Emergency physicians in our group ask that question daily with a combination of hope and fear. We’re not referring to one of our on-call psychiatric colleagues, rather to which one of us has the responsibility to spend roughly two hours or more during and after our shifts caring for the 10 to 20 behavioral health holding patients in one of our EDs. It’s not uncommon for the “Psych Doc” to average 10 interruptions per hour regarding Psych ED patients.
At some emergency departments, mental health patients can wait up to two weeks to be transferred
“Who’s the Psych Doc today?”
Emergency physicians in our group ask that question daily with a combination of hope and fear. We’re not referring to one of our on-call psychiatric colleagues, rather to which one of us has the responsibility to spend roughly two hours or more during and after our shifts caring for the 10 to 20 behavioral health holding patients in one of our EDs. It’s not uncommon for the “Psych Doc” to average 10 interruptions per hour regarding Psych ED patients. Our group now staffs five EDs, but one of them is in a separate county and has been in our system for less than a year, so what follows doesn’t include our latest addition.
Our four EDs see over 200,000 patients annually in a service area with a population of 500,000. Like many EDs, one can expect to find medically-cleared, behavioral health (BH) holding patients in every one of our EDs, but most are found in our ED with a dedicated, locked psychiatric 10 bed holding area and an adjacent 8 bed transitional care holding area. Our patient volumes break-down can be seen in table 1.
In any given 24-hour period, we expect to be holding a range of 20-30 patients in our 4 EDs, and have had up to 30 just in the one with the Psych ED. We see about 8000 ED patients a year with a primary diagnosis of anxiety, depression, suicidal ideation, homicidal ideation, psychosis, or substance abuse (SA). In a 6-month sample, 12% of our ED BH patients had multiple ED visits, 150 patients (4%) had more than 3 ED visits with primary BH-related diagnosis, and one had 99 ED visits.
Out of the estimated 8000 patients with a primary behavioral health diagnosis, approximately 3000 are admitted, with a 6-month re-admission rate of 7%. We also transfer roughly 200 patients a year to the state psychiatric hospital, 100 for geriatric psych (not covered locally), and 400 to inpatient detox facilities (also admit SA locally). Based on these estimates, we have an admission/transfer rate of ~45% for ED patients with a primary BH-related diagnosis. Our median Arrival to Medical Clearance time across the system is 2-3 hours, Medically Cleared to ED Departure time is 24 hours, and Arrival to Departure for Admit/Transferred BH patients is 27 hours. In a sample of over 1000 ED BH Hold patients, only one was admitted within 3 hours of ED Arrival. Occasionally our BH patients are held in the ED for over 2 weeks; generally the result of delays in transfer to state facilities.
Effect of State Psychiatric Hospitals
As of early December 2013, the average time on the waiting list before transfer to the state hospital was one week. Therefore, the 200 BH Holds that get transferred to the state hospital spend a collective 33,600 hours in our EDs, and that doesn’t include medical clearance time, or the required hours/days it takes to get the necessary refusals from other psychiatric hospitals before the state hospital will place these patients on its waiting list. By comparison, the 3000 patients admitted locally spend 72,000 holding hours in the ED. According to these estimates it takes almost half as much time to hold the 200 BH patients getting transferred to the state facility as it does getting 3000 BH patients admitted locally (and 7 times longer per patient: one day vs. seven).
In a simple test, if the BH Holding times were cut in half for those two groups (down to 12 hours and 3.5 days respectively), almost 53,000 hours of current ED bed space and resources in our system would be available for other use. Divide that “spare” 53,000 hours by 4 (overall LOS for all ED patients), and in theory we could see over 13,000 additional ED patients a year.
Shift Survival: The Impact of Psych Holding on ED Staff
We have taken a multi-step approach with administration and psychiatric colleagues in an effort to improve the care for this underserved (>50% Medicaid and Self-Pay), high-risk, and complex patient population. Our goal is to transition the care of medically cleared BH Hold patients to a BH team in early 2014, so ED nursing and EPs will no longer have primary responsibility for those patients. In addition to our hospitals, a local state-sponsored behavioral health center keeps some patients over 24 hours (10 beds), and sees over 150 patients daily (scheduled and walk-ins). Occasionally that facility sends patients to the ED for medical clearance, and those patients may be sent back (if that center has a bed available), or become ours.
