A new website showing trends in Oregon hospital discharge data provides a hint of what emergency room physicians have long said— that the state's hospitals serve as a poorly equipped stopgap for holes in the state’s behavioral health system, according to interviews.
The website, an Oregon Health Authority dashboard, indicates patients are spending less time on average in hospitals getting inpatient care or in emergency departments, with those numbers falling since hitting peaks during the pandemic. But Oregonians whose primary diagnosis is mental illness tend to stay in the hospital much longer, according to state figures.
Nearly half of patients whose primary diagnosis is mental illness, or 49.6%, stay in the hospital 7 days or more, according to the state. In contrast, the proportion of patients with other diagnoses staying that long, 19.7%, is far less.
Similarly, patients experiencing homelessness stayed in hospitals about three days more on average than those with housing, according to the dashboard. They also spent four hours more on average in emergency departments.
Dr. Sharon Meieran, a longtime emergency room doctor who also served as a Multnomah County commissioner, told The Lund Report discharging someone who is homeless and sick is particularly difficult because hospitals must first ensure they have adequate care lined up.
There are motels converted into shelters where people without stable housing can recuperate after being discharged from the hospital. But Meieran said that getting a patient into one of these settings often depends on the hospital social workers skills.
“They have to work their magic and make the connections,” she said. “But there are very few places dedicated to them.”
ERs cover for lack of mental health beds
The dashboard also shows that adults seeking care primarily for mental health or substance use disorders spent on average about 9 hours in emergency departments between July and September last year. Patients 17 and younger spent nearly 11 hours on average.
Christy Simila, professional practice director for the Oregon Nurses Association, told The Lund Report in an email that hospitals often have bed shortages in their mental health units, meaning patients have to be held in emergency departments if they are not safe to discharge.
Dr. Alex Skog, who sits on the board of the Oregon Chapter of the American College of Emergency Physicians, told The Lund Report that hospitals are converting beds in emergency departments to treat people with mental health issues. Meanwhile, these patients spend days in the emergency rooms waiting for inpatient psychiatric beds, he said.
“That falls on the emergency medicine doctor and takes away their focus from the patients that are presenting with emergencies and need stabilizing care,” he said.
Boarding challenges continue
Between July and September last year, the average stay in an emergency department was five hours and 12 minutes, according to the dashboard. That’s down from the peak of roughly six hour average stay in early 2022 when hospitals were strained by the COVID-19 pandemic.
Similarly, the average length of an inpatient hospital stay declined to just under five days, compared to a high of about five and a half in early 2022.
However, the dashboard highlights Oregon hospitals’ ongoing problem of having too many patients who cannot be released because they still need care at a skilled nursing facility or other setting.
The lack of room at step-down or speciality care facilities has meant hospitals are boarding patients who don’t need care, which is costly but often goes unreimbursed by insurance.
The issue has caught the attention of Oregon lawmakers pushing legislation, Senate Bill 296, intended to ease the hospital's boarding problem by making it easier for people who need skilled nursing or step-down care to qualify for Medicaid. The bill is now awaiting action in the Legislature’s budget committee.
Between July and September last year, patients who needed to be discharged to a skilled nursing facility for further care stayed at hospitals for an average of nearly nine days, according to the dashboard. That’s about five days more than those who were discharged to their homes.
Patients who needed to be discharged to either hospice or inpatient rehabilitation both stayed in hospital for more than 10 days on average.
Meieran recalled how a patient with a traumatic brain injury laid in a bed in the emergency department for weeks because there was no specialized facility that would take him. The patient sometimes became agitated and yelled before being sedated, she said.
Several hospitals have sued the state of Oregon in federal court, saying the state is forcing them to cover for officials’ unconstitutional failure to fund behavioral health. The case is pending.
Crowding hurts access
Dr. Craig Rudy, former president of the Oregon Chapter of the American College of Emergency Physicians, told The Lund Report that patients stuck in the hospital waiting for a lower-level of care means that someone admitted for sepsis or a heart attack can’t go to the specialty floor for care they need.
“It just represents a loss of access to care for anybody who comes to the emergency department because there’s just less physical space to see them,” he said. “That means they get seen in a hallway or in a waiting room or triage. Certainly, it’s a loss of dignity for those individuals.”
Skog said there have been times when he’s seen patients in decontamination rooms or hallways because the hospital he was working at was so full because of boarding. He said he’s also seen elderly patients admitted to a hospital but having to spend the night in a loud emergency department.
Rudy said when a hospital cannot offer kidney dialysis or cardiology services it creates “a system of care issue” that is not reflected in the dashboard. The dashboard is based on patient discharges and does not show how many people are being boarded, for how long and what kind of care they are not getting.
“We know that boarding is getting worse in our state,” he said. “We just don't know the severity of the problem.”
