In follow up to last week’s blog, it may be considered somewhat reflexive to speak to a confounding circumstance in the recognition and treatment of multi-substance abuse and addiction.  Mental illness is intertwined in the management of substance abuse and addiction.  Neither one of these complex conditions are adequately addressed through episodic care, whether it is rendered in an emergency department, a primary care office or from a three-day stay in a psychiatric facility.  Rarely are any of the underpinnings addressed adequately, and quite often the process can be viewed as simply inhumane.

Patients presenting with acute or chronic mental illnesses are unfortunately not treated disparately.  In the emergency department similarly, they are not treated any differently if they are 8 years old or 80.  Almost all comers are triaged for immediate medical risk and clearance, to be evaluated for possible psychiatric placement, either voluntarily or involuntarily, and then the waiting period begins.  With a lack of resources at many levels, any one patient can wait from several hours to several days, remaining in one room, being escorted to the bathroom and back, being fed and watered, with vital signs and cursory physical assessments made during their stay.  This is not the norm when it comes to the evaluation of other conditions.

Patients frequently require evaluation for acute and chronic conditions in emergency departments.  To serve as a relevant example in parity with psychiatric patient evaluations, purely medical evaluations are not left to languish for days in a room without a clearly recognizable proactive process occurring concurrently to treat them or direct them to a higher level of care, even when there are absolutely no hospital beds to move them to from the ED.  This is not the case with behavioral patients.  The inherent problem is somewhat like sorting wheat from the chaff - a straightforward filtering process when there are treatment algorithms that move the care forward while waiting for a room or transfer to another facility.  There is no sorting the wheat from the chaff regarding behavioral patients.  Ironically, psychiatrists and therapists frequently send their patients to the ED, knowing that there are no further options for them there.  This is also unlike other conditions where patients are sent to the hospital to get more definitive treatment.  You are either in or out, and once slated to be in, we are often challenged to explain to our patients, their families and ourselves how the process makes any sense.  It is often so uncomfortable on many levels that there are now allegations being made that it is unconstitutional to continue with such practices.

In many hospitals, one or several behavioral patients can spend days in an ED treatment room, with a gurney or a pull-up chair and a TV, awaiting transfer to a psychiatric facility.  Almost 100% of the time they never see or talk to a psychiatrist or a physician extender with specialized training in psychopharmacology or behavior management.  They are evaluated by social workers or case workers from contracted services or from the state.  Embedded in the waiting period is the ubiquitous trepidation to make any sudden treatment changes in fear of suboptimal outcomes.  If this were the standard practice with chest pain patients or surgical patients, as a couple of examples, that in and of itself could culminate in malpractice.  When a cardiologist consults on a chest pain patient in the ED, there is an evolution in the direction and planning of ongoing care.  The risk is not entirely absolved by the concerted efforts in the clinical decision-making process.  However, the shared rationale with timely executed dispositions are made in the patient’s best interest, whether the patient is admitted or discharged.  This is dramatically contrasted to the circumstances for behavioral patients, even when there are several specialists who could offer consultation.

When and if ever a psychiatrist consults for behavioral patients, there is a dearth of continuity in treatment regimens and the patients are rarely seen by the consultant.  This holds true even when the patient is in the same room for days or longer.  There is bedrock of reluctance to do much of anything other than have the patient wait to get a bed in a psychiatric facility, which can take days.  The consulting arrangement between institutions and behavioral consultants seemingly doesn’t incorporate or support the services in parallel to other acute and urgent conditions.  Lastly, there is a notable subset of patients who are back to their baseline prior to being transferred.  So maybe if the acute MI can resolve on its own why have a consultant?  Despite the sarcasm, it is without doubt that these patients would benefit by more timely consultations to hasten the results and forego the holding periods and transfers altogether.

For many with chronic mental illness, their acute exacerbations are noticeably improved after several days in the ED, despite essentially being kenneled, at which point, their psychiatric admission often becomes truncated.  At times patients are discharged within hours of arrival at the psychiatric facility, with absolutely no changes in medical regimens or follow-up care.  It’s that ridiculous.  Then there are the young ones, on their maiden voyage of the psychiatric hurry-up-and-wait cuing process.  Their families could become sources of material for producers of reality shows for real life in the ER because they are essentially held captive with their children.  Other kids are left all by themselves, while child life experts and others do the best they can to temper the added emotional burden that is integral with staying in a hospital room for days or week at a time.

As a disclaimer, in no way does the author believe that there is a blanketed lack of compassion or professionalism by any psychiatrist or other healthcare provider in the aforementioned, simply that the system is not just broken as many state that it is.  Rather, it is an unnecessarily risky and dismally resourced part of the healthcare system, where the can gets kicked down the road because nobody wants to or is able to pick it up.

There is virtually no consensus to address a healthcare crisis tsunami, which ultimately infiltrates many other departments’ capital budgets while adding on billions of dollars of redundant expenses.  Clinical depression is considered the most costly illness in the U.S.  “The World Health Organization projects major depressive illness to be the leading cause for disability worldwide by 2020.”  Refer to Florida Council For Community Mental Health.

Budgeting for resources for long-term solutions for effective episodic and long-term care centric to mental illness does not occur.  Unfortunately, existing resources have become more limited while patient volume increases, largely multiplied by deinstitutionalization that has propagated for well over four decades.  The circumstances are so out of balance that incremental changes must and will start to take place. 

Washington State filed an amicus brief to support the claims of psychiatric patients that “their constitutional rights have been violated, related to unlawful imprisonment.”  Refer to Emergency Physicians Monthly, Nov. 2014, Vol. 21, Number 11, Page 9.   There is a catch-22 between considerations of being found guilty of a felony crime versus not adhering to EMTALA legislation.  The Washington State challenge is truly provocative, with a definitive finding delayed until this week of December.  What’s instrumental for N.H. and other states is that many of us have shared discussions of possible short- and long-term solutions in lieu of scant resources, which, too, were highlighted in the reference.

Considerations to implement telemedicine capabilities offering psychiatric consultations is only one.  Psychiatric nurse practitioners are underutilized, valuable resources as well.  Centralized psychopharmacologists, not unlike centralized toxicologists (poison control experts), are possible immediate guardrails or off-ramps on the psychiatric highway of admissions.  The elephant in the room, however, often seems to be the fear of bad outcomes, so the ED and other less equipped clinics remain as obtuse holding tanks for behavioral patients.  This is the underpinning of those unwilling to see and or treat behavioral patients waiting for days in emergency departments or in communities for appointments that are many months away.  There are even fewer opportunities to get patients into detox or drug treatment centers.  This might be less of a concern if sovereign immunity were to be legislated for.  This could offer some protection for providers responsible for acute care of behavioral patients and associated comorbidities.

Further refinement of the EMTALA legislation is a must, as well as the development of clearer guidelines and support for the capabilities in discharging a larger percentage of behavioral patients from the ED, rather than simply having the majority of patients corralled. 

Feedback from psychiatrists, therapists, case workers and all those impacted by the boarding of psychiatric patients is requested and welcomed. 

Regards,

Lukas Kolm, MD, MPH

Please send your comments and questions to president@nhms.org or post a comment belows.