For the third time this week Ms. A, a 49 year old with a history of alcohol dependence and untreated bipolar disorder presents to your emergency department (ED) for suicidal ideations. Of course it is Friday night, or rather, Saturday morning, your department is over capacity and Ms. A is being uncooperative with both the triage nurse and the security staff attempting to maintain order.
More psychiatric patients competing for fewer inpatient beds spells trouble for the emergency department.
For the third time this week Ms. A, a 49 year old with a history of alcohol dependence and untreated bipolar disorder presents to your emergency department (ED) for suicidal ideations. Of course it is Friday night, or rather, Saturday morning, your department is over capacity and Ms. A is being uncooperative with both the triage nurse and the security staff attempting to maintain order. You are short staffed and now need a one-to-one sitter to ensure that Mrs. A’s alcohol level is not too high – or too low for that matter. You also have to decide whether to be in touch with the on-call psychiatry team, whether that be the on-call attending or psychiatry resident or social worker.
Much of the time these scenarios end with a few milligrams of lorazepam, a nap, and potentially a quick psychiatric consult hours after the initial presentation when the patient now denies suicidal ideations and is labeled as “low-risk.” This is quickly followed with a prescription that will likely never be filled, instructions that will likely never be followed, and discharge. Is this success or failure? On the one hand, the patient is apparently no longer suicidal, has calmed down and been medically cleared. On the other hand, is the appropriate treatment for alcohol abuse, bipolar disorder and suicidal ideations short acting benzodiazepines and a copious pile of papers with phone numbers? Can emergency physicians safely avoid a portion of psychiatric consults to begin alleviating crowding and medical waste? Odds are, Ms. A will be back with similar complaints, so you or your colleague will have the opportunity to try something else in the coming days.
Unfortunately, this story, and the treatment regimen, is far from unique. As the cost of healthcare continues to rise and rates of under and uninsured Americans escalate, EDs will remain a safety net for many who are unable to find healthcare elsewhere. This includes those with mental health and substance abuse (MHSA) conditions. Agency for Healthcare Research and Quality data shows that 12 million (one out of every eight) ED visits in 2007 involved either a diagnosis of a mental health or substance abuse condition. Moreover, when it comes to admission to the hospital, patients with a MHSA diagnoses were nearly 1.5 times more likely to be admitted by way of the ED when compared to patients with no MHSA condition. The majority of these admissions related to depression and substance abuse.
Although President Obama’s healthcare bill, “Patient Protection and Affordable Care Act” which was signed into law in March of 2010 includes an expansion of substance abuse and mental health provisions, it is unclear if the current mental health service infrastructure will be able to meet a rising demand in MHSA services. If coverage is not linked to access, it is likely the number of MHSA patients being seen in the ED will continue to increase.
Here’s the depressing part. Although the total number of patients treated in the ED for MHSA conditions continues to rise, resources to treat these patients do not. A 2004 national study jointly conducted by the American Psychiatric Association, National Alliance for the Mentally Ill, National Mental Health Association and American College of Emergency Physician’s (ACEP) sought practicing emergency physicians’ views on available mental health resources.
Specifically, responses from members of the ACEP were solicited through the ACEP’s monthly newsletters. Physicians from a total of 47 states and Puerto Rico were represented in the responses. The results indicated that 67% of emergency physicians reported a decline in mental health services in their community within the past year. This includes fewer available inpatient psychiatric beds. Between 1970 and 2002, the absolute number of inpatient psychiatric beds decreased by over 60%. Most of the beds that were lost came from state and county hospitals whose bed counts decreased nearly 90%. The reason for this decline is likely multifactoral. Medicaid, introduced in 1965, initially excluded “institutions for mental disease” from receiving reimbursement, which encouraged many states to move away from an inpatient model for psychiatric care. Additionally, reports of poor conditions and treatment of psychiatric patients in these facilities coupled with new therapeutic regimens more conducive to outpatient care has likely lead to the decline of available inpatient beds.
