Variations in Practice / The Suicidal ED Patient

[FlowRate]

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Patient comes in, chief complaint is suicidal ideation, according to the ED, and you're asked to consult.

What sort of patients do you end up sending home (or to other not-inpatient levels of care) overnight?

I'd find this interesting both in the case of residents (and their perceptions of what their overnight attendings will allow) and attendings (who may not be overnight, but have indepedent ability to dispo.)

Some semi-fictional examples from my current practice location:

Mid 20's patient with mild depression and some suicidal ideation without plan or intent, no prior attempts, modest life stress, and with good social supports. Either has a psychiatrist/therapist or is willing to attend a partial hospital or intensive outpatient program. Reliable-seeming collateral (girlfriend, parents) isn't worried about patient and is able to keep an eye on them for a couple days. This is the most straightforward overnight discharge.

30-something patient w/ borderline PD overdosed on one or two pills of something or says they're more suicidal tonight; well known to the department (no serious prior attempts, hospitalization not usually helpful, has psychiatrist/therapist), and at their usual chronic level of SI. If it's a super frequent person who we know very well, I might be able to discharge home overnight (if that's what the patient wants, they stop saying they're suicidal, and I get the right overnight attending), but often ends up being held to be staffed by an attending in the morning, who will likely discharge.

40-something homeless patient who seems to be more interested in sleep and sandwiches than a psychiatric interview who says they want to kill themselves (affect-incongruent). Not previously known to the department. Likely on a hold until morning at least, sometimes starting inpt bed search (depending on level of suspicion for whether or not they'll want to leave in the morning and how convinced you are that they're actually depressed/suicidal, because homelessness does suck...)

I'm obviously not saying any of these are the right ways of doing things. (In fact, I generally feel like we're far too "conservative" here.) I probably haven't perfectly characterized what the attendings at this particular hospital prefer us to do overnight. But hopefully this is enough to start a discussion.

 

[bashir]

We do not have a culture of holding people overnight just so an attending can lay eyes on them in the morning, a fact which it never occurred to me to be grateful for before. I would find it extremely frustrating to see someone at 3am if disposition would not be determined until a more reasonable hour anyway.

Certainly some attendings are more conservative and harder to talk into discharge, but by and large we get to exercise our clinical judgment and they go along with our plan as long as we can justify it.

 

[FlowRate]

We do not have a culture of holding people overnight just so an attending can lay eyes on them in the morning,

I may have given the wrong impression regarding that particular point. We never hold someone just to be seen by an attending. Usually it's that the patient isn't giving us what we need to be able to justify a discharge decision. Said patients often change their tune in the morning and then are seen by an attending.

Part of what I'm trying to get at with this thread is "how much" you need in order to justify that decision (to yourself, to your attendings.) Collateral? Partial/Outpt appointment within the next couple of days? etc. How "suicidal" can the patient be to leave?

 

[clausewitz2]

Patient comes in, chief complaint is suicidal ideation, according to the ED, and you're asked to consult.

What sort of patients do you end up sending home (or to other not-inpatient levels of care) overnight?

I'd find this interesting both in the case of residents (and their perceptions of what their overnight attendings will allow) and attendings (who may not be overnight, but have indepedent ability to dispo.)

Some semi-fictional examples from my current practice location:

Mid 20's patient with mild depression and some suicidal ideation without plan or intent, no prior attempts, modest life stress, and with good social supports. Either has a psychiatrist/therapist or is willing to attend a partial hospital or intensive outpatient program. Reliable-seeming collateral (girlfriend, parents) isn't worried about patient and is able to keep an eye on them for a couple days. This is the most straightforward overnight discharge.

30-something patient w/ borderline PD overdosed on one or two pills of something or says they're more suicidal tonight; well known to the department (no serious prior attempts, hospitalization not usually helpful, has psychiatrist/therapist), and at their usual chronic level of SI. If it's a super frequent person who we know very well, I might be able to discharge home overnight (if that's what the patient wants, they stop saying they're suicidal, and I get the right overnight attending), but often ends up being held to be staffed by an attending in the morning, who will likely discharge.

40-something homeless patient who seems to be more interested in sleep and sandwiches than a psychiatric interview who says they want to kill themselves (affect-incongruent). Not previously known to the department. Likely on a hold until morning at least, sometimes starting inpt bed search (depending on level of suspicion for whether or not they'll want to leave in the morning and how convinced you are that they're actually depressed/suicidal, because homelessness does suck...)

