My hospital psych unit is often filled to capacity and patients needing mental health admission wait in the ED. Or, often times, the patients get admitted to the IM hospitalist service to avoid "boarding" in the ED. Recently, the ED has been pushing for the psychiatrists to see the patient/round on them in the ED and ideally they want the psychiatrist to be listed as the attending for a patient who is not technically admitted to the hospital yet. The hospitalists are less intent on psychiatrists being listed as attending for mental health patients on medical floors awaiting admission, but still need the patients to be seen. Prior to this job, I've never worked in a hospital that admits psychiatric patients to medical beds just awaiting psych admission. And I've never seen a hospital where psychiatrists are the primary attending on patients outside of the mental health unit. What are your thoughts on this situation?
Attending on patients in the ED
- Thread starter nexus73
- Start date
- Joined
- Dec 2, 2004
- Messages
- 6,379
- Reaction score
- 4,361
Terrible--but is it better to have them lying on gurneys in hallways and assigned to no one?
- Joined
- Jun 15, 2004
- Messages
- 1,938
- Reaction score
- 3,546
What does your contract say your responsibilities are? Do you even have admitting privileges to the medical floor?
My hospital tries to do the same thing, but I refuse because they did not hire me to run an ad hoc inpatient psychiatric service. I am a consultant only to the ED or IM services. When they try to do this it is time to call the chief of staff because they aren't clear on what everyone's role is. If the chief of staff and the hospital wants to expand my role beyond my current contractual obligations then it is time for employment renegotiation, and most likely I'll be looking to move on, because I'm not interested in running an ad hoc inpatient psychiatric service when I could work at an actual inpatient psychiatric hospital with better support and resources. Everybody knows that. Don't be their whipping boy or girl.
My hospital tries to do the same thing, but I refuse because they did not hire me to run an ad hoc inpatient psychiatric service. I am a consultant only to the ED or IM services. When they try to do this it is time to call the chief of staff because they aren't clear on what everyone's role is. If the chief of staff and the hospital wants to expand my role beyond my current contractual obligations then it is time for employment renegotiation, and most likely I'll be looking to move on, because I'm not interested in running an ad hoc inpatient psychiatric service when I could work at an actual inpatient psychiatric hospital with better support and resources. Everybody knows that. Don't be their whipping boy or girl.
- Joined
- Oct 13, 2008
- Messages
- 7,397
- Reaction score
- 5,710
All of our units are routinely full. It's unusual to have bed openings sans the 2-6 hour time period for the room to be cleaned, a new patient to be accepted, and a resident to do the admission.
Patients routinely board in the ED, typically for 3-4 days at most; patients who require a longer boarding period for a specific reason may go up to IM to wait and of course sometimes they go to IM for acute medical care before being sent to an inpatient psych bed. Most of those patients are seen at least once a day by a psychiatrist. I believe ED patients are seen daily by attendings, floor consult patients who are overall very stable may be seen every other day or only by a resident, but that's usually only if CL is very busy. While in the ED or on IM, the ED/IM attg/res are the primary and psychiatry is purely consultant--all orders and final responsibility are on the ED/IM staff.
My point being that I don't think it's unusual to board patients in the ED or on medicine, it's not very unusual to expect psych consults to see those patients at least somewhat frequently, but I do think it would be unusual (and inappropriate) to expect psych to be the primary attending on the medical floor or in the ED.
Patients routinely board in the ED, typically for 3-4 days at most; patients who require a longer boarding period for a specific reason may go up to IM to wait and of course sometimes they go to IM for acute medical care before being sent to an inpatient psych bed. Most of those patients are seen at least once a day by a psychiatrist. I believe ED patients are seen daily by attendings, floor consult patients who are overall very stable may be seen every other day or only by a resident, but that's usually only if CL is very busy. While in the ED or on IM, the ED/IM attg/res are the primary and psychiatry is purely consultant--all orders and final responsibility are on the ED/IM staff.
My point being that I don't think it's unusual to board patients in the ED or on medicine, it's not very unusual to expect psych consults to see those patients at least somewhat frequently, but I do think it would be unusual (and inappropriate) to expect psych to be the primary attending on the medical floor or in the ED.
Last edited:
- Joined
- Oct 30, 2016
- Messages
- 3
- Reaction score
- 2
Ok but it sounds like the hospital needs to expand its psych facilities. Across the US, more psych patients are ending up in ERs. This is the fault of society, not individual on-call psychiatrists. Hospital administrators as well as legislators need to do their part, or no psychiatrists will work for them.
- Joined
- Oct 30, 2016
- Messages
- 3
- Reaction score
- 2
Are you a resident or an attending? Residents, of course, can be forced into all manner of overworking. But if you are an attending, you can walk. So, is it more work than you're being paid for? Keep in mind it's not just the hours you're working, but the liability you're taking on. If the ER gets flooded with psych patients, are they dumping all the liability onto one person? Yeah, if it got bad enough, I would leave that kind of job, and let them know it's time to upgrade their psych facility so that it meets the demands of modern America.
- Joined
- Jul 16, 2006
- Messages
- 1,951
- Reaction score
- 422
True. But the whole point is that the government doesn't care much about the mentally ill, and especially not the hospital administrators. Less and less inpatient psychiatric facilities are available, which is a huge problem. We obviously only want to hospitalized someone when we need to, but unfortunately the need is very high in many areas of the country.
