st2205

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I was hoping a few different people could chime in on the different settings of emergency psychiatry. A lot of people mention having a free standing psych ER in reviews as being a good thing. I'm curious about this since (and I could be completely off) it seems to me that having a ER specifically for psychiatric emergencies would somewhat skew the patient population since it would seem most the people who would end up in a psych ER would be brought in by police or by family, as opposed to many of the people who end up frequenting the regular ER for what they believe are other reasons but are really psychiatric in nature. Does being in a psych ER really provide educational benefits vs. a standard ER, since it seems like you'd be narrowing the patient diversity? Also, how often is psychiatry even integrated within normal ERs in general?
 

atsai3

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I was hoping a few different people could chime in on the different settings of emergency psychiatry. A lot of people mention having a free standing psych ER in reviews as being a good thing. I'm curious about this since (and I could be completely off) it seems to me that having a ER specifically for psychiatric emergencies would somewhat skew the patient population since it would seem most the people who would end up in a psych ER would be brought in by police or by family, as opposed to many of the people who end up frequenting the regular ER for what they believe are other reasons but are really psychiatric in nature. Does being in a psych ER really provide educational benefits vs. a standard ER, since it seems like you'd be narrowing the patient diversity? Also, how often is psychiatry even integrated within normal ERs in general?
The quality of work-life benefits of a free-standing psychiatric ER likely outweigh any putative educational benefits (which I doubt exist, as addressed below).

Having a free-standing psychiatric ER has several benefits. Two stand out in my mind: 1) It will be specifically staffed for the care of patients with psychiatric presentations. This is important because otherwise you will have nurses who do not have specific psychiatric expertise helping to manage your patients. They may page you about the wrong things, they may react differently to situations that a psychiatric nurse would feel more comfortable managing on his own, and they may want to respond with force to a patient with a psychiatric emergency who could be managed without force. For example, overmedication certainly comes to mind as a potential danger. 2) In a freestanding psychiatric ER, the psychiatric staff have sole responsibility for the patient. In a non-psychiatric ER, frequently (depending on the hospital) the ER staff and the psychiatry consult staff may have co-management responsibilities. There is already bad enough communication between the ER and psychiatry as is -- but if you introduce an additional layer of complexity, you can imagine that some patients may fall through the cracks. For example, in the management of a patient who is going through acute alcohol withdrawal, the ER staff may think that psychiatry is taking care of the patient -- and the psychiatry consult team (who is, by and large, not on site) may think that the ER staff is taking care of the patient. 3) In a freestanding psychiatric ER, the psychiatric staff are responsible for disposition (not the medical ER attendings). This is important because otherwise you will have medical ER attendings breathing down your neck about "getting that guy out of my ER" because they may not understand that some types of psychiatric patients take more time to assess, treat, and provide appropriate disposition for. A psychiatric ER may be able to avoid unnecessary utilization of acute inpatient care. For example, it is not difficult to imagine a scenario in which a patient presents with acute suicidal thinking while she is acutely intoxicated with alcohol, but after she "sleeps it off" overnight, she may decide in the morning that she is not suicidal after all and request to be sent home. In a non-psychiatric ER, that sort of plan ("let patient sleep it off overnight") is often an unacceptable disposition.

In terms of your education, it sounds like you are afraid that you will 'miss out' on patients who initially present with non-psychiatric complaints but who are subsequently found to require psychiatric assessment. I doubt you will 'miss out'. First of all, if you are thinking about medical chameleons (eg., the ER staff thinks that a patient is in a state of acute crisis due to pheochromocytoma), trust me the ER staff will probably call a psych consult anyway. Most ERs will have a fairly low threshold for calling psychiatry. Second, if someone gets admitted to the hospital for acute medical care but later is realized to have an underlying psychiatric cause, then they will certainly call the psychiatry consultation service. And since you as a resident will rotate through both services, you will get plenty of calls.

-AT.
 

strangeglove

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The quality of work-life benefits of a free-standing psychiatric ER likely outweigh any putative educational benefits (which I doubt exist, as addressed below).

