psychiatric services, emergencies, and the ER....

[vistaril]

Had a conversation with a community practice ER physician yesterday which really reinforced my belief that in many states(not all) things need to change in terms of this....

Medical ER's are *not* the place for this to happen. Especially in community settings(which is what the vast majority of er's are in).

Emergency rooms, for the most part, have *nothing* to offer these patients. And they are horribly inefficient. And they take up space, beds, etc which are needed to treat medical emergencies....which is the concept behind the er.

It's a question of what is best for patients. It is not best for the typical SI patient to go to a community ER with a chief complaint of SI, wait around for 10 hours in an er room until the mental health caseworker comes by to assess the patient, then be sent to the hospitalist(!) at the same hospital because there are no beds at the regional state facility or any private psych hospital in the area(if they wuld have taken him) where he waits 3-4 more days on a medicine unit waiting for a bed to open up. The er attending(a nice guy) asks me "why does the initial process have to be done in my er? What about the er offers an advantage over the fire department, or a police department for example?"....

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[BobA]

Had a conversation with a community practice ER physician yesterday which really reinforced my belief that in many states(not all) things need to change in terms of this....

Medical ER's are *not* the place for this to happen. Especially in community settings(which is what the vast majority of er's are in).

Emergency rooms, for the most part, have *nothing* to offer these patients. And they are horribly inefficient. And they take up space, beds, etc which are needed to treat medical emergencies....which is the concept behind the er.

It's a question of what is best for patients. It is not best for the typical SI patient to go to a community ER with a chief complaint of SI, wait around for 10 hours in an er room until the mental health caseworker comes by to assess the patient, then be sent to the hospitalist(!) at the same hospital because there are no beds at the regional state facility or any private psych hospital in the area(if they wuld have taken him) where he waits 3-4 more days on a medicine unit waiting for a bed to open up. The er attending(a nice guy) asks me "why does the initial process have to be done in my er? What about the er offers an advantage over the fire department, or a police department for example?"....

ER's can offer safety. They can give medication (even involuntarily) if needed. They can perform the medical assessments needed if there's a cause for concern that the issue may be delirium or substance induced. A fire department or police department can't necessarily do all these things.

Nationwide 1/8th of ER visits are primarily psychiatric in nature. Psychiatry is part of emergency medicine even if they don't like it. The ER doc could actually do the mental health assessment themselves, and then if they want they can discharge the patient. They don't have to want for a mental health worker - that's their prerogative.

 

[vistaril]

ER's can offer safety. They can give medication (even involuntarily) if needed. They can perform the medical assessments needed if there's a cause for concern that the issue may be delirium or substance induced. A fire department or police department can't necessarily do all these things.

Nationwide 1/8th of ER visits are primarily psychiatric in nature. Psychiatry is part of emergency medicine even if they don't like it. The ER doc could actually do the mental health assessment themselves, and then if they want they can discharge the patient. They don't have to want for a mental health worker - that's their prerogative.

they can't do those things(give meds, offer safety) now...they could with a few minor tweaks. Even better, set something up across states with catchment areas in pre-existing facilities inside community mental healh clinics that offers after hour temporary placement/holding there....emergency workers could bring the people there for initial evals.

And no, er docs cannot do the mental health assessment themselves because they are busy treating asthma exacerbations, MIs, sore throats, abdominal pain, etc....they are not mental health workers. And that doesn't even address the main problem, which is what happens after the er(whether it is someone in mental health or someone in emergency medicine) decides the pt isn't going to go home. They are STUCK at the hospital...just STUCK there. And then you have ER physicians and hospitalists STUCK with a patient who has no medical issues at all. None. The whole point should be to get patients assessed quickly and then get them to where they need to be in a timely and efficient manner. The current system in many states does exactly the opposite of that, consumes of ton of resources, and is bad for patients.

Are there tweaks that would have to be made to the system if psych patients didn't present to the ER? Sure, but these could be done....making those tweaks is FAR preferable than the status quo(which everyone seems to hate) and consumes a massive amount of resources. btw, some states have a system in place where the er doesn't become the dumping ground for psych patients. This is a much preferable scenario, and one states and community hospitals would be wise to adopt.

 

[vistaril]

Copied and pasted a great example of this in the EM forum. I don't agree with the exact language 100% at the end, but the point is dead on:

I agree with Doc B, this Psych BS is just cost-shifting by the government. We do NOTHING for psych patients who are depressed. What politicians want to have happen with psych patients would be too expensive to accomplish if the government put their money where their mouth is and truly funded mental health in a real way. But no, as is increasingly the case, they accomplish their goals through unfunded mandates, threats of EMTALA violations, etc. "Suicide is an emergency!" they proclaim. "We must take away people's freedom, or they'll hurt themselves!" "Hospitals! This is your problem that you must fix...ahem, for free." The solution is to dump the patients on ERs. Psychiatrists could easily rule out medical disorders (they're doctors for crying out loud!) and consult an internal medicine doctor for cases they wanted a second opinion on.

Most my depressed psych patients come in the following flavors:
1. The substance abuser- "I'm always depressed when I get drunk"
2. The homeless- Why are you depressed? "Because I'm homeless, I want a nicer free place to stay."
3. The borderline- "I'm going to be overly dramatic and claim suicidality to figuratively put my boot on the throat of society until it gives me what I want"
4. The drug-seeking- "My pain/anxiety is so bad that I'll kill myself if you don't give me narcotics/benzos."

I can count the number of cases on one hand in the past year that don't fall into the above categories. In general, we'd do better to hang a sign out front reading the following:

This is an emergency room. We don't really help people who are depressed. If you were truly suicidal, you'd be dead, not here in the waiting room of the ER. If your motivations are to get drugs such as benzodiazepines or narcotics, we are all out (for you). If you want more social support and are willing to be committed to a psych facility for an indefinite period of time after 1-3 days of sitting on an ER gurney, then come in. If you have been suicidal more than 2 times in the past year, poop or get of the pot, but quit involving us in the matter. Please be polite, and not too demanding as every minute we spend with you is a minute not spent with people who have true medical problems. By taking up too much of our time, you are literally killing other patients.

