24 HRS Admission?

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As a first year we take about six calls a month in my program. Lately I've had a slew of patient's while on call with CC: SI and some HI. The majority of cases are borderline (not PD), meaning there was not an attempt, but there was a lot of ideation.

Lately for most of these cases, my attending and I feel the pt can go home, as they deny that they are suicidal after speaking to me and social workers for about an hour or so. They are not psychotic, they are not suicidal or homicidal, and they have a good environment to go home with at least one person who agrees to watch them for the night.

Now, the ER residents and attendings all come over and say no no, this person needs to go into the hospital. They point out there SI is written in a few places in the chart and they don't want to risk letting the pt go home...and guess what, once the attending talks to my psych attending (comfortable at home) he usually (no, 100% of the time) crumples to the ER attending, after telling me on the phone 10 minutes ago that the dispo is OK.

Do most centers have some sort of policy that mandates people be admitted for at least 24 hours for suicidal observation and evaluation by a psych attending? We really don't have this at our program. Thoughts? I'm getting pissed at the ER. Or maybe I'm pissed I've let people go home without admitting all those times before.

 

[Adam_K]

I think that your case brings up a number of challenges inherent to emergency psychiatry with regard to suicidal ideation.

For simple logistical reasons, I think it is impossible to admit everyone that presents with SI. Plus, it may not even be beneficial to them, especially if they have certain personality traits.

In the absence of available crisis beds, this is often a tough call.

But, I gotta tell you, I don't like psych attendings undercutting their own residents after having discussed and agreed to a plan, simply because the nice folks in ER have malpractice fears.

Having seen supportive attendings spend the time and effort to educate ER physicians in cases like this, I wonder why yours doesn't make the effort. Sure, for him, it is an easy out. You and your fellow residents are the ones that do all the work. This attending, based on what you wrote, does not seem to be very oriented toward emergency psychiatry.

 

[whopper]

Now, the ER residents and attendings all come over and say no no, this person needs to go into the hospital. They point out there SI is written in a few places in the chart and they don't want to risk letting the pt go home...and guess what, once the attending talks to my psych attending (comfortable at home) he usually (no, 100% of the time) crumples to the ER attending, after telling me on the phone 10 minutes ago that the dispo is OK.

In my neck of the woods, it isn't so much malpractice as it is with the ER team trying to dump the patient on to psyche so we have to deal with the discharge.

The good ER docs treat us like we're part of the team, the bad ones turf. The good ones, when we tell them who are the malingerers (based on experience) they'll just discharge them themselves.

It also may depend on a weak psyche attending. Some of my attendings won't budge. Others always cave in.

1 particular attending in my program is very cynical, worked in a prison and can spot malingerers. HE never lets malingerers in unless its their first time. The other is a kind, nice, sweet motherly lady and she lets EVERYONE in.

The first guy is great for inpatient for Axis II's and malingerers, the 2nd doc isn't. However in outpatient where most of the patients have a real Axis I pathology and need TLC, the opposite happens, the 1st doc is mean to them, and the latter is what they need.

I too went through a lot of frustration with my attendings. One occasion, one of our patients was on topamax & depakote and in case you didn't know that can dramatically raise serum ammonia. I did a check and it was in the hundreds (one of the highest I've ever seen). I told the ER doc to bring the pt back to the ER so she could go to the medical floor. The latter nice, motherly attending & I went to the ER attending and he started screaming at her, to the point where her knees actually buckled.
I started telling the guy back in a stern voice "is that any way to treat a colleague sir? Don't you have any professionalism? If you don't believe us, just order another serum ammonia yourself. There's no need to act in this manner."

Unfortunately in my program, the 2 docs doing crisis are the motherly doc (and again, she is a good doc in outpt) or another guy (not the one I mentioned) who lets everybody in because he's too lazy too look into it. Other attendings do crisis but only during calls.

I still think my program is good despite this because every program I've seen has bad attendings here & there. By my 2nd year I could tell I was going to be a better doc than a lot of them. That's another problem we have because of shortage of psychiatrists--not just lack of doctors for pts, institutions are stuck with what they got.

Do most centers have some sort of policy that mandates people be admitted for at least 24 hours for suicidal observation and evaluation by a psych attending?

There's no such rule in my hospital. I have though been told that if you've never seen a patient before there is a 3 day standard of care for observation. I never saw this anectdotal bit confirmed in any source though. I have seen several screeners and docs say that if you know a patient and you discharge them even if they claim they are suicidal, but they have a known history of malingering and such, and you document carefully, that can be good enough.

One thing I've been doing is if I think the pt is BS or they might just need a little affirmation and not an admission, I let them stay in the crisis center as long as possible before I decide to admit or discharge. Malingerers might get sick of waiting or reveal their real nature. People needing affirmation sometimes just need a little food, someone to talk to and the extra hrs helps. Maximum stay in a crisis center by NJ law is 24 hrs.

 

[raspberry swirl]

im not an intern yet, but im doing my 2 months of ER (a painful last rotation of my medical school career, i might add), and we get a lot of psych patients in the ER, and this "suicidal ideation = admission" thing is something that really peeves me, and i've only been here 3 weeks. it actually happened yesterday - a guy came in after having a fight with his wife in which she said she was divorcing him, he went over to his fathers house, mentioned taking his gun and killing himself, left for his house, his father called the police, they intercepted him, one squad brought him over, while the other searched for and confiscated his firearm. its quite possible had the police not intercepted him, in the heat of the moment, he might have shot himself. but by the time he got to us, he was calm, sedate, remorseful, and just wanted to talk to his wife. no history of anything psych related at all. started marriage counseling with a psychiatrist the week before, had taken 2 days worth of lexapro, and thought he could probably get an appt the next morning. he had a very concerned family, and a father who said the patient could stay at his place til the patient and his wife worked things out. the ER docs here consult psych for every single SI. and so far, the psych nurse has agreed to admit all of them (no psych residents here). this patient waited for over 4 hours to be seen by psych (another issue), and then waited another 4 hours to get transferred (insurance issues). the whole thing was ******ed. i would have sent the guy home (assuming the firearm was removed, he was staying with his father, and we could get him an appt with his dr the next day). i'd say 1/3 of the people that come into this particular ER with SI dont need to be admitted.

 

[whopper]

If a firearm was involved I think referring them to psyche was justified.

Yeah, I know it was still BS as you make it out, but that is enough of a red flag for me to not get ticked with the ER doc.

One of the ER docs asks patients dozens of time if they are suicidal or depressed so he can dump the patient on us.

ER doc-"I know you're here for a sore throat but are you sure you're not depressed? You know sore throats can make people depressed you know. It can ruin your day and when your day is ruined--you get depressed."

pt-"I'm not depressed"

ER-doc-"you sure? have you ever been depressed in your lifetime? Ever? Common, you know you must have been at some point".....