I'm obviously not saying any of these are the right ways of doing things. (In fact, I generally feel like we're far too "conservative" here.) I probably haven't perfectly characterized what the attendings at this particular hospital prefer us to do overnight. But hopefully this is enough to start a discussion.

So our set up is a little different in the sense that we have a freestanding psych emergency evaluation center and are not typically seeing people in a medical ED (if they are not going to be admitted inpatient, the Major Academic Medical Center across the street just ships them over to us). Weekday overnights also have an in house attending starting at 1 AM, and the attending who does this is basically a vampire and has only been working overnights in this particular setting for more than a decade. On nights when he is not working, we of course have attendings available via phone, but since we get 3 months of doing this work with copious overnights as interns, by 2nd year the majority of overnight attendings are comfortable only being called if we have a discharge that we don't feel confident about. We also have the great advantage of a short-term crisis center in our system that we can put people in a cab and send them to not very far away, so we have a level of disposition between "inpatient" and "the street". It is also typically our practice to allow crackicidal individuals to sleep it off in an open seclusion room for 10 hours, at which time they wake up and generally are mostly interested in bus tickets.


Our very frequent fliers fall into two categories: 1) obviously malingering homeless folks, who if intoxicated are allowed to sleep it off as long as they don't do this too often, and otherwise we are very liberal with bus tickets and b) very, very, very poorly regulated people with BPD and truly epic histories of hospitalization. Our system as a whole has complex care plans in place for these later, and strenuous efforts are made to divert them. Generally suicidality without a clear plan will not get these folks admitted. If they do things to escalate beyond the point at which we can divert (like, say, being discharged, going to a bridge, and then calling the police to be brought back again), there are plans in place to admit folks with complex care plans to the service of very specific attendings on a consistent basis with the clear expectation that they will be discharged within a day or two of admission. In our area our version of ACT also takes on a fair number of people with problems mostly surrounding personality organization, which is very much a mixed bag in terms of results but does mean that the high utilizers have an on-call team that knows them well, will present when they do, and is often comfortable saying "this is baseline, we will be seeing them tomorrow, we would be opposed to admission", which makes everyone else feel better sending them out.

Gets trickier with kids. If they are saying they are suicidal and are not known to our system, they are probably coming in. If they have been admitted multiple times, the standard increases.

Of your example patients, first one, agreed, easy discharge. Second patient would also be discharged, even if they are saying they are suicidal if they can't articulate why this is different from the last eight times they have been admitted and can't identify clear goals for an admission. Third patient we punt to our crisis center.

I think sometimes we are a bit cavalier, but on the whole I think it works well. This is no longer really reflected in our inpatient census, unfortunately, because our sprawling regional hospital system has had the bright idea of direct admissions from remote outlying hospitals, where unsurprisingly the MSWs assessing the need for inpatient admission have vastly lower risk tolerance and so they get a bed here that they would never have received if they had come through our evaluation center.

 

[MedMan80]

At my old program most patients fell into #3 and our culture was to very much hold until next morning, by which many had "cleared up" enough to go home. We never had enough resources to send to other levels of care apart from outpatient (maybe the odd referral to rehab), vs admission. You have to carefully balance protective factors vs. risk factors, and like you mentioned some attendings were more careful than others. One attending we had would hold the patient as soon as he heard the word suicide, or heard the word impulsive..IMO 3 years of experience in our crisis center made me believe that the riskiest patients were those who were medically compromised (polysubstance withdrawal mixed in with chronic medical issues that were decompensated) than anything.

 

[Onions]

This is no longer really reflected in our inpatient census, unfortunately, because our sprawling regional hospital system has had the bright idea of direct admissions from remote outlying hospitals, where unsurprisingly the MSWs assessing the need for inpatient admission have vastly lower risk tolerance and so they get a bed here that they would never have received if they had come through our evaluation center.

Exactly this practice has brought to my own door even involuntary admissions that should never have even been offered an inpatient level of care. I can recall one woman in particular who was admitted for paranoid delusions and "disorganization" (God, I love that word...) and when she got to our facility, it turned out, yes, her husband actually is abusive, manipulative, and stalking her, confirmed with aggressive gathering of collateral information. This patient was herself a social worker whose employment was through the military, and she had very legitimate concerns about what involuntary paperwork with her name on it could mean for her own career.

