How are psych patients handled in community EDs?

[bonez318ti]

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For those smaller community shops without a psych ED or psych MD on call, how do you handle and dispo the range of psych patients? Anything ranging from:

depression (do you clear and discharge if no HI/SI? or hold them till the next morning for psych eval?)
SI (1:1 and psych in the AM, would you ever clear them?)
suicide attempt (treat/stabilize, transfer vs. psych in the AM? ever admit to medicine because you cant find anyone to take them b/c all psych beds are full?)
frank manic episode (sedation? transfer? psych consult in AM?)
psychosis (same as above?)

have you ever felt it necessary to write psych med refills?

 

[docB]

Let me begin by noting that the psych system in Vegas is the worst that I have ever seen or heard about. You probably think that I'm exaggerating. I'll try to dispel that notion by saying that I've been through about 6 rounds of various forms of consulting for EMRs, throughput and other worthy causes. Every consultant thought we were exaggerating. Then they had to redesign everything they had previously set up to deal with our psych system.

We have little to offer any patient in terms of psych services. Unless they meet criteria for a legal hold we refer them out. Criteria for a hold are dangerous to self or others or so psychotic that they can't care for themselves.

If you meet criteria you are "medically cleared" which is done in an ED for every patient in the region even if they present to a psychiatric facility. If they present to Las Vegas Mental Health (actually the Southern Nevada Adult Mental Health clinic) an ambulance will be called and they will be sent to an ED.

These patient will then be held in the ED under the care of EPs. SNAMH will send "evaluators" out to assess the patients sometime in the next few days. These are clinical social workers, not psychiatrists. If deemed to not meet criteria for inpatient care these social workers "recommend" that the EPs discharge the patients. We then have to let them go but are still liable if this goes bad.

If the patient is deemed to need inpatient care they are held, in the ED under the care of EPs until a bed opens up at the psych hospital. That can take days to weeks.

The astute among you will be thinking "How do they hold people indefinitely? Aren't the initial holds only good for 72 hours?" Right you are. Our system is so bad we routinely (every other day) have notaries come into the ED and have EPs sign court petitions to have these patient involuntarily committed just to buy the time it takes to find a place for them.

 

[squad41]

I completed my school required EM rotation at a shop that had an interesting circumstance in that they were a Level 1 but without residents and also in a decently small town. At any rate, my experience was very, very similar to docB's. We would get these patients all the time for 'medical clearance,' which perhaps docB or someone can explain to me, as I never really got what exactly we were supposed to do with that. Am I supposed to work them up like a sports physical to be 'cleared?" Rule out medically induced causes? Never saw anyone held for days waiting for the 'evaluator' to come see if they meet criteria, but 12+ hours was not uncommon, especially when the patient presented at an odd hour. It was also somewhat annoying that they would refuse to see any of these pts if etoh was on board, which frequently added more time they were in the ED waiting to be seen.

 

[dchristismi]

We are a psychiatric receiving facility, so we have a better system. But it is far from ideal.

Person shows up with whatever psychiatric complaint. ED doc sees them, determines if they have a medical issue and deals with any medical issues. (ie, is this person really just depressed and suicidal? Or is there an overdose that needs to be dealt with? Or is the suicidality in someone with no psych history due to a frontal lobe tumor? Do we know this person? It is a frequent flier that we can "clear" without a workup, or is it someone we don't know who does need a workup? And even if we do know them, do they have something else going on? Homeless "suicidal" dude with pneumonia who really needs a medical admit? Even the crazy get sick sometimes.)

When we decide they don't have a medical issue, we call our counselors, who are available 24/7, they call the on-call psychiatrist after interviewing the patient, and they manage the disposition.

Do they still sit in the department for eons? Sometimes. Is it better than what DocB has? Hell yes.

If the counselor/psychiatrist determine that the patient is "safe" to go home, it's their asses on the line. Very rarely do these folks leave, especially if they are under the Baker Act, which is Florida's law defining the 72 hour hold. Occasionally I will lift one, especially if it was a really dumb call by law enforcement, but this is pretty rare.

 

[Arcan57]

I'm much like DocB's system except our wait times are significantly better.

Depression/anxiety without SI/HI/psychosis gets referred out (with option to stay for psychiatric social worker (PSW) if desired, rarely taken).