 

[BS81]

dedicated Psych ER's, they work extremely well
more psych beds... i agree having someone take up a bed in the ED makes no sense, it would be better for them to just camp out on a seat in a Psych ED.
And in regards to EM docs doing a mental health assessment, did you ever do a ER rotation? They evaluate patients in 3-5 minutes, dx, treat and/or dispo. They are all about moving the meat, because that's what they are paid to do.

 

[silas2642]

Sure, and just who is going to pay for the additional psych ED beds?

 

[vistaril]

dedicated Psych ER's, they work extremely well
more psych beds... i agree having someone take up a bed in the ED makes no sense, it would be better for them to just camp out on a seat in a Psych ED.
And in regards to EM docs doing a mental health assessment, did you ever do a ER rotation? They evaluate patients in 3-5 minutes, dx, treat and/or dispo. They are all about moving the meat, because that's what they are paid to do.

Well that's the thing....psych er's can be great, but I don't know if we are talking about the same thing. I don't think we need attached psych Er's, meaning where the 'psych ER' is just a separate part of the regular ER and walking 10 feet(or through a door) gets you into the regular ER, and patients are initially first triaged through the regular ER. That still, imo, 'overmedicalizes' psych patients. And comes with it a lot of the same problems.

I'm talking about designated mental catchment areas where people present that have no connection or association with the regular er at all. There would be no 'er' about it. This would also eliminate psych patients being dumped to the hospitalist when their were no beds to be transferred to from the psych er.

And yes, I did an er rotation in med school(2 actually). And I've done several in residency. I'm aware of what em physicians do with psych pts, but the problem isn't whether they spend 5 seconds or 5 hours with the patient. The problem is they are in the WRONG PLACE. if the er physician pops in for 30 seconds and is able to dispo them out, fabulous...but that's usually not what happens. A lot of times they have to be held....then before they are transferred(from a place they never should have been in the first place) a bunch of expensive tests have to be done that are completely unneccessary. Then after all these expensive and completely unneccessary tests are done, there is no place to send the patient...again, no place to send him from a place he never should have been in the first place. And so then it's just a cluster**** all the way around....the hospital has spent a ton of money on unneccessary tests, a psych pt is sitting in a horrible environment for them, and now the hospital is left playing hot potato with someone they cant help...because they don't have a psych ward and there is no accepting psych facility. Everyone is screwed. The taxpayer, the hospital, other patients in the er.......often even the patient as well.

 

[nancysinatra]

One problem with bypassing the ER or the hospital is that you are asking patients to self triage themselves either as psych or medical. For sure, if you set up a freestanding psych place and take all comers, you are going to get a fair number of cases that look psychiatric but are actually medical, and some that are just medical. No doubt you can place a psychiatrist there and hope that they can weed out the cases that should go to the real ER, but do you really trust psychiatrists to do that correctly 100% of the time, and do it in the time frame necessary?

I moonlight at a freestanding psych "assessment center" (it's a psych ER, open 24/7) that has almost no medical services whatsoever. I don't think the place even has a crash cart. And every couple weeks we get someone coming in with chest pain or the like who thinks we're a regular ER, or patients whose families are so used to them going into the psych hospital that when they have SOB, that's where they go. We get ODs both accidental and intentional.

For the really urgent cases we call 911 and send them to the ER in an ambulance, but the EMS people have a lot of attitude and will boldly question whether our "psych" patient really needs to go to the ER.

I really like working at this place though, because it's never boring. But seriously the American public is just not smart enough that it's safe to assume people will go to the right kind of place for the right emergency.

 

[AleisterCrowley]

I agree with NancySinatra 100%

I may be losing it, but I keep getting these weird vibes/lingering recurrent notions that Vistaril is not a real psychiatrist. I can't seem to shake them either; he just seems like someone who is pretending to be a doctor online!

 

[surftheiop]

I think this is an interesting discussion. I think its pretty screwed up how long we force psych patients to stay in the ER, and even then we usually aren't getting them sent to the treatment setting that is the best match for their condition, instead they are getting sent to wherever has the shortest waiting time.

I feel like a lot of the ER issues could be alleviated if states expanded/built more psych hospitals. Makes me wish so bad we could have resisted the urge to explode the national debt occupying iraq for the last decade and instead beefed up infrastructure at home

 

[peppy]

I've worked in a place similar to what nancysinatra describes. In addition to overdoses, you also see a lot of delirium patients in these settings.
Oh and the occasional hypertensive urgency/emergency or diabetic on the verge of DKA thanks to psych patients seldom having great PCP follow up/compliance. ER docs may not like dealing with psych patients but they do have a role in confirming these patients are medically stable if the patient is going to a freestanding psych hospital.

As for building more psych hospitals, that era is gone. For better or worse: http://en.m.wikipedia.org/wiki/Deinstitutionalisation

 

[notdeadyet]

I've worked in a place similar to what nancysinatra describes. In addition to overdoses, you also see a lot of delirium patients in these settings.
Oh and the occasional hypertensive urgency/emergency or diabetic on the verge of DKA thanks to psych patients seldom having great PCP follow up/compliance. ER docs may not like dealing with psych patients but they do have a role in confirming these patients are medically stable if the patient is going to a freestanding psych hospital.

Ditto this. The idea of not having psych patients in the ER is just silly. You don't send psych patients off the street in acute crisis directly to an offsite treatment program for the same reason that you don't send medical patients off the street in acute crisis directly to the medical or neurology unit. The ER's job is to screen, priortize, treat/discharge what they can and re-route what they can't.

ER docs may b!tch about psych patients. Some of them also b!tch about folks that come into the ER for chronic pain conditions, primary care complaints, social work complaints, etc. This is the nature of their job. Many of them would love to do nothing but emergencies all day, but the problem is that patient's don't come to the ER with triage stickers on their foreheads so there is evaluation to be done.

