Treating the psychiatric patient in the ED: 3 changes I’d like to see

“Most EDs do not have separate secure areas in which psychiatric patients can be held. They typically don’t have a psychiatrist immediately available to evaluate the patient and provide guidance on management, and they do not have extra nursing staff to monitor often unpredictable patients.”

This was a comment on one of my blog posts.

Well, we have been talking about the way psychiatric patients get to the ED and what happens or does not happen when they do. Many of you have lamented the lack of personnel, the dearth of services and the waits that these patients experience because of dwindling inpatient resources. What can be done about this deplorable set of circumstances?

1. I believe that hospitals are going to have to provide separate service areas for these patients. The stark white room with only a gurney and a chair, with no television or magazines or anything stimulating to do, must go. Replace it with a hallway or a suite of rooms with a centrally located nurses station and a common area that give patients a little more room to walk, space to interact and even a special area for visitations from family. The lone guard outside the door, symbolizing both threat and security, must be replaced with trained mental health staff in this special area, staff who know about the signs of escalating agitation and potential for violence in these patients. A small emergency room within the main ED, this area could be secure and therapeutic at the same time, much as an inpatient psychiatric unit might be. This should become a standard for emergency departments who wish to receive mental health patients.

2. Psychiatric coverage is going to be needed for these service areas. As many commenters have pointed out, both patients and providers alike, it seems that there are never enough psychiatrists around to see mental health patients when they do come to the ED for help. One criticism, spot on in some cases, is that psychiatrists do not respond in a timely manner to requests from the ED physician for consultation and help in the management of difficult psychiatric presentations. They do not come out in the middle of the night to see patients and they do not give timely input that would be helpful to the ED staff. In many rural areas, even if there  is a small community hospital, there are no psychiatrists anywhere. There are no mental health centers to send a screening clinician.

3. Services such as telepsychiatry may be the answer to psychiatrist shortages in the future. Being able to see multiple patients in multiple hospital EDs over a regular or extended shift, without the hassle of driving from place to place, is one of the virtues of telepsychiatry. A patient who might have sat for days waiting for an inpatient admission because no mental health input was available to begin treatment in the ED, may be the beneficiary of a mental health consultation and initiation of services from the first day they are evaluated. A fair number of these patients, their treatment begun in the ED, may actually be improved enough to go home directly from the hospital after a few days.

Now, I know what is going to  happen as soon as these kinds of changes are proposed.

There will not be enough space. There will not be enough money (when is there ever enough money?). We can’t dedicate an entire area of precious emergency department real estate for a babysitting service for mental health patients. Psych patients will be running amok all over the department, threatening and yelling and getting into other patients’ business. We can’t spare staff for this in the ED. Psychiatrists will never come down to see these patients even if we do set them up in their own place. Telepsychiatry equipment is expensive and we’ll never be able to afford it.

The fact is, as my old mentor Everett Kuglar, MD used to tell me, these patients are not going to go away. Someone is going to have to treat them.

No matter how much hospital administration tries to ignore their existence, no matter how little funding state legislatures provide for their care, people with schizophrenia and depression and substance abuse problems and other mental health problems are going to be with us.

We can choose to ignore them, but the problem will only get worse. We can choose to maintain the present day status quo, which in my opinion will only lead to more frustration for patient and provider alike.

We can choose to spend a little money, time and physical and human resources to turn this around.

Sometimes if you want to make an omelet, you have to break some eggs.

Greg Smith is a psychiatrist who blogs at gregsmithmd.

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  • meyati

    The VA in Albuquerque did this, and mental patients go there for both physical and emotional support. A severe physical trauma still goes to the ER. A psychiatric nurse runs the psych ER. My son goes there for stitches, abscesses, if he falls, has pneumonia, etc. His health has improved because of this. He’s not so scared to go in. At the regular ER he never knew how he’d be treated-politely or rudely-and sometimes other patients didn’t want a freak in their with them. They have a hallway for them and the nurse has her examining room. As you say, patients can pace and move around to work off agitation.
    I’d call your voice– A voice in the wilderness.

    • Greg Smith MD

      meyati

      “He’s not so scared to go in.”

      That to me is the key. Patients have to be comfortable coming in for legitimate reasons to seek the care they need, without worrying about being bullied, abused, misunderstood or ignored.

      Sounds like the VA, once again, is ahead of the curve on this issue as they have been on others in mental health treatment.

      Greg

  • http://barefootmeds.wordpress.com/ Barefootmeds

    I’m on my psych rotation now and I couldn’t agree more. In South Africa (where I am) we estimate that a third of the population requires psychiatric help, yet only 2-4% of the national health budget is allotted to mental health – and that includes prevention, screening, treatment AND rehab.
    Psychiatric patients go straight to medical emergency, unless they are medically stable and appropriately referred to Psych OPD during office hours (and it happens rarely). And then these patients who are suicidal or anxious or manic or maybe a little maladjusted have to wait in an area where we have inebriated patients, screaming monitors and active resuscitation going on. It doesn’t help their wellness at all.
    Psychiatric facilities the world over could definitely do with your suggested changes.

    • Greg Smith MD

      Barefootmeds

      Wow, one third versus 2-4%. Very telling, that.