Danger to self/other/unable to care for self gets worked up for medical comorbidities and once cleared the psych social worker is called. If the patient is amenable then they are seen by video conference (takes around 3-6 hrs to initiate). If the patient is uncooperative or too psychotic to communicate over video chat then the PSW drives to our hospital. There are a relatively small number and Houston is a huge city so drive times between hospital are substantial. This takes anywhere from 4-12 hrs to get their assessment. If they think the patient is ok for referral, they discuss it with the ED doc and we coordinate dispo. In general, disagreements tend to crop up only in cases where the patient changed their story (endorsed suicidality to us and repented after the wait) and we're given the benefit of the doubt in terms of dispo.

Once the evaluation by the PSW has occurred and the patient needs to stay the work begins on finding a facility to take the patient. This involves the PSW calling every facility in the city they think might take the patient and having the EP fill out 7-9 exclusionary forms (with around 20 questions each) to make sure we're not trying to dump something they can't handle (wound care, WBC >14, severe MR, pregnancy, etc) on them.

Once a facility is located, there is a doc-to-doc conversation between the EP and the psychiatrist who accepts the patient. This conversation never involves the EP who initially evaluated the patient unless they pick them up again on their next shift (happens but uncommon). Then an ambulance is called and the patient is transported.

Interestingly, having the psychiatrist evaluate the patient in the ED and approve for transfer to a facility for which he has admitting privileges doesn't actually speed things up since the system is not set up to allow anyone but the PSWs to talk to the receiving facility about acceptance.

The whole process usually takes ~10hrs with outliers in the 24-30hr range for pregnant psych or dual diagnosis players. The major downside is that we have to pull our sitters from our tech pool so on days when we're holding 3 or more our phlebotomy and dispo to depart (admitted) times skyrocket.

 

[docB]

I completed my school required EM rotation at a shop that had an interesting circumstance in that they were a Level 1 but without residents and also in a decently small town. At any rate, my experience was very, very similar to docB's. We would get these patients all the time for 'medical clearance,' which perhaps docB or someone can explain to me, as I never really got what exactly we were supposed to do with that. Am I supposed to work them up like a sports physical to be 'cleared?" Rule out medically induced causes? Never saw anyone held for days waiting for the 'evaluator' to come see if they meet criteria, but 12+ hours was not uncommon, especially when the patient presented at an odd hour. It was also somewhat annoying that they would refuse to see any of these pts if etoh was on board, which frequently added more time they were in the ED waiting to be seen.

I have a tendency to rant. This is not a rant. Pure fact. Ahem...

The concept of "medical clearance" evolved as an answer to a real problem. Delirious patients would be placed in jails or psych wards and then would die of their unrecognized strokes or hypoglycemia. To fix this real problem a system was created where psych patients had to be "medically cleared." Many states (including mine) went as far as to codify this process in law.

This process, created to address a real problem quickly caused many unintended, bad consequences (similar to EMTALA, Core Measures, etc.). Psych patients now crowded EDs. Psych facilities could cherry pick patients out of the EDs leaving hospitals with the burden of caring for uninsured psych patients. Psych facilities could demand various diagnostic studies prior to transfer shifting that cost from themselves to the hospitals.

The system many of us have now is very popular with psych facilities. No so much with hospitals and EDs.

 

[nancysinatra]

I'm in psych and I have no trouble believing the worst of these stories. My worst experience in all of residency was consults, because we'd have to explain to the other services why a medically stable patient might have to wait on their service for up to 12 days in some cases. There just are no beds a lot of the time. Same is basically true in the ER.

The medical clearance thing is complicated. Some of the stuff the psych hospitals demand is just plain ridiculous. On the other hand there are some scary situations that arise in psych hospitals. I just started moonlighting at a stand alone psych place, where people come in and there's no real triage (just a nurse who takes their vitals and CC), and they wait for hours to be seen by me or a telepsych doc. Well lo and behold, a certain percentage of these patients are actually arriving with chest pain, fevers, and other non psychiatric stuff. One lady came in with a 3rd degree burn all over her hand. I've seen more "focal" neuro exams in the last month than in the 3 previous years of residency. Last week I had a guy almost non-responsive in the waiting area who had OD'd on benzos and vicodin. When the nurse saw him he was walking around but by the time I saw him the drug levels must have been peaking and he wouldn't wake up. I must say it takes a special kind of patient or family member to drag themselves or loved on to a PSYCH facility when they have a medical problem.