At the better hospitals, there are attached psych ERs they can send psych patients to when they are medially cleared, dedicated wings that handle social work issues necessary for discharge for homeless patients when they are medically cleared, tracks for what are primary care complaints when they are medically cleared, etc. etc. etc. But the key point is that patients need to be medically cleared before they can be re-routed. Anything else is substandard care and ethically and legally dodgy. For smaller community hospitals that lack these attached specialty services, patients are likely going to be treated in the ED before they can be transferred offsite. This is the nature of community medicine. Write your congressperson.

 

[ReInventor]

What happens when someone comes into a psych ER/CPEP? I am volunteer EMS so I'm in the medical ER all the time but I'm curious how the process differs at the CPEP? Is there somewhere I could read about this?

 

[vistaril]

I've worked in a place similar to what nancysinatra describes. In addition to overdoses, you also see a lot of delirium patients in these settings.
Oh and the occasional hypertensive urgency/emergency or diabetic on the verge of DKA thanks to psych patients seldom having great PCP follow up/compliance. [/url]

wild idea- last I checked, I went to medical school. I think I would know when someone is altered because they are in DKA or whatever. Psychiatrists are eventually going to see the patient, and if they want to consult medicine or whatever that's fine. The idea that most psych patient needs to be 'medically cleared' by medicine and ER docs personally and a bunch of expensive labs and tests ordered is insanity. Would there have to be tweaks in the system? Sure....but that's a horrenous excuse for the current system in many states(see the em thread about this), which by any standard is working horribly.

When you look really think about it, the MDD suicidal patient presenting to a medical ER for help makes no more sense than presenting to Home Depot. What in the world can the medical ER offer that patient that Home depot cannot? There isn't any reason the mental health social workers in many states who initially assess these patients can't go over to an office in the back of home depot rather than the ER. There isn't any reason why Home depot can't work on sending the patient to a psych facility(if the mental health assessment done at Home depot indicates as such) any worse than the medical ER.

Yes, ER physicians do complain about people coming in with hangnails, mild sinus infections, outpatient vaginal discharges, etc......those aren't emergencies, but at least they *can* do something. They can treat give an abx for the mild sinus infection, they can treat the discharge, etc.....so it's a totally different thing.

 

[michaelrack]

Psychiatrists are eventually going to see the patient.

As long as some type of doctor is going to be seeing the patient, then I am in substantial agreement with you. I do think that this doc would need access to basic labs, including BAL/UDS. I wouldn't be comfortable with a patient going to a psych ER/home depot and being sent home without PHYSICALLY seeing some type of MD or at the very least a NP (SW discussing it over the phone with a psychiatrist is not sufficient)

 

[peppy]

wild idea- last I checked, I went to medical school. I think I would know when someone is altered because they are in DKA or whatever. Psychiatrists are eventually going to see the patient, and if they want to consult medicine or whatever that's fine. The idea that most psych patient needs to be 'medically cleared' by medicine and ER docs personally and a bunch of expensive labs and tests ordered is insanity. Would there have to be tweaks in the system? Sure....but that's a horrenous excuse for the current system in many states(see the em thread about this), which by any standard is working horribly.

I can see your point about how the system could be changed. As things currently stand, I think you'll find that most of these freestanding psych hospitals have very limited medical capabilities. At the place I was at, we can't do IVs or IV medications. We can't get any labs other than UDS, urine pregnancy, and ETOH level. I don't think we have any ACLS meds available. It's not a great situation for someone who may be exhibiting "psychiatric" symptoms because of medical illness to be in.

 

[nancysinatra]

wild idea- last I checked, I went to medical school. I think I would know when someone is altered because they are in DKA or whatever. Psychiatrists are eventually going to see the patient, and if they want to consult medicine or whatever that's fine. The idea that most psych patient needs to be 'medically cleared' by medicine and ER docs personally and a bunch of expensive labs and tests ordered is insanity. Would there have to be tweaks in the system? Sure....but that's a horrenous excuse for the current system in many states(see the em thread about this), which by any standard is working horribly.

When you look really think about it, the MDD suicidal patient presenting to a medical ER for help makes no more sense than presenting to Home Depot. What in the world can the medical ER offer that patient that Home depot cannot? There isn't any reason the mental health social workers in many states who initially assess these patients can't go over to an office in the back of home depot rather than the ER. There isn't any reason why Home depot can't work on sending the patient to a psych facility(if the mental health assessment done at Home depot indicates as such) any worse than the medical ER.

Yes, ER physicians do complain about people coming in with hangnails, mild sinus infections, outpatient vaginal discharges, etc......those aren't emergencies, but at least they *can* do something. They can treat give an abx for the mild sinus infection, they can treat the discharge, etc.....so it's a totally different thing.

I get where you're coming from, but how often do suicidal MDD patients even show up? I've probably seen 3 or 4 pure cases of this in residency. The vast majority of what I've actually seen involves a mishmash of Axis I, Axis II, and flagrant substance abuse. Invariably the person who comes in with SI will have a self reported hx of "bipolar schizophrenia" and a horde of social stressors. Their thought process is usually less than pristine. Then they make a vague or not completely believable threat of suicide. Oh and we see lots of malingering too. Amid all that, then there will often be some questionable medical thing maybe going on too. And half of them have overt somatic complaints.

A really typical scenario is that someone comes in wanting pain meds or xanax, and they complain of "pain" and then when they don't get what they want they threaten suicide. The ER consults us despite the obviously malingering. And I think that scenario is way more common than the truly suicidal MDD patient coming in describing the plan they've been plotting for 2 months involving CO poisoning. Those people don't announce their plans.

I suppose you could set up free standing "Suicide Centers" for such people, but would people go?

And people DO present to Home Depot with SI. Home Depot calls 911, and the police bring the patient to the hospital. I've seen it.

I like the idea in a way though... Just like I like the idea of the first line treatment for depression being 3 months of mandatory documented exercise at a level adequate to make a difference, and only then an SSRI, but who's going to do that?

