Psychiatry patients and solutions

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nexus73

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This article is 7 years old but seems it could have been written 20 years ago or 20 days ago. Is anything going better for ED psych patients these days? Locally the one bright spot is there are more medical boarders than psych boarders now. So we got that going for us which is nice.

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It's only gotten worse. I know an ED that has been boarding a psych patient for nearly 2 months. And I'm sure some of you have seen worse. While I'm sure that psychiatric care is underfunded and challenging, it seems that psych facilities have no incentive to improve their capabilities and can too easily foist it on to EDs with no recourse for the EDs. This is hell.
 
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We have telepsych, which often results in the patient refusing to "talk to the robot" and also doesn't help in general.

What's even more "entertaining" is that I have to take time to discuss the case with the telepsych doc. This generally ends up being them prattling on for 5 minutes with me saying "mmhmm".

Listen, psych. I don't care about his risk factors for whatever. I wanna know one thing: "Are you gonna lift the hold or not?"
 
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Psych facilities can deny whatever they want wbc count to elevated blood pressure to high.

Also psych isn’t under the control of hospitals
 
We have telepsych, which often results in the patient refusing to "talk to the robot" and also doesn't help in general.

What's even more "entertaining" is that I have to take time to discuss the case with the telepsych doc. This generally ends up being them prattling on for 5 minutes with me saying "mmhmm".

Listen, psych. I don't care about his risk factors for whatever. I wanna know one thing: "Are you gonna lift the hold or not?"
Do you find telepsych recommending admission more often than not?
 
The mental health system isn’t working because the healthcare system as a whole isn’t working. It’s probably no different or in many ways better than getting patients in to see GI or some other specialists through the ED. If you read Mount Misery by Samuel Shem published some 25+ years ago not much has changed in the mental health world
 
Do you find telepsych recommending admission more often than not?

They never. NEVER lift the hold. Even the ones where I would lift the hold, but can't or won't because I don't play those games.

They also won't shut up about the patient and why their loneliness or whatever stems from their latent attraction to their childhood friend or some other nonsense like that.
 
The mental health system isn’t working because the healthcare system as a whole isn’t working. It’s probably no different or in many ways better than getting patients in to see GI or some other specialists through the ED. If you read Mount Misery by Samuel Shem published some 25+ years ago not much has changed in the mental health world
No offense meant, serious question - Do you work in an ER? The mental health boarding problem is a whole different beast. Nothing like medical specialties. It’s sooo much worse.
 
No offense meant, serious question - Do you work in an ER? The mental health boarding problem is a whole different beast. Nothing like medical specialties. It’s sooo much worse.
I work in outpatient psych. I don’t do anything inpatient or ED these days as I know that it has become a complete nightmare. Inpatient psych in my state (FL) was trying to manage medical problems in patients with no resources
 
No offense meant, serious question - Do you work in an ER? The mental health boarding problem is a whole different beast. Nothing like medical specialties. It’s sooo much worse.

It is indeed terrible. I happen to work in a place where psych somehow has rules carved out for themselves so they don't have to respond to consults, EMTALA be darned. We do have psych beds relatively easily available but they are constantly full, so it's a near constant cycle of boarders in the ED.
 
It is indeed terrible. I happen to work in a place where psych somehow has rules carved out for themselves so they don't have to respond to consults, EMTALA be darned. We do have psych beds relatively easily available but they are constantly full, so it's a near constant cycle of boarders in the ED.
I don’t think EMTALA requires consult unless it’s to stabilize a patient. EMTALA defines a patient with a psychiatric emergency as stable once they’re in a safe space to prevent harm to self/others…like an ED room with 1:1 sitter. After that EMTALA doesn’t apply and it’s hospital bylaws that may require timely consult from psych.
 
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I don’t think EMTALA requires consult unless it’s to stabilize a patient. EMTALA defines a patient with a psychiatric emergency as stable once they’re in a safe space to prevent harm to self/others…like an ED room with 1:1 sitter. After that EMTALA doesn’t apply and it’s hospital bylaws that may require timely consult from psych.

Yeah, after some reading into it, I think you're right, and I should have better familiarity with EMTALA. See this doc page 51. I'm still very frustrated that I've been at my current job nearly 2 years and couldn't recognize my psychiatrists at all. We're working on revamping the hospital bylaws currently but it is a slow and arduous process.
 