We are set up with 4 beds (with all monitors and oxygen tanks removed) in our academic medical center's ED. This is by no means a "psychiatric ED;" the beds are separated by curtains. There is no seclusion room. We are officially a "co-located" consult service in the emergency department. This, believe it or not, is a much safer arrangement than we had a year ago, which was not much more than a resident and a clerk sitting by the door of our psych hospital, waiting for walk-ins. At least now there are staff present to help out when things get out of hand. There is, in theory at least, an attending available in person or over the phone at all times who signs off on all the dispositions.

So what happens is, our patients are not out patients as long as they're in the ED; we're just "consulting" on them, which means the ED wants them out as fast as possible to maintain their stats. This eliminates the option of holding people overnight, because the ED attendings' attitude is, well, do they need admission or not? I can usually bargain with them for 6am, knowing that I'll get my way in the end because I guess clinicians who are used to working odd hours (ED physicians) easily forget that no one at DSS is going to answer the phone until 9am at the earliest.

But in general, we try to put readmission reduction plans in place for high utilizers. One of our most interesting cases was a transgender male>female in her 60's living somewhere in the gray area between factitious illness and malingering who had recently been discharged from a 3 month hospitalization wherein she had prolonged her stay by blackmail with continued suicidal threats, with the trump card of one or two serious suicide attempts in the past. She came in again (at 2am, the strategic night-time presentation to a facility with no CPEP) with the same complaint "I'm hearing voices telling me to kill myself." Her basic MO, as with most malingerers, was manipulation and restriction of the flow of information: she never disclosed details about herself, and one time even told me "I can't remember" when I asked her where she grew up. Thing with this patient is, she's going to die prematurely, but probably not of suicide. She has an ejection fraction of like 20%, and had been well known (and not well liked) by our cardiology department, who had gotten quite sick of seeing her come in with serious cardiac complaints and then refuse testing/interventions. Maybe that is suicide anyway (separate discussion). As my PD concluded about her: "this is probably end-stage." I did end up discharging her the following morning, as we were able to mobilize her readmission reduction plan in the light of day.

I will discharge patients if, for example, their outpatient support is robust and their suicidality is vague, or if they self-aborted. I might have been too cavalier at times; I recall one young man who had prepared to hang himself, but changed his mind before obtaining a rope. He had recent and upcoming appointments with his psychiatrist and therapist, and came in with a close friend who was willing to keep a close watch on him. I sent him home that night, after working out all manner of safety planning with him, and he came back two weeks later, this time almost having actually hanged himself. I nevertheless try not to let experiences like this give me a hair trigger; the flip side was a young borderline fellow who had been admitted for a serious suicide attempt, transferred to internal medicine when he developed rhabdomyolysis just before he was supposed to be discharged to a PHP, and then readmitted by my C/L attending who felt that "he is just too high-risk." Seems to me like that logic should have him locked away on the unit for the rest of his life...

 

[cara susanna]

What's interesting is that research suggests hospitalization is not effective for actually improving suicidality and, IIRC, some research has even suggested that it may make things worse.

 

[clausewitz2]

What's interesting is that research suggests hospitalization is not effective for actually improving suicidality and, IIRC, some research has even suggested that it may make things worse.

Absolutely. And when the legal system decides to take empirical evidence into account on this topic, I would gladly change our practice. As is, there is an expectation that suicidality should lead to hospitalization and failure to do this leaves one open to a very easy lawsuit without very careful consideration.

EDIT: In my ideal world where no one cared about lawyers, I think there are a few, very narrow categories of people who would ever be eligible for an involuntary commitment, and just plain feeling suicidal or even possibly planning suicide is not one of them. But that world is unlikely to ever be.

 

[cara susanna]

Absolutely. And when the legal system decides to take empirical evidence into account on this topic, I would gladly change our practice. As is, there is an expectation that suicidality should lead to hospitalization and failure to do this leaves one open to a very easy lawsuit without very careful consideration.

EDIT: In my ideal world where no one cared about lawyers, I think there are a few, very narrow categories of people who would ever be eligible for an involuntary commitment, and just plain feeling suicidal or even possibly planning suicide is not one of them. But that world is unlikely to ever be.