 

[nancysinatra]

I think I would know when someone is altered because they are in DKA or whatever.

I don't trust most of my attendings to know this.

 

[vistaril]

As long as some type of doctor is going to be seeing the patient, then I am in substantial agreement with you. I do think that this doc would need access to basic labs, including BAL/UDS. I wouldn't be comfortable with a patient going to a psych ER/home depot and being sent home without PHYSICALLY seeing some type of MD or at the very least a NP (SW discussing it over the phone with a psychiatrist is not sufficient)

but in many ers now the em physician doesn't really see the patient. Maybe they should, but they don't. They will see that a psych pt(SI maybe) was brought in to room 8, and then they'll just call the mental health assesser. They may eyeball the person or they may not depending on what they have been told(for example if obvious malingering they may go in just to dc them in a hurry). But I've known plenty er physicians who dont even physically see the patient at any point, depending on what they have been told about how the pt got there.

 

[vistaril]

I get where you're coming from, but how often do suicidal MDD patients even show up? I've probably seen 3 or 4 pure cases of this in residency. The vast majority of what I've actually seen involves a mishmash of Axis I, Axis II, and flagrant substance abuse. Invariably the person who comes in with SI will have a self reported hx of "bipolar schizophrenia" and a horde of social stressors. Their thought process is usually less than pristine. Then they make a vague or not completely believable threat of suicide. Oh and we see lots of malingering too. Amid all that, then there will often be some questionable medical thing maybe going on too. And half of them have overt somatic complaints.

A really typical scenario is that someone comes in wanting pain meds or xanax, and they complain of "pain" and then when they don't get what they want they threaten suicide. The ER consults us despite the obviously malingering. And I think that scenario is way more common than the truly suicidal MDD patient coming in describing the plan they've been plotting for 2 months involving CO poisoning. Those people don't announce their plans.

I suppose you could set up free standing "Suicide Centers" for such people, but would people go?

And people DO present to Home Depot with SI. Home Depot calls 911, and the police bring the patient to the hospital. I've seen it.

I like the idea in a way though... Just like I like the idea of the first line treatment for depression being 3 months of mandatory documented exercise at a level adequate to make a difference, and only then an SSRI, but who's going to do that?

1) of course you are right about the most common scenario for presentation(substance abuse, axis 2, maybe some axis 1), but they even furthers the point that these people have no business being in a medical ER either if there prime reason for presentation is a psychiatric cc. What the hell can the ER offer these people? Nothing. You mention somatic complaints, and of course that is true as well. But they certainly don't need to be worked up. I've never met an axis2 opana snorter who when they don't have pills says "feeling real great today, no physical complaints".

2) Of course the police in many states will bring the person with SI at home depot now to the er. The point of my post was that states who have this policy(the need to 'medicalize' every psych presentation) would be wise to rethink it.

3) In terms of 'who is going to change that', that is an excellent question. I'm a taxpayer(as most of us are here), and my principle concern in a lot of arenas is how to reduce cost for the taxpayer. Taxpayer is the holiest of all monies imo, and every single govt dollar spent should be accounted for and spent most efficiently, be it for medical, mental health, social security, whatever.....understanding that, I think the idea of de-medicalizing initial psychiatric presentations would be a lot more efficient and cost effective. It's all just a matter of who gets the funding and foots bills however. As people in the ER thread mentioned, it is in the interest of state mental health departments right now to have the suicidal patients present to medical ERs, get a bunch of expensive and unneccessary tests, then be transferred to hospitalist services when there are no immediate beds and be babysitted, and then finally be transferred(if ever) to a psych hospital....that is not in the best interest of the taxpayer or health spending standpoint overall though.

 

[notdeadyet]

As people in the ER thread mentioned, it is in the interest of state mental health departments right now to have the suicidal patients present to medical ERs, get a bunch of expensive and unneccessary tests, then be transferred to hospitalist services when there are no immediate beds and be babysitted, and then finally be transferred(if ever) to a psych hospital....that is not in the best interest of the taxpayer or health spending standpoint overall though.

Tests to rule out a medical etiology of acute mental illness aren't "unnecessary." When you find someone on the street with no known history wandering around aimlessly bumping into people and talking to themselves, there are exams, labs and tests to do to rule out a medical etiology. Making assumptions that "the dude's crazy" is sloppy medicine and one sure way to kill the odd patient.

For folks who have been medically screened and determined to be acutely mentally ill, I agree with you that transferring them to a hospitalist service on the wards to be babysat until a psych bed opens up is not the best use of taxpayer money. That said, I don't know anywhere that does that. The wards block that. At worst, the patient ends up sitting the ED for a prolonged length of time. Not good for the ED or the patient, but this is more ammo for why we need to reallocate funds to appropriate emergency psychiatric services.

 

[vistaril]

Tests to rule out a medical etiology of acute mental illness aren't "unnecessary." When you find someone on the street with no known history wandering around aimlessly bumping into people and talking to themselves, there are exams, labs and tests to do to rule out a medical etiology. Making assumptions that "the dude's crazy" is sloppy medicine and one sure way to kill the odd patient.

For folks who have been medically screened and determined to be acutely mentally ill, I agree with you that transferring them to a hospitalist service on the wards to be babysat until a psych bed opens up is not the best use of taxpayer money. That said, I don't know anywhere that does that. The wards block that. At worst, the patient ends up sitting the ED for a prolonged length of time. Not good for the ED or the patient, but this is more ammo for why we need to reallocate funds to appropriate emergency psychiatric services.

The vast majority of psych patients presenting to the ER aren't someone with NO KNOWN HISTORY presenting psychotic and disorganized. The idea that every psych pt must go through the incredibly wasteful process of being triaged through the ER just for this small group is ridiculous, and shows a complete lack of problem solving. Surely other triage centers that aren't medical emergency rooms could figure out some avenue to eventually get these people with no known history and are very psychotic a UDS, basic labs, and eventually imaging and medical clearance.