Although largely worthless from an EM perspective, in order to avoid daily confrontation we have acquiesced to our psychiatric colleagues’ ongoing demands and routinely perform “screening” labs for “medical clearance” (CBC, CMP, EtOH, APAP, ASA, UDS, and HCG prn). As somewhat of a compromise for EPs ordering “routine screening” labs for medical clearance, our psychiatrists are now supposed to have a doc-to-doc discussion before refusing any patients based on “medical acuity” and can no longer deny patients based on having “exceeded maximum therapeutic benefit at our facility”. The American Psychiatric Association (APA) 2006 clinical practice guideline (CPG) regarding medical clearance states “there are no specific guidelines about which tests should be ‘routinely’ done”. The APA has an updated CPG still in draft form, dated Jan2014 regarding medical clearance. It also makes no specific recommendations for routine lab testing, citing insufficient evidence, but refers to only three observational studies from 1981, 1990, and 1994, in which about half of the patients in each study had a medical cause/component for their apparent psychiatric condition. The draft 2014 APA CPG does not reference more recent articles in the EM and psychiatric literature which show a lack of evidence for “routine” lab testing for medical clearance.
EMS preferentially transports patients with primary BH complaints to our hospital with the Psych ED. We utilize standing orders for triage of BH patients. Patients receive a medical screening examination by an EP or advanced practice provider (APP). APP/EPs write Psych Holding orders including Med Rec while the patients remain in the ED (these are not admission orders). BH patients seen by APPs are almost always shared visits with an EP. The decision to admit/transfer is the responsibility of the EP. We use our own health system’s BH counselors (Master’s-prepared social workers or higher) once patients are medically cleared to assist in disposition and placement.
Uninsured substance abuse patients usually need financial assistance, and our counselors spend countless hours obtaining such state-funded “sponsorship” before detox facilities will accept those patients. Unfortunately, our state requires ‘sponsored” SA patients to report directly from the ED to the inpatient detox facility, even if it means spending days in the ED, and they will lose both funding and their place in line if discharged from the ED. Our counselors know what BH facilities will accept specific BH patient types (e.g. geriatric psych vs. intellectually disabled vs. SA), and what those facilities require in order to transfer, far better than our EPs ever will. Occasionally our counselors are able to refer SA patients to intensive outpatient programs, but often patients refuse that option if they are eligible for inpatient detox. The EPs and BH counselors perform a shift-handoff at least three times daily to review disposition plans for all BH Holds. In late 2013 our state announced an effort to improve BH/SA crisis services by promoting alternatives to the ED. As of early 2014, those alternatives have not materialized to my knowledge.
All of our EDs use tele-psychiatry and in addition, the Psych ED has a rounding psychiatrist M-F half days. Tele-psychiatrists may order/rescind involuntary commitments, as do EPs, but mainly tele-psychiatry is relied on for medication management recommendations and to bolster the EP’s disposition plan (discharge, admit, transfer). While some EPs are comfortable initiating and rescinding involuntary commitments, in general there is greater comfort from a risk reduction perspective when a board-certified psychiatrist agrees with the EP, and/or offers the disposition plan (i.e. discharging patients with chronic SI but otherwise low risk). Let the buyer beware; tele-psychiatry isn’t cheap. In our region I’ve heard of estimates ranging from $150-250 per consult, and repeat assessments aren’t necessarily discounted. We tend to consult tele-psych initially (if rounding psychiatrist not available) and if patient status changes (e.g. initially implement involuntary commitment, then rescind several days later if the patients improves and becomes stable for discharge).
What the Future Holds
Recently, we began transitioning the nursing care of our Psych ED Hold patients from ED RNs to BH RNs. We continue to seek alternative locations outside the EDs to potentially cohort all medically cleared BH Hold patients (similar to the regional BH center approach). We also added all ED patients with a LOS >24 hours to our hospitals’ twice weekly care management/social work LOS committee meetings, and have already expedited the transfer, placement, and/or return of geriatric patients to skilled nursing facilities and state hospitals. Finally, our health system’s ACO is exploring having county paramedics transport selected BH/SA patients directly to BH/SA facilities instead of the ED.
Needless to say, we can’t wait for the day when we endorse the care of our medically cleared behavioral health holds to our psychiatric team. Our patients deserve it. As good as we are as emergency care providers, the ED isn’t the place for patients to stay for days at a time. For some, a warm, private room with cable TV and a few free meals is just what the doctor ordered. In general however, EDs shouldn’t have to host “the guests who never leave”.
John is a practicing emergency physician and medical director in North Carolina. In other health systems he also served as chief of staff, health system board trustee, and director of medical education.