Oh, yes, I completely agree. Unfortunately, the system requires us to pursue actions that are not only suggested to be ineffective, but may even be harmful in terms of reinforcing suicidal behavior. I find it very frustrating.

 

[Onions]

I think there are a few, very narrow categories of people who would ever be eligible for an involuntary commitment

I completely agree, and JFK's push for deinstitutionalization ideally would have accomplished this. But in 2018, the concept of "community mental healthcare" is still a flimsy panache, endorsed by lawmakers who have no corresponding interest in resource allocation.

 

[DisorderedDoc417]

Patient comes in, chief complaint is suicidal ideation, according to the ED, and you're asked to consult.

What sort of patients do you end up sending home (or to other not-inpatient levels of care) overnight?

I'd find this interesting both in the case of residents (and their perceptions of what their overnight attendings will allow) and attendings (who may not be overnight, but have indepedent ability to dispo.)

Some semi-fictional examples from my current practice location:

Mid 20's patient with mild depression and some suicidal ideation without plan or intent, no prior attempts, modest life stress, and with good social supports. Either has a psychiatrist/therapist or is willing to attend a partial hospital or intensive outpatient program. Reliable-seeming collateral (girlfriend, parents) isn't worried about patient and is able to keep an eye on them for a couple days. This is the most straightforward overnight discharge.

30-something patient w/ borderline PD overdosed on one or two pills of something or says they're more suicidal tonight; well known to the department (no serious prior attempts, hospitalization not usually helpful, has psychiatrist/therapist), and at their usual chronic level of SI. If it's a super frequent person who we know very well, I might be able to discharge home overnight (if that's what the patient wants, they stop saying they're suicidal, and I get the right overnight attending), but often ends up being held to be staffed by an attending in the morning, who will likely discharge.

40-something homeless patient who seems to be more interested in sleep and sandwiches than a psychiatric interview who says they want to kill themselves (affect-incongruent). Not previously known to the department. Likely on a hold until morning at least, sometimes starting inpt bed search (depending on level of suspicion for whether or not they'll want to leave in the morning and how convinced you are that they're actually depressed/suicidal, because homelessness does suck...)

I'm obviously not saying any of these are the right ways of doing things. (In fact, I generally feel like we're far too "conservative" here.) I probably haven't perfectly characterized what the attendings at this particular hospital prefer us to do overnight. But hopefully this is enough to start a discussion.

Before any of the above happens the ED docs have placed the patient on a MH hold and we’re stuck with taking them or they go to jail.

 

[clausewitz2]

I completely agree, and JFK's push for deinstitutionalization ideally would have accomplished this. But in 2018, the concept of "community mental healthcare" is still a flimsy panache, endorsed by lawmakers who have no corresponding interest in resource allocation.

Yeah, I think forcing "treatment" on people in most cases where we end up doing it is a terrible idea regardless of the availability of mental health resources.

 

[clausewitz2]

Before any of the above happens the ED docs have placed the patient on a MH hold and we’re stuck with taking them or they go to jail.

Wait, ED docs in your state can send people to jail?

 

[splik]

Wait, ED docs in your state can send people to jail?

not sure of the specifics above but in certain places psych patients from the ED are put in jail because there is nowhere else for them e.g. Mentally ill? Go directly to jail

we live in a weird twilight zone where we criminalize mental illness and medicalize criminality.

 

[Armadillos]

not sure of the specifics above but in certain places psych patients from the ED are put in jail because there is nowhere else for them e.g. Mentally ill? Go directly to jail

we live in a weird twilight zone where we criminalize mental illness and medicalize criminality.

WTF that is insane that they are dumping these patients to the jail. Isn’t that an EMTALA violation? I would not practice medicine in a state allowing this (granted lack of decent doctors may be part of the problem in the first place).

 

[michaelrack]

WTF that is insane that they are dumping these patients to the jail. Isn’t that an EMTALA violation? I would not practice medicine in a state allowing this (granted lack of decent doctors may be part of the problem in the first place).

If it is done as part of the commitment process (ie under court order), it should be ok as far as EMTALA

 

[clausewitz2]

not sure of the specifics above but in certain places psych patients from the ED are put in jail because there is nowhere else for them e.g. Mentally ill? Go directly to jail

we live in a weird twilight zone where we criminalize mental illness and medicalize criminality.