And yes, in some places these psych admissions do get admitted to medicine. See the ER thread devoted to this. In Nevada apparently they routinely spend a few days in the ER and then another week or more on a medicine unit.

Even some academic centers with inpatient psych units in the same hospital system sometimes have a ridiculous amount of difficulty with this nonsense. A not atypical example is when psych refuses to admit a pt from the ER with a CK of 1400 or whatever. Well of course he has a CK of 1400 and a slight bump in creatinine. He is a known psych pt who is psychotic as hell and had a 20 minute scuffle with police, then was put in restraints and struggling against them forever. I'm surprised it isn't a good bit higher! Obviously, the right thing to do in this situation is give the pt a bag or two of fluids in the ER and then send him straight to psych. But psych demands that his CK being trended out far enough so that he cant possibly be kept in the ER that long, so he has to go to medicine. The medicine resident and attending thinks it is all bs(which it is), but psych promises that once his CK is under some arbitrary and meaningless number they will take him on psych probably the next day. Well tommorrow rolls around and sure enough his CK is trending down(shocking!), but whaddayaknow.....psych is now telling medicine there are no beds to be had on psychiatry, so they will have to keep the patient on medicine awaiting transfer. And so this goes on for 4-5 more days, with the psych consult service spending about 2 minutes with the patient and his care every day, and making med recs...and the medicine service that got the dump and then the bait and switch is rightfully pissed. And then after a week or so when a bed finally opens up the pt really know longer meets criteria for admission, and so............

 

[OldPsychDoc]

...
Even some academic centers with inpatient psych units in the same hospital system sometimes have a ridiculous amount of difficulty with this nonsense. A not atypical example is when psych refuses to admit a pt from the ER with a CK of 1400 or whatever. Well of course he has a CK of 1400 and a slight bump in creatinine. He is a known psych pt who is psychotic as hell and had a 20 minute scuffle with police, then was put in restraints and struggling against them forever. I'm surprised it isn't a good bit higher! Obviously, the right thing to do in this situation is give the pt a bag or two of fluids in the ER and then send him straight to psych. But psych demands that his CK being trended out far enough so that he cant possibly be kept in the ER that long, so he has to go to medicine. The medicine resident and attending thinks it is all bs(which it is), but psych promises that once his CK is under some arbitrary and meaningless number they will take him on psych probably the next day. Well tommorrow rolls around and sure enough his CK is trending down(shocking!), but whaddayaknow.....psych is now telling medicine there are no beds to be had on psychiatry, so they will have to keep the patient on medicine awaiting transfer. And so this goes on for 4-5 more days, with the psych consult service spending about 2 minutes with the patient and his care every day, and making med recs...and the medicine service that got the dump and then the bait and switch is rightfully pissed. And then after a week or so when a bed finally opens up the pt really know longer meets criteria for admission, and so............

If that's how psych operates at your location, I'm less surprised that you have such a low opinion of your profession.

Thankfully, it's not like that here.

 

[vistaril]

If that's how psych operates at your location, I'm less surprised that you have such a low opinion of your profession.

Thankfully, it's not like that here.

so what does your community program do when all your inpatient beds are full and there is a guy on the medicine service just waiting for a psych bed? Do you have a magic wand you can use to open up a bed?

And it's not everyone in the profession. I think the psych residents at 10-15 programs are, on the whole, pretty good. Then the psych residents at the next 10-15 are decent. But after that, well.....

 

[billypilgrim37]

If that's how psych operates at your location, I'm less surprised that you have such a low opinion of your profession.

Thankfully, it's not like that here.

Sent from my DROID RAZR using SDN Mobile

 

[BobA]

Sent from my DROID RAZR using SDN Mobile

Many things Vistaril describes don't happen (or are extremely rare) at the four hospitals I work at. It must be really bad where he is.

Occasionally, a severely ill patient needing high level involuntary admission might wait 3-4 days in the ER in a psych ER or dedicated psych room admitted under the care of a psychiatrist (not the ER doc). If this happens, the person needs to be in a secure place with fully trained security, seclusion rooms, ability to restrain and administer involuntary medications, etc, etc. The ER is the most reasonable place for these patients to be as it has all these necessary things.

Transfers from medicine to a voluntary psych unit usually happen on that day or within 1-2 days, but might take 2-3 days if the patient is involuntary - but these rarely happen because dangerous patients are co-managed in an ER seclusion room by ER/hospitalist and psych and aren't admitted to medicine in the first place.

For less severely ill patients, I think urgent care mental health can work, but only if connected to decent outpatient services. I have worked in a mental health urgent care clinic at the VA for a year which worked surprisingly well. The secretary was very experienced and savvy and was able to triage many seriously ill patients to the ER. Since it was a VA, we were able to refer people to the many different types of outpatient treatment programs that were available and avoid hospitalization in most cases.

 

[vistaril]

Many things Vistaril describes don't happen (or are extremely rare) at the four hospitals I work at. It must be really bad where he is.

Occasionally, a severely ill patient needing high level involuntary admission might wait 3-4 days in the ER in a psych ER or dedicated psych room admitted under the care of a psychiatrist (not the ER doc).

3-4 days waiting in the ER is 'really bad'....where I work is much better than that at least.

 

[BobA]

Ditto this. The idea of not having psych patients in the ER is just silly. You don't send psych patients off the street in acute crisis directly to an offsite treatment program for the same reason that you don't send medical patients off the street in acute crisis directly to the medical or neurology unit. The ER's job is to screen, priortize, treat/discharge what they can and re-route what they can't.

ER docs may b!tch about psych patients. Some of them also b!tch about folks that come into the ER for chronic pain conditions, primary care complaints, social work complaints, etc. This is the nature of their job. Many of them would love to do nothing but emergencies all day, but the problem is that patient's don't come to the ER with triage stickers on their foreheads so there is evaluation to be done.

