The view of psychiatric care in the ER from here
In yesterday's Washington Post, we found this article:
http://www.washingtonpost.com/wp-dyn/content/article/2007/01/28/AR2007012801352.html?referrer=google
The numbers and reports speak for themselves: close to 47 million Americans uninsured, 700,000 of whom reside in Maryland. Organizations such as the National Alliance for the Mentally Ill, the Emergency Nurses Association and the American College of Physician Executives are lobbying for changes that just don't appear to be coming soon enough. Pick up the phone and call any of your healthcare providers (including Psychiatrists and therapists), and you'll most likely hear this response "...if this is an emergency, please go to the nearest Emergency Department." Yes Virginia (and DC), Maryland Emergency Departments are crowded too.
The Institute of Medicine (http://www.iom.edu/CMS/3809/16107/35007.aspx) released their 300+ page report on the many issues faced by Emergency Departments across the country last year. This extensive report details the many issues that are faced by Physicians and Nurses on a daily basis when covering the Emergency Departments in the 6000+ hospitals throughout the country.
Needless to say, there's work to be done.
The frustrating part of all of this is that this issue is being treated like the patient in the overcrowded hallway who is difficult to see. "There's no beds available so maybe if we just put him on a guerney....". Families stand next to their loved ones anxiously in hallways while they wait for news...care...anything. As the department becomes more crowded the times (we call them T.I.D.'s - the acronym for 'time-in-department') increase. The physician sees the patients, then writes orders for the RN for tests; ED techs come and draw blood, radiology techs come and take x-rays and then the waiting increases while the results are being completed and consults are taking place. - this is not a process that takes "only minutes".
In the psych area of the Emergency Department, the assessment process can take additional hours. I once assessed an 8 y/o who was feeling suicidal. This was her second visit to the ED in a week. She was having a difficult time managing her feelings and had a plan on how she would end her life. This second visit was exacerbated by the sniper shootings that were happening in the Washington DC area at the time. Her school had been placed on "lock-down" and all of the students were placed in the cafeteria. Imagine being in a crowded, noisy cafeteria for hours with several other children in a stressful situation. She went home and told her parents that she wanted to kill herself and they brought her to the ER.
The medical evaluation (including all of the necessary labs and tests) took place; and then our psych evaluation followed by an extensive discussion with her parents about their ability to keep their daughter safe. As they were concerned that they would not be able to do so (and because this was her second visit in a short amount of time), we decided that the safe thing would be to refer the patient to a child psychiatric unit at a hospital that was several miles from our ER. (this meant that transfering the patient to the hospital would involve a trip on the beltway) for the Ambulance.
More time; more wait. The paperwork to transfer the patient needed to be completed, the registration and subsequent precertification with the insurance company would need to take place, the paperwork would need to be faxed to the accepting hospital and then reviewed with their attending physician (who would need to be woken up) and then, once all of the paperwork had been accepted, the call would have to be placed to the ambulance company to find transportation for the patient.
It was close to 2:00am when most of the process was completed and all we would need to do is call the ambulance and arrange for transportation.
This was when we were approached by the parents who asked that we "wait until morning to transfer the patient". - "This is too much for her" mom said.
She was right. Her daughter woke up to go to school early that morning, she was in a noisy school, followed by a tough conversation with them about how she wanted to end her life which lead to a trip to the Emergency Department. The wait for a bed, the evaluation by the Doc and the RN, the multitude of questions that I had asked her about her ability to be safe (not to mention the tears that followed as a result of the intensity of the discussion)..it had been a long day for her.
As the ER was quieting down a little, we met as a team to discuss the issue and then followed up with the Administrator on call to determine if she could buy some time in our ER and get a little sleep before being transferred to an inpatient psychiatric unit where the multitude of questions and evaluations would start all over again.
"This isn't the Hilton" - okay - we expected this because, Emergency Departments are busy (we mentioned this before right?).
At the end of the collaborative discussion, we advocated for our little patient and when I left her, one my colleagues had taken the oversized bear out of our waiting area and placed it in a chair that was at eye-level to where our patient slept soundly on a guerney in a quiet area of our ED. Mom, coverred in the warm blanket provided to her, watched over her daughter until the morning when she would be transferred out around 7:00am.
I wish that every congressman, congresswoman, senator, advocate and critic could see what we see every day in Emergency Departments.
What I know for sure is that this is a critical issue demanding the same attentive care that we all strive to provide for our patients every hour of every day they are with us.