Wow..."disgusting" is really the only word I can think of.

 

[NickNaylor]

Most of the attendings who work overnight in our PED tend to be quite conservative. If someone presents at 9-10pm and has a clear history of malingering, they will simply be “observed” overnight and discharged in the morning.

I agree with @clausewitz2’s breakdown as that tends to be how I approached things at, e.g., my PED moonlighting gig, where there was no attending to check-out to.

Category #1: SI in the setting of acute or very recent (24-48 hours) intoxication. I would typically observe overnight and, if improved, discharge the following morning. 99% of people would be able to be discharged unless they were crashing from a stimulant binge which might leave them too sedated to safely discharge. They would typically be able to be discharged after an additional 24 hours. Refer for outpatient substance treatment (most people refuse).

Category #2: SI in the setting of a chronic history of malingering. Unless their presentation is markedly different than usual, I ask them if there’s anything they need from me and they are immediately discharged. I try to identify what they are trying to achieve by presentation - often housing, respite, medication refills - and discuss with them the more appropriate setting to pursue those resources. At my moonlighting gig, this would happen before they even got into the PED. Refer for outpatient treatment (which they inevitably never follow-up with).

Category #3: SI in the setting of a non-substance-related illness or someone with no known history. I’m typically most conservative with this kind of patient. Even if a UDS is positive for a substance which might explain the presentation and/or they admit to substance use, I would still observe for 24-48 hours. If they improve, great - discharge with outpatient follow-up and substance treatment referrals. That is probably the most common outcome for new patients with substance-related complaints. For patients without any significant history and with no evidence of substance-related complaints, I will almost always observe overnight and see how they do. Might recommend inpatient admission or some other intervention depending on how things go.

Of course, this is speaking in very broad generalities and other aspects of the history would obviously play a role, but as a general rule that’s my approach with these types of patients.

 

[DisorderedDoc417]

Wow..."disgusting" is really the only word I can think of.

I should state that 99 times out of 100, the patient is brought in. We of course don’t want anyone in jail with mental illness. Once in a while though, a jerk with ASPD gets put on a hold and if it is just the right circumstances they rightly go to jail.

 

[clausewitz2]

I should state that 99 times out of 100, the patient is brought in. We of course don’t want anyone in jail with mental illness. Once in a while though, a jerk with ASPD gets put on a hold and if it is just the right circumstances they rightly go to jail.

In this state if the police petition an involuntary commitment and after our assessment we feel like they don't need to be in a hospital, we send them home.

I am horrified that a psychiatrist evaluation of some kind is overridden by someone from EM placing a hold such that you guys are unable to discharge them.

 

[calvnandhobbs68]

In this state if the police petition an involuntary commitment and after our assessment we feel like they don't need to be in a hospital, we send them home.

I am horrified that a psychiatrist evaluation of some kind is overridden by someone from EM placing a hold such that you guys are unable to discharge them.

Right. And how can you "bring them in" if the beds are full (which is what the news report is saying)? The point at the end of that article is spot on. Would you want to go to that hospital ED for help if there's a chance you'll be involuntarily committed by some ED doctor and tossed in jail for a night?? And do they toss their medicine patients in jail if they have a bed shortage? Wtf.

 

[DisorderedDoc417]

Right. And how can you "bring them in" if the beds are full (which is what the news report is saying)? The point at the end of that article is spot on. Would you want to go to that hospital ED for help if there's a chance you'll be involuntarily committed by some ED doctor and tossed in jail for a night?? And do they toss their medicine patients in jail if they have a bed shortage? Wtf.

Frankly, it is never the case that there is a bed shortage here. The First year resident sometimes admits as many as 30 patients on their weekend and it still doesn’t fill. We get a lot of traffic but the system moves patients quickly as it gives all the benefit of the doubt to the citizen. Some states are not this way, obviously. I agree with and appreciate what the above people are saying but the people who end up in jail have no discernible mental illness acutely contributing to their presentation on eval. I am thinking of the 35 yo male who is on his 7th admission of the year by the month of March and caused 10s of thousands in damage as well as hurting another patient the last time he is here. That person might end up in jail upon eval.