At the better hospitals, there are attached psych ERs they can send psych patients to when they are medially cleared, dedicated wings that handle social work issues necessary for discharge for homeless patients when they are medically cleared, tracks for what are primary care complaints when they are medically cleared, etc. etc. etc. But the key point is that patients need to be medically cleared before they can be re-routed. Anything else is substandard care and ethically and legally dodgy. For smaller community hospitals that lack these attached specialty services, patients are likely going to be treated in the ED before they can be transferred offsite. This is the nature of community medicine. Write your congressperson.

I'd also like to say that the ER doc gets paid handsomely to triage these patients.

 

[BobA]

3-4 days waiting in the ER is 'really bad'....where I work is much better than that at least.

Like I said, it happens "occasionally" - 3-4 days in the psych ER is the exception rather than the rule.

 

[vistaril]

I'd also like to say that the ER doc gets paid handsomely to triage these patients.

Sometimes not....in community hospitals many ER groups bill patients directly rather than have an hourly salary. These patients generally are either no pay or medicare/aid, and sometimes even the govt insured ones don't often pay because of the nature of the care provided in ER

But the larger point is that ER physicians aren't complaining because it is personally inconvenient for them. From an ease of job standpoint, Im sure it is easier for them to occupy 2 of their beds as the hours on their shift wind down with people they aren't doing anything for. I think ER physicians(and everyone that isn't a psychiatrist, including many psych patients) are frustrated because it is a combination of crappy care and great waste.

 

[notdeadyet]

Many things Vistaril describes don't happen (or are extremely rare) at the four hospitals I work at. It must be really bad where he is.

Ditto this.

Vistaril has a point of view that is very different from most on this forum. While I disagree with many of his opinions, I'm happy that folks feel comfortable expressing their ideas even if they go against the norm. Viva la difference...

Where I get frustrated is that Vistaril's descriptions of his personal experiences (not this thread, but cumulatively) show that his psychiatry program is held in low esteem by other physicians where he is, is managed by attendings that are typically described as not knowing much and exhibiting poor clinical judgment, and is in a general environment full of policies that go against the grain of typical standards of care.

I support Vistaril's right to have a minority viewpoint, I just get concerned that with the confidence and volume of his posts that less experienced visitors to the forum might walk away with the mistaken impression that his experiences and quality of training is typical. I encourage potential psychiatrists to read the forum thoroughly and research programs carefully. A decent academic psychiatry residency does not operate at the level he describes, at least none of the ones I know well.

 

[OldPsychDoc]

I support Vistaril's right to have a minority viewpoint, I just get concerned that with the confidence and volume of his posts that less experienced visitors to the forum might walk away with the mistaken impression that his experiences and quality of training is typical. I encourage potential psychiatrists to read the forum thoroughly and research programs carefully. A decent academic psychiatry residency does not operate at the level he describes, at least none of the ones I know well.

Good point. And for that reason I'll respond to this:

so what does your community program do when all your inpatient beds are full and there is a guy on the medicine service just waiting for a psych bed? Do you have a magic wand you can use to open up a bed?
And it's not everyone in the profession. I think the psych residents at 10-15 programs are, on the whole, pretty good. Then the psych residents at the next 10-15 are decent. But after that, well.....

First off--if we had a bed, there's no way we (attendings or residents) would pull the scenario you describe:

Even some academic centers with inpatient psych units in the same hospital system sometimes have a ridiculous amount of difficulty with this nonsense. A not atypical example is when psych refuses to admit a pt from the ER with a CK of 1400 or whatever. Well of course he has a CK of 1400 and a slight bump in creatinine. He is a known psych pt who is psychotic as hell and had a 20 minute scuffle with police, then was put in restraints and struggling against them forever. I'm surprised it isn't a good bit higher! Obviously, the right thing to do in this situation is give the pt a bag or two of fluids in the ER and then send him straight to psych. But psych demands that his CK being trended out far enough so that he cant possibly be kept in the ER that long, so he has to go to medicine. The medicine resident and attending thinks it is all bs(which it is), but psych promises that once his CK is under some arbitrary and meaningless number they will take him on psych probably the next day. Well tommorrow rolls around and sure enough his CK is trending down(shocking!), but whaddayaknow.....psych is now telling medicine there are no beds to be had on psychiatry, so they will have to keep the patient on medicine awaiting transfer. And so this goes on for 4-5 more days, with the psych consult service spending about 2 minutes with the patient and his care every day, and making med recs...and the medicine service that got the dump and then the bait and switch is rightfully pissed. And then after a week or so when a bed finally opens up the pt really know longer meets criteria for admission, and so...

Our "known psych patients, psychotic as hell" are triaged to a somewhat less stressful psych holding area where they are evaluated by 24/7 crisis SWs, and can be medicated if needed. Our staff would not refuse an admission with the CK scenario described above, assuming they had been rehydrated and start to trend downward. If they did have a medical consequence that actually met normal criteria for a hospitalist service admission, they are seen and managed by a competent 7-day/week C/L service in cooperation with med-surg services that value psychiatry, and from there may be discharged if appropriate or transferred to psych if needed. On a really busy weekend (like this past one--inpatient beds didn't turnover as well as expected since county case managers and other services weren't available d/t the 3-day MLK holiday, etc), we might have a dozen people who have to spend 24-36 hours in the ED, again in a dedicated mental health area before they get admitted or otherwise dispo'd. But we don't admit people to medicine just to hold them. And we manage to utilize our resources to provide appropriate treatment to those who need it. And I think our staff & residents are "pretty good" and "decent" as well.

 

[vistaril]

Ditto this.

Vistaril has a point of view that is very different from most on this forum. While I disagree with many of his opinions, I'm happy that folks feel comfortable expressing their ideas even if they go against the norm. Viva la difference...

Where I get frustrated is that Vistaril's descriptions of his personal experiences (not this thread, but cumulatively) show that his psychiatry program is held in low esteem by other physicians where he is, is managed by attendings that are typically described as not knowing much and exhibiting poor clinical judgment, and is in a general environment full of policies that go against the grain of typical standards of care.