I don’t think EMTALA requires consult unless it’s to stabilize a patient. EMTALA defines a patient with a psychiatric emergency as stable once they’re in a safe space to prevent harm to self/others…like an ED room with 1:1 sitter. After that EMTALA doesn’t apply and it’s hospital bylaws that may require timely consult from psych.
I've been given mixed interpretations of this; that EMTALA isn't done if they remain acutely suicidal / high risk...
 
I've been given mixed interpretations of this; that EMTALA isn't done if they remain acutely suicidal / high risk...
I remember a couple years ago a big health system paid a huge fine because psych patients were sitting in the ED for weeks without a psychiatrist seeing them. The fine was levied as an EMTALA violation, but legal commentary I read disagreed with the fine as an EMTALA violation and believed the hospital paid the fine because the optics were really bad and taking on the federal government in a lawsuit to prove you didn't violate EMTALA is not cheap.

The situation was interesting because the hospital had a psych unit but only took voluntary patients, so any involuntary patients just sat in the ED waiting for the state hospital, some I think as long as 6 weeks without psychiatry consulting. But it wasn't clear if it was an EMTALA violation as it was never litigated and there were opposing views. The text of EMTALA has to be stretched a long way to make this fall under EMTALA, but it seemed EMTALA was the only tool available for the feds to drop the hammer on the hospital.
 
I remember a couple years ago a big health system paid a huge fine because psych patients were sitting in the ED for weeks without a psychiatrist seeing them. The fine was levied as an EMTALA violation, but legal commentary I read disagreed with the fine as an EMTALA violation and believed the hospital paid the fine because the optics were really bad and taking on the federal government in a lawsuit to prove you didn't violate EMTALA is not cheap.

The situation was interesting because the hospital had a psych unit but only took voluntary patients, so any involuntary patients just sat in the ED waiting for the state hospital, some I think as long as 6 weeks without psychiatry consulting. But it wasn't clear if it was an EMTALA violation as it was never litigated and there were opposing views. The text of EMTALA has to be stretched a long way to make this fall under EMTALA, but it seemed EMTALA was the only tool available for the feds to drop the hammer on the hospital.
I know hospitals who have closed down their psych units altogether to avoid these issues..
 
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I don't claim to have all of the solutions, but certainly funding is a major issue. The patients boarding in your EDs are not there because some lazy psychiatrist is keeping open beds at their facility. There has been closure of psych units/facilities all over the country. The system is clogged up with chronically severely ill/homeless patients who end up being rehospitalized on a monthly basis as well as patients who are themselves boarding in psych waiting for some other placement (elderly dementia pts whose family decided to abandon them). Many psych hospitals have simply gone financially bankrupt providing charity care. Perhaps bringing back more long-term government-funded asylum-type facilities would help unclog the system.
 
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They never. NEVER lift the hold. Even the ones where I would lift the hold, but can't or won't because I don't play those games.

They also won't shut up about the patient and why their loneliness or whatever stems from their latent attraction to their childhood friend or some other nonsense like that.
That’s why my guy likes to bring in the Jordan Peterson “past authoring” stuff. No idea what it is, I know he’s controversial etc. Not endorsing it etc: just makes me laugh to see that on his notes.
 
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I don't claim to have all of the solutions, but certainly funding is a major issue. The patients boarding in your EDs are not there because some lazy psychiatrist is keeping open beds at their facility. There has been closure of psych units/facilities all over the country. The system is clogged up with chronically severely ill/homeless patients who end up being rehospitalized on a monthly basis as well as patients who are themselves boarding in psych waiting for some other placement (elderly dementia pts whose family decided to abandon them). Many psych hospitals have simply gone financially bankrupt providing charity care. Perhaps bringing back more long-term government-funded asylum-type facilities would help unclog the system.

There was a guy (not me) who said exactly this not that long ago on this forum.
Shame he's not around.
 
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It is indeed terrible. I happen to work in a place where psych somehow has rules carved out for themselves so they don't have to respond to consults, EMTALA be darned. We do have psych beds relatively easily available but they are constantly full, so it's a near constant cycle of boarders in the ED.

A lot of the arrangements with psych facilities (in our county in CA we have a "crisis center" contracted by the county to accept and help all mental health problems, and they get about $13M over three years) are not bound by EMTALA. They are not emergency departments. They are not hospitals with an emergency department. Thus they do not fall under the federal statute.
 
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