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Commentary: Who ‘owns’ the psychiatric patient in the ED?
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by Elspeth Cameron Ritchie, MD, MPH
Who “owns” the psychiatric patient in the ED? Is it the ED physicians or psychiatry/behavioral health? How does ownership change after they have been admitted to the inpatient ward but are waiting on a bed?
I ask this question not just for rhetorical, but for practical reasons. Like many major metropolitan hospitals, mine is one that has a very busy ED. Operations there are made more complex by a heavy volume of patients with major mental illness and substance abuse.
Lack of information
I have been a psychiatrist for a long time, and I’ve been to multiple psychiatric conferences, but have not seen this issue addressed before. A literature review does not reveal much either, except a little on how free-standing psychiatric EDs are run. There is literature on patient outcomes depending on whether they are seen by ED personnel or behavioral health personnel, but not on who should manage them.
When presenting to the ED, some patients come in with suicidal or homicidal ideations. They are quickly labelled as needing evaluation by psychiatry intake staff.
For others, it is cellulitis or a head trauma that gets them to the ED, but the major mental illness behind the physical wounds causes them to be referred to psychiatry. If a motor vehicle accident or gunshot wound secondary to substance use brings them in, they go straight to the trauma bay and psychiatry will see them later.
Personal experience
Several years ago, a room in our ED was designated a “psychiatric observation area.” Here, up to six “clearly psychiatric” patients wait to be evaluated by our social work intake staff. They are monitored there by behavioral health technicians employed by the department of psychiatry. However, their medical needs are monitored by nursing staff from the ED.
While the “psychiatric observation unit” arrangement works well most of the time, problems arise when patients are there for extended periods, often over a weekend. Since our psychiatry units are often full, patients may have to wait many hours, or rarely, up to 30 hours before a bed is available. Again, this is a common scenario throughout the country, with some hospitals reporting waits of up to 5 days.
If the patients are agitated, the ED physicians will give them medications for agitation but would like psychiatry to assume the responsibility for putting them on regular psychiatric medications, usually antidepressants and antipsychotics.
For their part, the psychiatrists, who are often extremely busy with managing the inpatient wards and with consults, do not feel equipped to take over another population of acute patients. In our case, it does not help that the ED is at the other end of a very large hospital.
Available options
So, I looked at how other local facilities manage their psychiatric patients in the ED. Again, there is nothing in the literature I could find that addressed this issue.
There are a range of related options, in terms of location and ownership:
- No separate location for psychiatric patients in the ED;
- Designated rooms for psychiatric patients, designed for additional privacy and/or safety;
- A separate room within the ED, but part of the ED (our model);
- A separate clinic within the ED with its own nursing station and individual rooms (a model used by other hospitals within our system);
- A psychiatric ED, co-located with the ED, often known as a CPEP, or Comprehensive Psychiatric Emergency Program (modeled in New York and other states);
- A standalone Comprehensive Psychiatric Emergency Program, without a nearby ED (the model in Washington, D.C.).
In my research I find that staffing varies; the first four locations generally are run by the ED and the latter two by Behavioral Health, either public or privately.
So, what is ideal? Probably none of the models fit perfectly for every scenario. But I am raising this question to open a dialogue on the best plan or plans. I would like to hear what works or does not at other EDs.
For more information:
Elspeth Cameron Ritchie, MD, MPH, is professor of psychiatry at Georgetown University School of Medicine, professor of psychiatry at George Washington University School of Medicine, and professor of psychiatry at the Uniformed Services University of the Health Sciences. She is also a member of the Healio Psychiatry Peer Perspective Board.
Disclosure: Ritchie reports no relevant financial disclosures.