I support Vistaril's right to have a minority viewpoint, I just get concerned that with the confidence and volume of his posts that less experienced visitors to the forum might walk away with the mistaken impression that his experiences and quality of training is typical. I encourage potential psychiatrists to read the forum thoroughly and research programs carefully. A decent academic psychiatry residency does not operate at the level he describes, at least none of the ones I know well.

I've already been fairly open about being in a large university 'name' program....Let's just say it is north and east of Missouri. I think my training is better than ~90% of psych programs. From what I hear of some of the programs in the southeast and texas and some of the non-california west, as well as some of the community-like programs out there....I shudder to think about the quality of some of the residents there.

And sure, I definately agree my viewpoint is the minority viewpoint here. But not within medicine as a whole it isn't. Just quickly browsing practically every other forum on this website makes that pretty clear.

 

[michaelrack]

. A decent academic psychiatry residency does not operate at the level he describes, at least none of the ones I know well.

To be fair to Vistaril, a lot of the issues involved in disposition of psych patients in crisis depend on the state/local policies rather than the quality of the psychiatry residency program.

 

[tkim]

I work in a community ED and we routinely board psych patients who have been medically cleared for days at a time, waiting for a bed.

If it's a peds psych, forget about it. My personal record for a peds psych boarded in the ED is one week.

Dual-diagnosis? Couple days.

Geri psych? Good luck.

Most of the time it's a day to two. We have an inpatient psych floor, so every morning there's a chance we can send one or two up. But our ED routinely has 3-4 beds locked up for psych patients waiting for a bed. Then the waiting room piles up, and our 21 bed ED has now become a 18 bed ED. It adds up.

These patients have no where else to go, but they certainly aren't getting the treatment they need in the ED. A 1-1 sitter and Haldol isn't treatment.

 

[vistaril]

I work in a community ED and we routinely board psych patients who have been medically cleared for days at a time, waiting for a bed.

If it's a peds psych, forget about it. My personal record for a peds psych boarded in the ED is one week.

Dual-diagnosis? Couple days.

Geri psych? Good luck.

Most of the time it's a day to two. We have an inpatient psych floor, so every morning there's a chance we can send one or two up. But our ED routinely has 3-4 beds locked up for psych patients waiting for a bed. Then the waiting room piles up, and our 21 bed ED has now become a 18 bed ED. It adds up.

These patients have no where else to go, but they certainly aren't getting the treatment they need in the ED. A 1-1 sitter and Haldol isn't treatment.

yep....that is what almost every community ER doc(across multiple states) tells me.....

 

[vistaril]

To be fair to Vistaril, a lot of the issues involved in disposition of psych patients in crisis depend on the state/local policies rather than the quality of the psychiatry residency program.

yep...in memphis don't you have a state facility in like downtown memphis that can serve as a direct entry point for mental health patients off the street?

 

[vistaril]

or transferred to psych if needed. On a really busy weekend (like this past one--inpatient beds didn't turnover as well as expected since county case managers and other services weren't available d/t the 3-day MLK holiday, etc), we might have a dozen people who have to spend 24-36 hours in the EDQUOTE]

yeah this is a very common scenario across the country, and I guess that's where we disagree on how much of a problem it is. I don't find it acceptable that a dozen people are spending a day+ to a day and a half(and I bet in some cases over weekends it may be more) in the ER after a decision on dispo has been made. You're talking about 350+ bed hours there....those are 350+ bed hours that could have been used to triage and dispo 75+ additional ER medical patients...

And just because they are shuffled over to the psych area of the er doesn't mean they aren't using those bed hours. Most ers who have a psych area of the er where psych pts are held *love* to open that area up for things like er obs(like trending a second set of cardiac markers) if psych wasn't occupying it....so you're just shuffling patients around(and the guy waiting for cardiac markers isn't moved) and the result is still a net loss of one bed.

 

[michaelrack]

yep...in memphis don't you have a state facility in like downtown memphis that can serve as a direct entry point for mental health patients off the street?

Sorry, I have no idea. I live in Memphis, but I practice medicine and play poker in the great state of Mississippi.

(in my post, I was referring to problems with disposition during residency in West Virginia. I don't know anything about mental health care in TN)

 

[notdeadyet]

yeah this is a very common scenario across the country, and I guess that's where we disagree on how much of a problem it is. I don't find it acceptable that a dozen people are spending a day+ to a day and a half(and I bet in some cases over weekends it may be more) in the ER after a decision on dispo has been made.

And here is where I think some folks are disagreeing with you.

When these people present to the ED, they are determined to need inpatient care or no inpatient care.

If the patient does not need inpatient care and are medically cleared, they are discharged with outpatient referrals (which varies from actual appointments next day to a one-sheet of local drop in psych services). If the patient is sitting for days for this, there is a problem with either when the ED folks activate psych resources (RARELY a problem, because ED folks as a rule are looking to discharge anyone they safely can) or how responsive the psych folks are.

If they does need inpatient care, they are admitted to the psych unit or transferred to a psych unit. How long this takes depends on the hospital's psych department or local psych departments. If this takes days, it's a problem that the psych department or county mental health department need to address. But with current services constantly being cut, they probably won't.

Where folks disagree with you is your solution to bypass the ED entirely. For patients who do not need inpatient care, it cuts down on someone occupying a bed for an hour or two, but that isn't the problem. The problem is the patient who does need inpatient care. For folks in such crisis that they do need inpatient care, a 24 hour clinic is not going to be sufficient. If the situation you're describing at your place is accurate and patients are waiting days in the ED or on a medical unit before they can be transferred, units that your psych department has a vested interest in relieving, you can imagine how long that patient will sit in an offsite clinic that will not have the resources an ED does.