 

[AD04]

I am thinking of the 35 yo male who is on his 7th admission of the year by the month of March and caused 10s of thousands in damage as well as hurting another patient the last time he is here. That person might end up in jail upon eval.

That's interesting. When does it stop being a mental health issue and more of a criminal issue? I can only recall of one attending who called the cops on a patient while the patient was in the inpatient psychiatric unit. This patient was a frequent flyer and would physically threaten residents and attendings. After the cops paid him a visit, he never threatened again.

 

[DisorderedDoc417]

That's interesting. When does it stop being a mental health issue and more of a criminal issue? I can only recall of one attending who called the cops on a patient while the patient was in the inpatient psychiatric unit. This patient was a frequent flyer and would physically threaten residents and attendings. After the cops paid him a visit, he never threatened again.

I think what you highlight above is exactly that. Justice should be blind to Criminality, even in the presence of mental illness unless it meets the incredible burden of NGRI/GBMI situations.

 

[nancysinatra]

the people who end up in jail have no discernible mental illness acutely contributing to their presentation on eval.

Are you saying that people get sent from your ED to jail because they did something criminal while in the ED? Or are you saying they are brought to the ED by police, under a police initiated mental health hold of some kind, and then, if there are no inpatient beds for them, they go to jail because that is the process in your state?

Isn't that unconstitutional? Don't people need to be arrested before they are sent to jail? Can't arrests only be made if there is a legal, constitutional justification for doing so? If the reason the police put them on a hold was mental health related, then they are in your ED for mental health reasons. That's different from being under arrest! Unless they also do something in the ED that warrants calling the police, I cannot understand why they'd be sent to jail. Even if they are antisocial. Being antisocial is not in and of itself a crime.

 

[enoughsaid12]

Psychiatric Hospitalization, like on the medicine side, is meant for acute stabailization. An analogy is the diabetic in DKA. You close the anion gap, get the sugars down, and then discharged. You aren’t going to cure their diabetes, that isn’t the point. I would argue most “SI” patients really only neeed 1-2 days in the hospital. You get them through the moment or crisis. Mitigate risk (ie get rid of guns, sober them up, get a family member at bedside, and get them outpatient follow up) and get them out. In fact, often times this can be done with an overnight stay in the ED. There is nothing inherently therapeutic about the psych hospital. Other than safety it really provides very little. This all seems intuitive but it seems to be forgotten often. 90 percent of patients can probably avoid hospitalization if EDs had more resources.

 

[nancysinatra]

I can recall one woman in particular who was admitted for paranoid delusions and "disorganization" (God, I love that word...) and when she got to our facility, it turned out, yes, her husband actually is abusive, manipulative, and stalking her, confirmed with aggressive gathering of collateral information. This patient was herself a social worker whose employment was through the military, and she had very legitimate concerns about what involuntary paperwork with her name on it could mean for her own career.

I think this scenario/issue needs to be better addressed within our field. It amounts to false imprisonment, but I've never heard of a case where anyone got prosecuted for that. There's also character defamation involved in a way, since that person now has (an unwarranted) involuntary commitment on their record, and yes, it will probably result in them getting fired from the military, in this case. Good luck getting the courts to overturn that or do anything else to remedy it.

I know we all tend to be a lot more worried about the reverse situation - not hospitalizing someone who does need it - vs the situation where you commit someone using information that later turns out to be false, but I wish this were not the case. I'm currently working part time in a state where the commitment laws happen to place more emphasis on liberty than most other states, and, at least philosophically, I'm glad for that. Cases where I would have committed the patient without a thought in other states where I've worked, I've had to really justify. I've been cross examined here on a couple cases that elsewhere, the patient's lawyer would have made zero effort. Of course this only applies to patients who refuse voluntary admission, but at least for those cases it puts more of the liability on judges, and leaves us to sort out who TRULY needs commitment - not just who might sort of be a kind of danger to themselves. In the state I normally work in, that sort-of-maybe-a-danger is unfortunately the standard of care for admission.

 

[nancysinatra]

Psychiatric Hospitalization, like on the medicine side, is meant for acute stabailization. An analogy is the diabetic in DKA. You close the anion gap, get the sugars down, and then discharged. You aren’t going to cure their diabetes, that isn’t the point. I would argue most “SI” patients really only neeed 1-2 days in the hospital. You get them through the moment or crisis. Mitigate risk (ie get rid of guns, sober them up, get a family member at bedside, and get them outpatient follow up) and get them out. In fact, often times this can be done with an overnight stay in the ED. There is nothing inherently therapeutic about the psych hospital. Other than safety it really provides very little. This all seems intuitive but it seems to be forgotten often. 90 percent of patients can probably avoid hospitalization if EDs had more resources.