Having a free-standing psychiatric ER has several benefits. Two stand out in my mind: 1) It will be specifically staffed for the care of patients with psychiatric presentations. This is important because otherwise you will have nurses who do not have specific psychiatric expertise helping to manage your patients. They may page you about the wrong things, they may react differently to situations that a psychiatric nurse would feel more comfortable managing on his own, and they may want to respond with force to a patient with a psychiatric emergency who could be managed without force. For example, overmedication certainly comes to mind as a potential danger. 2) In a freestanding psychiatric ER, the psychiatric staff have sole responsibility for the patient. In a non-psychiatric ER, frequently (depending on the hospital) the ER staff and the psychiatry consult staff may have co-management responsibilities. There is already bad enough communication between the ER and psychiatry as is -- but if you introduce an additional layer of complexity, you can imagine that some patients may fall through the cracks. For example, in the management of a patient who is going through acute alcohol withdrawal, the ER staff may think that psychiatry is taking care of the patient -- and the psychiatry consult team (who is, by and large, not on site) may think that the ER staff is taking care of the patient. 3) In a freestanding psychiatric ER, the psychiatric staff are responsible for disposition (not the medical ER attendings). This is important because otherwise you will have medical ER attendings breathing down your neck about "getting that guy out of my ER" because they may not understand that some types of psychiatric patients take more time to assess, treat, and provide appropriate disposition for. A psychiatric ER may be able to avoid unnecessary utilization of acute inpatient care. For example, it is not difficult to imagine a scenario in which a patient presents with acute suicidal thinking while she is acutely intoxicated with alcohol, but after she "sleeps it off" overnight, she may decide in the morning that she is not suicidal after all and request to be sent home. In a non-psychiatric ER, that sort of plan ("let patient sleep it off overnight") is often an unacceptable disposition.

In terms of your education, it sounds like you are afraid that you will 'miss out' on patients who initially present with non-psychiatric complaints but who are subsequently found to require psychiatric assessment. I doubt you will 'miss out'. First of all, if you are thinking about medical chameleons (eg., the ER staff thinks that a patient is in a state of acute crisis due to pheochromocytoma), trust me the ER staff will probably call a psych consult anyway. Most ERs will have a fairly low threshold for calling psychiatry. Second, if someone gets admitted to the hospital for acute medical care but later is realized to have an underlying psychiatric cause, then they will certainly call the psychiatry consultation service. And since you as a resident will rotate through both services, you will get plenty of calls.

-AT.
Where are there "freestanding" psych ER's that are not located in hospitals that also have medical ER's? Where I work there is a CPEP, which is a psych emergency room, but we are located right next to the medical ER, and we get many consults from them.
 

atsai3

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Where are there "freestanding" psych ER's that are not located in hospitals that also have medical ER's? Where I work there is a CPEP, which is a psych emergency room, but we are located right next to the medical ER, and we get many consults from them.
Didn't mean to imply that there were freestanding psych ER's in hospitals without med ER's. By 'freestanding' I mean a dedicated psych ER with a separate staff and separate attendings.

Whether or not the med ER calls the psych ER for consults (as opposed to the psych consult team) may differ depending on the hospital.

-AT.
 

kugel

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Just to (possibly needlessly) clarify some of the common formats for practicing emergency psychiatry:

1) treating patients in the hospital general ER. Maybe in a "single" exam room instead of "curtain 4", but still inside the main ER. The psychiatrist may be on-call to the ER, or covering all psychiatry consults to the hospital and have responsibility to the ER in addition.

2) dedicated psych ER inside a general hospital, i.e. "across the hall" from the main Emergency Dept.

3) freestanding psych ER. This one is separate from any hospital. Doesn't even come under state/fed regulations as a hospital (no EMTALA regs), and no direct access to emergency medical care for patients. There are a number of these in California, and I suspect some in other states.

4) Psych ER (Psych Emerg Service, "PES") attached to a free-standing psychiatric hospital - but no general hospital. Very much like #3 above, but can admit to inpatient facility on-site (if there are beds open). In some of these cases, facility will be under state/fed regs as a hospital (e.g. EMTALA).

There are obviously significant advantages and disadvantages to each. Some choose to practice at more than one PES in the area, thus being involved in more than one type of PES.