And it also doesn't address the crux of the problem, which is one of the basic Psych 101 rules: you need to first rule out a medical cause for a patient's presentation. It also doesn't address a secondary problem: many to most folks psych is consulted on for the ED have a psychiatric complaint as a secondary one. They report SI after being in a MVA, they are found to have unmanaged psychosis after coming in for a COPD exacerbation, etc. The vanilla cases of someone walking into the ED saying, "I'm sad" is a small minority.

If what you are describing is accurate, it sounds like your ED, psych department and possibly county department of mental health need to have a sit down. But taking the ED out of the equation looks neat but isn't going to happen for reasons of safety (i.e.: dead patients).

 

[vistaril]

If what you are describing is accurate, it sounds like your ED, psych department and possibly county department of mental health need to have a sit down. But taking the ED out of the equation looks neat but isn't going to happen for reasons of safety (i.e.: dead patients).

well it's not going to happen because mental health resources are limited and state mental health departments prefer to pass the buck to someone else. As they say, me paying 50 bucks for something is a lot more expensive than someone else paying 100 dollars to buy it for me. That's what it all comes down to.

The ED forum(and other ed docs in the community I've talked to) are very informative on this matter.

 

[hamstergang]

It also doesn't address a secondary problem: many to most folks psych is consulted on for the ED have a psychiatric complaint as a secondary one. They report SI after being in a MVA, they are found to have unmanaged psychosis after coming in for a COPD exacerbation, etc. The vanilla cases of someone walking into the ED saying, "I'm sad" is a small minority.

At least around me, this isn't the case. I think that most patients referred to our psych hospital from EDs showed up reporting depression or were picked up by police for odd/dangerous behavior.

 

[notdeadyet]

I think that most patients referred to our psych hospital from EDs showed up reporting depression or were picked up by police for odd/dangerous behavior.

I'd make a pretty big distinction between the former or the latter. People who wander into the ER stating that they're depressed (which is low in my neck of the woods, but it sounds like individual mileage varies) is a whole different work-up than someone brought in for odd behavior. Much bigger differential on the latter.

 

[vistaril]

I'd make a pretty big distinction between the former or the latter. People who wander into the ER stating that they're depressed (which is low in my neck of the woods, but it sounds like individual mileage varies) is a whole different work-up than someone brought in for odd behavior. Much bigger differential on the latter.

usually here the 'odd' behavior doesn't have an organic feel to it at all. And is actually very rarely only odd.

 

[hamstergang]

usually here the 'odd' behavior doesn't have an organic feel to it at all. And is actually very rarely only odd.

Yeah, I should edit that. While they report it in their one-liner as odd/bizarre, it's usually more like aggressive or manic-y.

 

[Scorcher31]

I have to agree with vistaril to an extent. There is a lot of passing the buck and psych hospitals everywhere are underfunded. In my relatively population dense state there just aren't enough psych beds for patients. Unfortunately this means most of the time they end up waiting in the ED as there is really nowhere else for them to go.

 

[notdeadyet]

I have to agree with vistaril to an extent. There is a lot of passing the buck and psych hospitals everywhere are underfunded. In my relatively population dense state there just aren't enough psych beds for patients. Unfortunately this means most of the time they end up waiting in the ED as there is really nowhere else for them to go.

Yep. Everyone agrees on this point. The disagreement is whether or not the solution is to throw the baby out with the bathwater and have emergent patients bypass the ED and go to offsite clinics.

 

[Scorcher31]

Yep. Everyone agrees on this point. The disagreement is whether or not the solution is to throw the baby out with the bathwater and have emergent patients bypass the ED and go to offsite clinics.

True but the most efficent fix would be probably be to increase funding/beds on a national scale. Especially with all the attention mental health has been getting over the past year or so.

Personally I would feel relatively comfortable working psych patients up medically and sending them to the ED if I had any medical concerns or felt it was not primary psych. That may change as I get further out, and it's safe to say very few attendings would feel comfortable doing that. The problem is a large chunk of us work at stand alone psych hospitals. It takes me more than a day to get any lab including urine preg, UDS and no labs over the weekend so options are limited.

Although there are exceptions, if we are skipping the ED patients still need to go to a site that can:

1. Provide a medical assessment to make sure patients are medically stable and that the sx are not related to a non psych illness

2. Get a quick turn around time on labs and studies

3. Psychiatrically assess patients and set up appropriate dispo

4. House patients safely while they wait for beds to open up (since we aren't increasing actual hospital beds)

 

[vistaril]

True but the most efficent fix would be probably be to increase funding/beds on a national scale. Especially with all the attention mental health has been getting over the past year or so.

Personally I would feel relatively comfortable working psych patients up medically and sending them to the ED if I had any medical concerns or felt it was not primary psych. That may change as I get further out, and it's safe to say very few attendings would feel comfortable doing that. The problem is a large chunk of us work at stand alone psych hospitals. It takes me more than a day to get any lab including urine preg, UDS and no labs over the weekend so options are limited.

Although there are exceptions, if we are skipping the ED patients still need to go to a site that can:

1. Provide a medical assessment to make sure patients are medically stable and that the sx are not related to a non psych illness

2. Get a quick turn around time on labs and studies

3. Psychiatrically assess patients and set up appropriate dispo

4. House patients safely while they wait for beds to open up (since we aren't increasing actual hospital beds)

a lot of these issues that some of us raise(and why er and medicine colleagues have little respect for our field in many cases) is us demanding unneccessary tests in the ER.

The *vast* majority of the people I see in the ER....all I want is a UDS. And even then in many cases it is not emergent.

But all the bmps, cbcs, liver panels, thyroid panels, repeat imaging, etc drives er and medicine docs crazy....as it should.

 

[notdeadyet]

Although there are exceptions, if we are skipping the ED patients still need to go to a site that can:

1. Provide a medical assessment to make sure patients are medically stable and that the sx are not related to a non psych illness

2. Get a quick turn around time on labs and studies

3. Psychiatrically assess patients and set up appropriate dispo

4. House patients safely while they wait for beds to open up (since we aren't increasing actual hospital beds)

Yeah, I think you have it nailed. And right now that's an ED or something darn close to it.