What you're describing applies only to a certain category of hospitals - the acute psychiatric inpatient unit. Yes that describes probably most psych hospitals as we know them today, and the ones where residents typically rotate. However there are other kinds of hospitals. Austin Riggs, Menninger - those are a couple examples. I think they are cash only and they have much longer lengths of stay and focus on things like personality disorders or treatment resistant mood disorders. There are some inpatient DBT programs out there too. Eating disorder hospitals also have longer stays. Forensic hospitals can have stays of decades. So no, not all psychiatric hospitalization is meant for acute stabilization. There is a lot more we can do for patients in the hospital, but the financing has made it such that we don't offer those services to very many people.

 

[splik]

Psychiatric Hospitalization, like on the medicine side, is meant for acute stabailization. An analogy is the diabetic in DKA. You close the anion gap, get the sugars down, and then discharged. You aren’t going to cure their diabetes, that isn’t the point. I would argue most “SI” patients really only neeed 1-2 days in the hospital. You get them through the moment or crisis. Mitigate risk (ie get rid of guns, sober them up, get a family member at bedside, and get them outpatient follow up) and get them out. In fact, often times this can be done with an overnight stay in the ED. There is nothing inherently therapeutic about the psych hospital. Other than safety it really provides very little. This all seems intuitive but it seems to be forgotten often. 90 percent of patients can probably avoid hospitalization if EDs had more resources.

your argument is flawed because such brief hospitalizations increase the risk of suicide. If you only hospitalize someone for 1-2 days and then send them out nothing will have changed except you have increased their hopelessness because the one thing that might have helped has not.

 

[nancysinatra]

your argument is flawed because such brief hospitalizations increase the risk of suicide. If you only hospitalize someone for 1-2 days and then send them out nothing will have changed except you have increased their hopelessness because the one thing that might have helped has not.

Astute patients are the ones probably most affected by this, because they know perfectly well they're being "kicked out." Nothing says "I don't care" more than a doctor who seems more interested in discharging the patient than actually helping them.

 

[clausewitz2]

Frankly, it is never the case that there is a bed shortage here. The First year resident sometimes admits as many as 30 patients on their weekend and it still doesn’t fill. We get a lot of traffic but the system moves patients quickly as it gives all the benefit of the doubt to the citizen. Some states are not this way, obviously. I agree with and appreciate what the above people are saying but the people who end up in jail have no discernible mental illness acutely contributing to their presentation on eval. I am thinking of the 35 yo male who is on his 7th admission of the year by the month of March and caused 10s of thousands in damage as well as hurting another patient the last time he is here. That person might end up in jail upon eval.

While the countertransference reaction is perfectly understandable, you aren't actually meant to enact it!

 

[DisorderedDoc417]

While the countertransference reaction is perfectly understandable, you aren't actually meant to enact it!

I don’t know exactly what you mean. But if you as a provider allow someone to hurt others on the unit, you’ll be responsible for it. There are criteria for admission to a psych hospital, and whether you meet those criteria or not should determine whether someone is admitted. Hold or no hold.

 

[clausewitz2]

I don’t know exactly what you mean. But if you as a provider allow someone to hurt others on the unit, you’ll be responsible for it. There are criteria for admission to a psych hospital, and whether you meet those criteria or not should determine whether someone is admitted. Hold or no hold.

Obviously you shouldn't admit people to a psych hospital who don't belong in a psych hospital. I am just puzzled how you are not outraged by the idea that someone can come to an ED, be detained due to mental health concerns, be judged not to warrant inpatient admission, and be sent to jail instead.

 

[enoughsaid12]

your argument is flawed because such brief hospitalizations increase the risk of suicide. If you only hospitalize someone for 1-2 days and then send them out nothing will have changed except you have increased their hopelessness because the one thing that might have helped has not.

I think you missed the part where i stated that you mitigate the risk factors 🙂 (get rid of guns, get family at bedside, follow up appointment, sober up etc). Most of these things can be done in 24-48hrs. No indication for these long hospitalizations that frequently occur. Stabilize, and transfer to outpatient care.