This loss in beds has resulted in many mental health patients being “boarded” or simply held in the ED, until appropriate dispositions can be reached. The American Hospital Association reported that 42% of member hospitals have seen an increase in the boarding of mental health patients in recent years. ACEP’s survey of ED medical directors found that 80% report boarding of psychiatric patients. Boarding times and numbers can vary by geographic location, with an increase in time and number of patients seen in urban EDs. In this same survey, medical directors report that 60% of patients being admitted to a psychiatric unit stay in the ED for over 4 hours, a third for over 8 hours and 6% over 24 hours.
Even when a patient has been admitted, or will be admitted, to the psychiatric service, his or her care remains the responsibility of the ED physician so long as the patient is being boarded in the ED. Nearly two-thirds of ED physicians report “no psychiatric services involved with patient care while patients are being boarded in the ED”. Additionally, most of these physicians feel that patients with MHSA require more resources (including nursing) than many patients without MHSA conditions. Furthermore, only 50% of EDs in California that responded to a 2008 survey published in Academic Emergency Medicine have access to on-call mental health providers. Among rural EDs, on-call availability of mental health providers drops to fewer than 25% of hospitals polled.
Despite significant utilization of the ED by those with MHSA conditions and a decrease in available mental health services, it remains unclear if EPs themselves are adequately prepared to care for these patients. There is no formal requirement of residency training programs, as dictated by the Accreditation Council for Graduate Medical Education (ACGME), with regard to evaluating and treating patients with MHSA conditions. A survey of EM residency training programs indicates limited psychiatric training for most residents. Only 24% of EM programs and less than 3% of pediatric EM programs “provide formal psychiatric training” for their participants. Moreover, past studies have shown significant clinical disagreements between ED physicians and psychiatrists when it comes to treating psychiatric conditions in the ED. The most recent study comparing agreement between ED physicians and consulting psychiatrists in the ED showed only a 67% agreement regarding the involuntary holding of a patient and a 76% agreement regarding final disposition. The authors of this study suggested that disagreement
s between ED physicians and psychiatrists may exist in part to psychiatrists’ ability to access past psychiatric medical records more readily than EM physicians. However, as discussed above, there is limited formal psychiatric training for EM residents and this fact is likely contributory to these disagreements.
There are relatively limited, quick reference resources available for current ED physicians on the evaluation and treatment of patients with MHSA conditions. The American Association for Emergency Psychiatry (AAEP) maintains an online bibliography with recommended references and readings about specific MHSA issues. Although the AAEP’s bibliography may not be useful as a real time quick reference for emergency physicians, the resources are continually updated and germane to psychiatric conditions seen in the ED.
The Expert Consensus Guideline Series, also available from the AAEP’s website (www.emergencypsychiatry.org) provides guidelines for behavioral emergencies based on the collective feedback of experts in the field. These guidelines, presented in succinct charts and brief reviews, cover the initial evaluation of patients, the use of restraints and pharmacologic agents for agitated and aggressive patients of all ages.
One particularly useful risk stratification instrument available to ED physicians is the modified SAD PERSONS scale, a clinical decision making instrument designed to evaluate the suicide risk of a patient (opposite page). This tool has been validated in the literature for use by non-psychiatrists. This ten-question tool can quickly and easily be used by the ED physician in helping to make a disposition decision.
At least for the foreseeable future, there will continue to be a rise in patients seen in the ED for MHSA conditions. In addition to the rise in absolute number of patients seen in the ED for MHSA conditions, these patients are at a far higher risk of overall morbidity and mortality. For example, Crandall and colleagues examined the subsequent suicide mortality among patients seen for suicidal behavior in one specific university-based, urban Level I trauma center. Patients seen for a first time overdose, suicidal ideations or self harm showed a relative risk of 5.7, 6.7 and 5.8 respectively for future suicide death compared to ED patients seen for other complaints.
These facts, coupled with the limited psychiatric resources available to many ED physicians, necessitates the development of a more standardized and robust emergency medicine residency curriculum when it comes to evaluating, treating and providing appropriate dispositions for patients with MHSA conditions. Furthermore, the development of quick reference resources designed for ED physicians on the treatment of patients with MHSA conditions will help ensure these patients receive appropriate care while in the ED and the necessary follow up after discharge.
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