Your colleague signs Jane out to you as you start your night shift. She is an otherwise healthy 36-year-old with bipolar disorder and suicidal ideation who is calmly watching you from her stretcher. “She's medically clear and waiting for psych placement,” he says.
Jane waits in your ED all night, and at 6:30 a.m. as you are preparing to end your shift, the charge nurse tells you, “Central State says she needs an ECG and a chest x-ray.” No facilities have a bed except this state psychiatric facility. What do you do?
With stable vitals and no medical history or physical complaints, Jane doesn't need an ECG or a chest x-ray. Our responsibility when medically clearing a patient is to rule out a medical condition that warrants observation or admission. We approach psych patients just as we would medical patients with an adequate history and physical, including vital signs and a mental status exam. We're more suspicious of organic pathology for geriatric patients, those with acute severe psychosis, or those too altered to give a history. We order tests on them and others whose presentations warrant further investigation.
Every EP has had patients headed for psych who we sent to medicine instead because we found a medical etiology for their psychosis. We take our responsibility seriously, and try not to burden the psych team with a missed medical diagnosis. Not every patient needs labs or imaging for us to be comfortable discharging him. If we board-certified EPs—experts in ruling out medical emergencies—decide we would send Jane home without a litany of arbitrary tests, why is that not good enough for medical clearance?
Psychiatric facilities see things differently, however. Jane has already had a full complement of unnecessary lab tests (all normal, of course) because your colleague, like every EP, knows the drill. Medical screening to us means ruling out an emergent medical condition right then, but psychiatrists want assurance that there will be no medical problems during their entire psychiatric admission.
You can't blame them. Medical emergencies in psych facilities go badly, and one too many of us has inadvertently dumped a patient on their facility with a brain tumor, delirium, or rhabdomyolysis. A single bad outcome destroys their confidence in our ability, and makes them want more “objective” evidence to guarantee there will be no surprises during a patient's extended stay. Even though you may have a policy, as we do in Virginia, that a healthy psych patient under 60 doesn't need blood work, psych will want it anyway.
Pan-Testing for What-ifs
The fallacy with seeking peace of mind through labs and imaging is that negative results don't guarantee that a medical emergency is absent any more than abnormal results indicate one is present. This conundrum is why we train for years. Unfortunately, no test, screening algorithm, or doctor is going to get it right 100 percent of the time. There need to be more reasonable expectations. It is not the ED's role to pan-test for the what-ifs. We use our expertise and unique knowledge to order only what we need to rule out immediate health threats. There is no evidence that psychiatry's escalating requirements for screening exams are needed if the EP deemed them unnecessary. By ACEP policy, Jane didn't even need a urine drug screen. (Ann Emerg Med. 2006;47:79; http://bit.ly/35jPSZF.)
Unfortunately, policies are paper tigers in the trenches of an ED. Clearing psych patients medically can be summed up by a cynical version of the Golden Rule—he who has the gold makes the rules. In our world, this means he who has the bed makes the rules. We can't order psych to take an admission, so we're forced to play their game. Fighting an ECG and a chest x-ray for Jane requires extra phone calls and energy that will back up your department and delay her transfer. Psych units within your own hospital system may work with you, but freestanding psych facilities without immediate access to medical resources are often not a fight you're going to win. If you refuse to cooperate, they can just refuse to give Jane a bed.
Patients like Jane wait in EDs all over our country. The prevailing sentiment that psych patients stack up in the ED because there are no appropriate beds is not always true. I have had patients in my ED for hours while facilities say, “We want this lab. Now fax us another lab. We didn't get your fax; fax it again. Now we want imaging,” all while the bed is open and waiting. Devoting the limited resources of a small ED to getting those tests backs up the department and adversely affects the care of other patients. It's exhausting and expensive, and, frankly, it's bad medicine.
A colleague recently held a patient in his ED for 48 hours waiting for her to poop out a foreign body, something we regularly send patients out to do without supervision. Jumping through such hoops leaves patients sitting for days with no psych care. Psych holds burden the nurses with paperwork, and they siphon staff away from the rest of the ED or even the local police force. They also divert the EP from other patients when their psychiatric condition escalates. EDs can't function this way.
How do we get psychiatrists and psychiatric institutions on board with more streamlined processes that keep our EDs from backing up? Fighting it at the grassroots level in the middle of a shift by digging in your heels and refusing to order tests is often not feasible. Solving this issue is going to require communication at the administrative level between EDs and psych facilities.
Psychiatrists need to curtail the obstructionist practices of staff who cling to checklists and demand every test, even on healthy patients. Instead of sending healthy psych patients to the ED and only clearing them after wasting resources on unnecessary tests, should we have freestanding psych intake departments do their own tests and only send patients to the ED when they suspect they have a medical issue? It's time to start brainstorming because there has to be a better way.
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Dr. Simonsis a full-time night emergency physician in Richmond, VA, and a mother of two. Follow her on Twitter @ERGoddessMD, and read her past columns athttp://bit.ly/EMN-ERGoddess.Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.