hospitals have admitted ever increasing numbers of severely mentally ill, publicly- financed patients.
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