There are generally two main tasks in the ED, assessing whether or not pt needs admission and securing a safe, appropriate discharge if they dont, including documenting assessment and all the medicolegal stuff. Ironically, the easiest part is doing the Psychiatry evaluation. Disposition is the anxiety provoking mental anguish. I wonder how other folks think through discharging a psychiatrically stable patient with mild to moderate MR or some cognitive limitation to less than ideal place, like dangerous chaotic inner-city shelter.
Discharging MR patients from ED
- Thread starter Madden007
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I generally trust social work on this one, they know the ins and outs of the dispo agencies. I'd love for all of my patients to go to great, well-funded shelter/group homes/etc in the nice part of town, but the system just doesn't work that way. If you don't have money, you go to wherever the state/city/county has set up. Luckily we have some decent ones in my area. In my old job (different state), much different story. Very area specific.
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How have they functioned in previous environments? I find it really hard to predict these things based on clinical symptoms, so turning to prior history is really helpful. If you can demonstrate good reasoning why psych hospitalization will be unlikely to improve mental functioning and how their prior history demonstrates that they've been at least able to keep themselves out of imminent danger in their environment, then you're ok.
Ideally, someone has access to respite care, family, case management, ACT team, or other outpatient interventions to improve their function. You certainly should try to arrange services if possible, although the system often makes hope for better pretty dismal without a strong individual advocate (e.g. family).
Ideally, someone has access to respite care, family, case management, ACT team, or other outpatient interventions to improve their function. You certainly should try to arrange services if possible, although the system often makes hope for better pretty dismal without a strong individual advocate (e.g. family).
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This is key, especially "how have they functioned in the environment they *just* came from?" They were doing something before they got to you. If they can no longer safely maintain in whatever environment they were in before, then you should probably admit them to address that. If they can safely maintain in that environment, you should send them back to it with appropriate referrals. Arranging an optimal setup for them in the community is not a realistic goal in the ER (though if a social worker wants to try I more than welcome that!).
I find myself repeating the AA Serenity Prayer often when in the ED. My guess is that most people in chaotic, inner-city shelters would qualify for some degree of mild intellectual disability or cognitive impairment, but we can't take on that responsibility. We just need to have the wisdom to tell situations we can change and those we can't.
On one end of the spectrum, you have those who say the ED is purely for acute stabilization of treatable psychiatric conditions (or an easy paycheck), and on the other end you have people who feel an intense urge to fix any psychosocial problem they come across. If you're too far down one end, you'll miss opportunities to make a significant difference in a patient's life (even if those opportunities are not technically psychiatric interventions) and if you drift too far down the other end you just end up reenforcing the patient's institutional dependence. Either situation seems to promote burnout, as you inevitably feel your job is pointless.
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It may be a little of both, but "I was hearing voices or feeling suicidal because of how I was treated at the shelter so I came to the hospital" is a demonstration of function.
H
HarryMTieboutMD
Our hospital policy is that in order to be admitted to psychiatry a patient’s presentation must include a psychiatric illness with a symptom that significantly impairs the patient’s ability to function or possesses a likelihood of serious harm to himself/herself or others and CANNOT be solely due either a neurocognitive illness (dementia) or neurodevelopmental disorder (ID, ASD). Of course we get a lot of these consults in the ED/from other services but it's purely a dispo issue that social work can figure out.
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We have an inpatient child and an inpatient adult unit dedicated specifically to ID and ASD so unfortunately we do not have this luxury. This unit is perpetually full and so these folks often end up admitted temporarily to other units on CO/1:1 waiting for a bed to open up on the appropriate floor.
This goes just as well as you'd expect.
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We have a huge housing shortage in large parts of the country, so people are living in less than ideal situations or becoming homeless *all the time*. This is a problem that can only be solved at the societal level, and you certainly aren't going to fix it on the night shift at your local ED. Do your best and try not to become too cynical too quickly.