So I can understand why some states would want people "cleared" first. Not that I wouldn't like to deal with some of the simple medicine myself but when you're the only doctor in a completely full psych hospital overnight you would never have the time.

 

[EctopicFetus]

We have it pretty nice. I work at 3 places.

We have a company called who sends out their MH counselors and they assess the patient. If they think they can go home and the ED doc thinks so too we DC them.

If they are a hold they try to get a bed. If they cant get them to a psych facility then we admit them to obs. This prevents constipation of the ED. Its a great system cause I used to hate writing for Seroquel and other psych meds for patients in the ED.

 

[Birdstrike]

In know some hospitals where the psych holds are especially long, have figured out it costs more to hold an uninsured psych than a psych admission at an outside psych hospital costs.

So, what do they do?

Literally, pay for the patient's admission to a psych hospital so they can transfer them and take less of a loss.

 

[docB]

In know some hospitals where the psych holds are especially long, have figured out it costs more to hold an uninsured psych than a psych admission at an outside psych hospital costs.

So, what do they do?

Literally, pay for the patient's admission to a psych hospital so they can transfer them and take less of a loss.

This is what I have advocated in my area. Our public/indigent mental health service is so bad that I think we should contract with a private facility and send the patients there. For example we routinely spend more than >$250 to hold a psych patient for 3 days. If we paid a private facility that $250 and sent the patient out immediately we'd save money, the patient would be in an appropriate facility and the public facility would either die out or get better.

 

[la gringa]

For those smaller community shops without a psych ED or psych MD on call, how do you handle and dispo the range of psych patients? Anything ranging from:

depression (do you clear and discharge if no HI/SI? or hold them till the next morning for psych eval?)
SI (1:1 and psych in the AM, would you ever clear them?)
suicide attempt (treat/stabilize, transfer vs. psych in the AM? ever admit to medicine because you cant find anyone to take them b/c all psych beds are full?)
frank manic episode (sedation? transfer? psych consult in AM?)
psychosis (same as above?)

have you ever felt it necessary to write psych med refills?

in a word: VERY POORLY

i have had it as good as in-house psych and on-site SW's to do evals (though i occasionally had to go over them if i wasn't comfortable dcing someone)

residency at a county hospital - at least a 2-3 day wait, worse if going to the county psych hospital

current gig - very variable. if you are a newer psych pt with no major comorbidities, insured, and not dual diagnosis... several hours after psych has seen them by the skype TV thing we use... done roughly 0830-2200 only.

they make med recommendations, usually reasonable.

add in dialysis, dual dx, methadone... increasingly hard. i've seen people held up to a WEEK in an ED room, in a gown, being watched 24/7. if you weren't psychotic already, you will be after a week in an 8x8 room...

 

[deleted109597]

in a word: VERY POORLY

That's two words, but I agree.
Identify pathology. Consult mobile crisis (or whatever psych is called in your neck of the woods). Involve magistrate/justice of peace invariably. Wait. Have psych refuse transfer until you treat K of 3.4, trace leuk esterase, or some other completely unrelated item.

Heaven forbid it be pediatric psych. I've seen wait times in the weeks for them. Imagine living in an ED for 2 solid weeks. As a teenager. With psych problems.

 

[deleted65604]

At my old job, we had a psych unit upstairs. If they said the S word, I admitted them (serving them the papers of involuntary commitment if they put up a fuss). They would hold them usually for just 12-24 hours until they talked them out of saying the S word. In three years of working there, I never saw a counsellor or psychiatrist in the department.

Currently, if a patient says the S word, we call these people called mental health examiners. I'm not sure what exactly their training is, but about 30% of the time, they send the patient home, 30% of the time, they get sent to a magical place called "psych triage"(sounds like where they should go in the first place rather than my ER), and about 30% of the time, they arrange for a bed for them somewhere which usually takes 12-24 hours. If it looks like they aren't going to get a bed soon, we admit them to medicine to literally baby-sit.

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.

 

[docB]

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.

I agree with this. I rarely have people I think are real risks.

I had a guy a few months back who was a real risk. 60, male, vet, medical problems, no family. Came in because a neighbor called police because the guy was acting weird and giving all his stuff away. He had access to guns. He admitted he was depressed and had thought about suicide but he wouldn't say too much. THAT is a suicide risk. Those are so rare I remember him months down the road. I've seen ~50 psych patients since him.