High Acute Inpatient Psychiatric Bed Occupancy Associated with Increased Rates of Suicide among Veterans
Inpatient psychiatric treatment is important to suicide prevention. Hospitalization allows for identification and management of psychiatric and physical illnesses, coordination of care, and access to support services; it also provides time for personal or psychiatric crises to stabilize. However, despite an increasing incidence of suicide, there was a 25% reduction in the number of acute psychiatric beds per capita (from 28 to 21 beds per 100,000) in the US from 2003 to 2016. This retrospective cohort study examined the relationship between the incidence of suicide among Veterans and acute inpatient psychiatric bed availability using occupancy as a measure of hospital strain and access. The study sample included 6.7 million Veterans enrolled in VA primary care for at least one year between 2011 and 2016 at any of 111 VA hospitals with acute inpatient psychiatric units across the country. Investigators used both VA and publicly available data. Acute psychiatric bed occupancy was categorized as the per cent of beds occupied per quarter using thresholds of ≤85%, 85.1%–90%, 90.1%–95%, and >95%. Patient variables included age, race, gender, homelessness, rurality of residence, and US Census Division aggregated to the hospital quarter. Community variables included VA and non-VA acute psychiatric beds and non-VA community mental health spending per capita.
- High acute VA psychiatric bed occupancy (>95%), not beds per capita, was associated with a 10% higher incidence of death by suicide. Extrapolated over the 6-year study across 145 hospital quarters with occupancy >95%, this hospital strain contributed to an estimated excess of 64.5 suicides.
- The absolute number of acute VA inpatient psychiatric beds decreased by 13% from 4,419 in 2011 to 3,860 in 2016, while mean occupancy decreased from 68% to 65% over the same time period; the number of deaths by suicide increased from 2,193 in 2011 to 2,464 in 2016.
- The VA national average of 65.5 acute psychiatric beds per 100,000 Veterans was three times the US national average of 22/100,000 in 2016.
- Changes in VA acute psychiatric beds, non-VA (i.e., community) psychiatric beds, spending on community mental health per capita, and the proportion of Veterans with a mental health diagnosis were not associated with the incidence of suicide among Veterans enrolled in VA care.
- Measuring hospital occupancy and establishing occupancy benchmarks should be included in patient safety reports as psychiatric bed overcrowding joins overall hospital, emergency department, and intensive care unit occupancy as a risk for higher mortality.
- Occupancy calculations were made monthly and aggregated at the quarter due to low number of suicides in smaller units of time, potentially limiting the precision of the analysis.
This study was funded by HSR&D and VA’s Office of Rural Health. Dr. Kaboli is a core investigator with HSR&D’s Comprehensive Access and Delivery Research and Evaluation (CADRE) Center, Iowa City, IA. Dr. Augustine is part of VA’s James J. Peters VA Medical Center, Bronx, NY.
Kaboli P, Augustine M, Haraldsson B, et al. Association between Acute Psychiatric Bed Availability in the Veterans Health Administration and Veteran Suicide Risk: A Retrospective Cohort Study. BMJ Quality & Safety. August 16, 2021;online ahead of print.