      Glad to hear, in a way, that we are not alone in this in the US. I agree that systems worldwide need to be revamped to treat mentally ill patients with the respect they deserve.

      Greg

    • querywoman

      Psych wards are always needed. Nigeria doesn’t have enough mental institutions. In the old Soviet Union, people were actually trying to get in them to get decent food and other treatment.
      Many people are grateful to have been involuntarily committed.
      Most people seek psychiatric care voluntarily.

  • Rob Burnside

    If what I’ve just read on another respected medical blog is true–that suicide rates are highest in rural areas, where psychiatric services are severely limited or nonexistent–we shouldn’t require further convincing. Dr. Smith is right-on, across the board. Can anyone seriously doubt the value of his suggestions? If not, what are we waiting for? Lives are at stake here!

  • medicontheedge

    In a perfect world…. all it takes to make that happen is money. Lots of money. In today’s healthcare and hospital economy, where highly paid CEO’s are driving staff to do more with less, I don’t see this happening any time soon. It is too bad.
    In my ED, these folks are often staged out in the hallways, because they need constant “observation”, so they don’t even have privacy, let alone a supportive, caring, and EFFECTIVE treatment milieu.

    • Greg Smith MD

      medicontheedge,

      I agree totally and it is very frustrating.

      Throwing cash at this problems probably WOULD help, but yes, where is the funding to come from?

      I have been asked to do a telepsychiatry consult with a patient right out in the hallway “because we don’t have a room available”, in front of other patients, an active nursing station, and visitors passing by.

      I refused.

      These folks with mental illness deserve the same right to privacy as anyone else.

      Thanks for your comment.

      Greg

  • June

    I had a spinal tap done in an ED after a CT of my head confirmed an infection. When returned back to an ER shortly afterward as I am drowsy and cannot feel my limbs I was being denied medical help and being yelled at I need a psychiatrist. I eventually ended up in psych ward due to the ED doctor falsifying records and then pretending the condition I was left in was a mental illness. I can assure you that psychiatrists are willing to go along with this and will write up charts to make it look like you are mentally ill instead of medically ill.

    I would like to see ED doctors owning up to their mistakes and stop pretending the patient they left disabled is mentally ill.

    I would like their to be a stop put to medically ill persons being put in psych wards under false pretense of being mentally ill to cover up negligence that happened in the ED.
    Complications for what the ED doctor did to me include brain herniation, spinal tap leaks, death and more. How and why can they get away with doing these things?

    In the psych wards they can also bring over the doctors to treat you medically and keep you hooked up to the IV antibiotic treatment they failed to give in the ED. The treatment they failed to give at the time of the spinal tap. All they have to do is keep the door closed in the psych hospital day and night and who would know you are even in the place bed bound being spoon fed food because those places are not monitored and nurses will not tell what is going on. Any patient with a brain disease such as Meningitis, CNS infection, stoke I feel could be at risk of having this happen.

    • Greg Smith MD

      June,

      I am very sorry you had this bad experience. It sounds terrible.

      “I can assure you that psychiatrists are willing to go along with this and will write up charts to make it look like you are mentally ill instead of medically ill.”

      Good psychiatrists will NOT do this. Good psychiatrists are medical doctors first, mental health clinicians second.

      Competent psychiatrists do not want to “make it look like you are mentally ill”. They want you to get better and look like you are well and whole.

      Greg

      • June

        How does a person stop this stuff from going on then?

        A relative of mines boyfriend said to me when I told them what had really happened that he knew something was seriously medical wrong with me because he had to hold on to me to stop me from falling over, he said I was as cold as ice and my pupils appeared to be sitting at the bottom of my eyelids. If you look at the records after the spinal tap you see things written on the charts such as abnormal gait, latency of speech, weak barely moving herself,pale, poor eye contact and a lot more. They continued to take blood in the psych wards. The hospitals had concealed all the blood work showing, low potassium, sodium, anion gap too many too mention.

        They have done a lot of stuff to block me from getting diagnostic tests to find out the extent of the bodily damage i have. I did manage to get an MRI of my spine. The x-ray spine and MRI shows 10 problems. I need many other tests done but the damage concealment is in full force including blocking me from getting a bone scan.

    • querywoman

      I’ve been labelled “mental” over a skin disease. “Delusional.” I had no choice but to endure. No biopsy, no dermatoscope exam.
      I have a nasty form of atopic eczema.
      They always say about skin disease that the patient picked at it, caused it, and that’s why it gets worse.
      I used to think I had the controversial Morgellons Disease. Now I believe what I have is just a bad form of atopic eczema, and my skin doctor agrees.
      I have been with my dermatologist about 5 years, and he is an activist. He has literature in his office about how psoriasis may have been the Biblical leprosy.
      My body slowly formed layer after layer of usually white scaly tissue for years. It looks a lot like my skin. It’s probably autoimmune.
      As it peels, it often settles into “nodules,” which look worse until the scabs come off.

      Being able to take pictures easily in the modern digital prove helps me prove what it is, that it is not coming back and it is going through a peeling process.
      If my doctor and I each get another 50 years in our physical bodies, perhaps we will be able to make lives easier for other dermatologic patients.
      It’s quite a battle, since stigma against skin disease is socially embedded.