Reframing our view of ‘unnecessary’ emergency department visits
Many working in health care will be aware of the policy push to keep people out of emergency departments and divert them to services in the community, such as primary care and community mental health and social services. But what happens when adequate community care and supports are simply not available? What impact does this have for patients presenting to the Emergency Department (ED), and how can EDs respond?
In 2014, researchers at the Centre for Research on Inner City Health at St. Michael’s Hospital surveyed 166 adults recruited at six different downtown Toronto EDs. Our study participants had visited the ED five times or more in the past year, and had at least one visit for a mental health or substance use-related concern. In addition to asking them about their health and hospital use, we asked what was driving their ED visits. We also conducted qualitative interviews with a sub-set of 20 participants, going into more depth about their perspective and experiences related to emergency care. We emerged with an important message for health care policy-makers: until comprehensive and robust community supports are available, we should put resources into welcoming ‘frequent presenters’ with mental health and/or addiction concerns into the ED.
We found that people with mental health and substance use-related problems reported coming to the ED repeatedly for very good reasons. Our interviews are full of descriptions of the sense of urgency, fear and need people feel when presenting to the ED. Our study participants also help clearly illustrate why the ED is their destination of choice. Some participants described a lack of social supports – having no one to turn to when in crisis. Others described a lack of timely access to primary and/or psychiatric care, or indicated that crisis lines or centres did not or could not respond to their needs. Many were told to go to the ED by physicians, social workers and crisis centres. In the end, if we were to summarize the ‘why,’ it would seem to be this: EDs are always open, they have physician and nursing staff that can assess any concern, they are the normalized destination when in crisis, and there is a perception that they cannot turn people away, unlike other services.
People might choose to visit the ED on a frequent basis, but that does not mean they always have good experiences there. Our participants told us that hospital personnel often disagreed with them about the appropriateness of their visits or about what constitutes an emergency. Many participants felt stigmatized and treated poorly as a result of their frequent ED visits or their mental health and/or addictions challenges. Participants described being met with impatience from hospital staff during repeat visits, and feeling that providers were tired of seeing them. They shared experiences of what they saw as perfunctory or unsympathetic care, which they often attributed to the fact that they were in the ED frequently. In terms of mental health and substance use concerns, one participant reported being viewed as “just a psych case,” while addictions-related stigma was described even more often. Instead of the ‘safe place’ people were hoping for – and deserve – they often found themselves dismissed from the ED, without having their concerns addressed.
EDs are being asked to compensate for issues caused, in part, by the under-resourcing of community care and supports at different levels. For example, there is a clear need for low-barrier, 24/7, comprehensive mental health crisis centres in Toronto – with access to physicians (while some crisis centres do exist, they do not provide access to medical care). Multidisciplinary, 24/7 outreach/community Crisis Response Teams of service providers with the skills and training to effectively engage and support people in crisis is also a promising model of care. In addition to helping support and resolve crises, there needs to be equitable access to trauma-informed, recovery-oriented, long-term supports, to help prevent future crises. Finally, access to adequate housing, income and employment opportunities can substantially improve health and the recovery trajectories of people with mental health and addictions challenges.
Making the hospital a safe place
While substantial investments are needed to fill the gaps in community care and supports, as identified above, this transformation – if it is indeed coming – will take time. As we wait and advocate for change, we suggest embracing the fact that some people with mental health and addictions concerns keep coming to the ED for help, and moving to make it the ‘safe place’ they need and deserve.
How do we do that? First, we acknowledge that EDs as currently resourced cannot be asked to answer for the system failures described above. We also recognize that EDs in many urban centres are dealing with their own pressures including overcrowding, understaffing, and vicarious trauma.
Then, we go about identifying the supports and resources needed to make the ED the place that people need it to be, given the current gaps in short- and long-term services and supports, including health and mental health services, and affordable safe housing. These supports could include policies to support staff around burnout, and training in providing trauma-informed and non-stigmatizing care. An earlier study in Toronto demonstrated that providing compassionate contact with trained volunteers in the ED could serve to increase patient satisfaction, and reduce ED use. Authors hypothesized that people who were satisfied with their treatment did not feel the need to return as frequently. Hospitals could also consider the provision of dedicated, 24/7 space and staff in or adjacent to EDs, where services such as crisis counseling, coordination with community care and welcoming communal space could be made available.
While our sample was small, the issues interviewees raised are supported in the literature, and resonate with our experiences as researchers and service providers. We believe they speak to the need for a shift in the relentless policy emphasis on reducing ED use, in particular for people with mental health and/or addiction concerns – and in the context of a system that simply does not provide comprehensive and appropriate community supports.
We need to create good alternatives to hospital use for complex chronic health and mental health conditions. This includes a range of evidence-informed, community-based services, and greater attention to the social determinants of health, such as housing, employment, and income support, to address core unmet needs. Until then, people are coming to hospital EDs for a good reason, and EDs need the resources to welcome everyone, no matter what they need, or how often they need it.
Dr. Vicky Stergiopoulos is a clinician scientist at the Centre for Research on Inner City Health, the Li Ka Shing Knowledge Institute, and the Psychiatrist-In-Chief at St. Michael’s Hospital. Deb Wise Harris is a communications specialist at the Canadian Mental Health Association, and former research coordinator at the Centre for Research on Inner City Health at St. Michael’s Hospital.