 

[DisorderedDoc417]

Obviously you shouldn't admit people to a psych hospital who don't belong in a psych hospital. I am just puzzled how you are not outraged by the idea that someone can come to an ED, be detained due to mental health concerns, be judged not to warrant inpatient admission, and be sent to jail instead.

In the case that there are no criminal concerns, I absolutely do share your outrage.

 

[enoughsaid12]

I don’t know exactly what you mean. But if you as a provider allow someone to hurt others on the unit, you’ll be responsible for it. There are criteria for admission to a psych hospital, and whether you meet those criteria or not should determine whether someone is admitted. Hold or no hold.

If they don’t meet criteria for a hold it’s hard to justify hospitalization. Just ask the insurance companies.

 

[DisorderedDoc417]

If they don’t meet criteria for a hold it’s hard to justify hospitalization. Just ask the insurance companies.

Honestly that’s not the case here.

 

[MedMan80]

I wonder of Esketamine will take off as a treatment in PED..

 

[Jules A]

Obviously you shouldn't admit people to a psych hospital who don't belong in a psych hospital. I am just puzzled how you are not outraged by the idea that someone can come to an ED, be detained due to mental health concerns, be judged not to warrant inpatient admission, and be sent to jail instead.

I work at one hospital where the police will drop off individuals who have been assaultive or committed a crime for "an evaluation". Sometimes because they pulled out the SI card and other times for no easily discernible reason. The often end up certified by the ED docs who then request admission to the acute unit. With the exception of the few with SMI-psychosis or mania which would be amenable to psychiatric care they are released back to police custody aka jail.

 

[clausewitz2]

I work at one hospital where the police will drop off individuals who have been assaultive or committed a crime for "an evaluation". Sometimes because they pulled out the SI card and other times for no easily discernible reason. The often end up certified by the ED docs who then request admission to the acute unit. With the exception of the few with SMI-psychosis or mania which would be amenable to psychiatric care they are released back to police custody aka jail.

Oh, I have no problems with discharging people to the sheriff or police custody if they have active warrants. We are not the criminal justice system and should not substitute for it. The gross part is people coming in saying "I want to kill myself" and the response being "well you don't need to be admitted so go to jail instead."

A system that does not let you send people home who don't need to be hospitalized is disgusting. If we are going to be imprisoning people involuntarily we have to at least pretend we are only doing it when therapeutically necessary.

 

[DisorderedDoc417]

Oh, I have no problems with discharging people to the sheriff or police custody if they have active warrants. We are not the criminal justice system and should not substitute for it. The gross part is people coming in saying "I want to kill myself" and the response being "well you don't need to be admitted so go to jail instead."

A system that does not let you send people home who don't need to be hospitalized is disgusting. If we are going to be imprisoning people involuntarily we have to at least pretend we are only doing it when therapeutically necessary.

I hope you don’t run off on such presumptuous thinking when you treat your patients, and I hope that if you do you have good attending oversight... my system doesn’t do the above. And generally speaking, we don’t admit people that are so stunningly and obviously undeserving of an admission to a psych hospital (hope your system doesn’t either, but clearly you keep ruminating on safety checks to ensure a “normal person didn’t sneak in” or something). Good Lord you have an active imagination, though. Bravo on that account.

 

[clausewitz2]

I hope you don’t run off on such presumptuous thinking when you treat your patients, and I hope that if you do you have good attending oversight... my system doesn’t do the above. And generally speaking, we don’t admit people that are so stunningly and obviously undeserving of an admission to a psych hospital (hope your system doesn’t either, but clearly you keep ruminating on safety checks to ensure a “normal person didn’t sneak in” or something). Good Lord you have an active imagination, though. Bravo on that account.

There seems to be a profound disconnect between what you are talking about and what other folks in this thread are boggling at. The linked article above and one of your previous posts talked about ED docs putting a mental health hold on someone and then, if no beds were available or if you decided not to admit them, that they would go to jail instead.

That is literally 100% of what I find problematic. I don't really understand why you don't. If that is not happening, great. If it is happening, that is appalling. Simple as that.

I have literally no idea what the connection is between anything I've ever said and a concern about "normal people sneaking in", so I really can't address that.