- Joined
- Aug 9, 2012
- Messages
- 2,856
- Reaction score
- 5,420
I think it is very doable to have IM hospitalists "board" a patient with them as primary and psychiatry as consulting. It is sub-optimal for literally all involved but we run into that not-infrequently. The ED is welcome to consult you but that should never come with the strings of being the primary physician, it is their ED, they literally specialize in running that type of unit. They can find another bed for the patient if they have a problem with the length of stay.
- Joined
- Oct 15, 2006
- Messages
- 4,580
- Reaction score
- 2,796
The matter being is there aren't enough beds for the amount of acute crisis presenting to the ED. It would be better to have an army of social workers on staff with PHPs everywhere. Cheaper and you can dispo them more quickly out of the ER than taking up a hospital bed just to "board".
I wish residencies would figure this out and start aligning themselves with the new practice of Inpt to PHP and back than the old practice where limited documentation and the expectation of keeping someone on the unit indefinately because of a 'gut feeling' arose.
Or... just bring back asylums.
I wish residencies would figure this out and start aligning themselves with the new practice of Inpt to PHP and back than the old practice where limited documentation and the expectation of keeping someone on the unit indefinately because of a 'gut feeling' arose.
Or... just bring back asylums.
- Joined
- Nov 17, 2011
- Messages
- 1,954
- Reaction score
- 912
The disposition of a patient in the ED can be very poor when presenting with psychiatric issue as part of the presenting problem. I once presented with shaking of unknown origin and an intolerable energy, along with inability to eat or sleep well. I was already on benzos and Seroquel. The ED doctor recommended increasing my Ativan dose to 12 mg a day (because I was a "big guy") and adding Abilify in addition to Seroquel I was already on. Fortunately, I knew this was a bad idea. Not everyone would. It seems like it would be a good idea to have one psychiatrist floating around every hospital for the ED and admitted patients. I recently asked my psychiatrist why there are none who work for the major outfits around me (meaning why psychiatrists operate more like dentists in their own shops instead of being part of the major hospital and outpatient organizations). She said they're not willing to pay them enough.
The hospital is still pushing for the psychiatrists to be the attending doctors for ED patients boarding. I have various objections to this. Mostly because I have no say in how the ED is run, don't know the nurses, have no control over how patients are roomed (they recently put two psychotic patients together into a single-bed room (they sat in chairs with the bed removed) when the ED was full). I don't think I can be the attending of record in this situation because I'm taking on the liability of how the ED is run when I have no weight to meaningfully affect the ED policy. What if one of those psychotic patients attacked the other one, and I'm listed as the attending for both? Bad news I think. I can always put in orders to the effect of "keep this patient in his own room with a 1:1 for safety", but that order may not get followed (and would I be responsible for not following through to make sure the order was followed?), and I'd have to basically be writing orders to the effect of making the ED into the ad hoc psych unit mentioned above. I don't think it's feasible or safe.
Not sure what I'm going to do. Otherwise, it's a pretty good job, I just think higher ups are acquiescing to ED docs demands.
Not sure what I'm going to do. Otherwise, it's a pretty good job, I just think higher ups are acquiescing to ED docs demands.
- Joined
- Nov 30, 2009
- Messages
- 4,326
- Reaction score
- 9,968
It's not uncommon for psychiatrists in EDs to write orders on patients that they are not the primary physician for. Ive worked at a few places where this has been the case. I kind of prefer it because then you know the orders are in and placed correctly in a timely manner and you can put in what you want (including labs, imaging etc if indicated). Being the primary physician for the patient where there is no separate space for psych is a different situation altogether. If you can have a specific bit of the ED just for psych patients and with staff working with them (including security and nursing) it may not be terrible. However, even in that situation, I would still only agree to "joint" management (i.e. both the EM doc and psychiatrist) are jointly listed. It is not a good idea for patient care for you to be the primary if you are not physically located in the ED. Also if the patients have medical issues that need addressing it is better that the ED docs deal with it (or have IM consult and deal with it).
Agreed. One of the more vexing things is with a recent ED expansion the ED physicians actually pushed against dedicated psych beds/space for some unknown reason. Maybe wishful thinking (or magical thinking) on their part, e.g. "If you don't built it they won't come" perhaps. It hasn't exactly worked out that way, for some reason psych patients keep coming.
- Joined
- Mar 24, 2014
- Messages
- 5,761
- Reaction score
- 7,160
Maybe it is more because an emergency department isn't really a place to house psych patients. The odd thing about our system is that we don't spend money on less restrictive and lower levels of care so that we end up spending more and more on highest levels of care in the most restrictive environments. The inpatient units in our private hospitals are all being shut down or reduced in size and the outpatient community mental health services were already shrinking prior to this. As our hospital CEO likes to point out, the politicians love to talk about expanding care for the mentally ill and implementing community based care, but they never seem to get around to paying for it. They do crap like have a suicide prevention program that consists of a few posters, some wristbands that say suicide awareness, and maybe a volunteer speaker or two and they call it good. With the end result of the program is that people know to call 911 if someone mentions suicide and that's about it. Then the patient is brought to the hospital and has a horrible experience with the mental health system and we wonder why suicide rates or other measures of mental health are not improving. Maybe it will get better in this state now that they passed an expansion of medical marijuana for treatment of mental disorders.
