Tuesday, January 30, 2007

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.

Sunday, November 12, 2006

Listservs and Innovation

I was reading one of my favorite listservs this morning. It has to do with Addiction and the way healthcare providers encourage patients to seek treatment for their addictions to alcohol and drugs. One of the things that is encouraged frequently with Alcoholism is the importance of attending 90 meetings in 90 days. Not an easy task when trying to get your life back from a disabling addiction but it is something that definitely helps when you're trying to find new ways of living and re-establishing relationships.

Attending meetings, and therapy groups (outpatient or other) is really hard to do because it calls for consistency and change. A former colleague of mine once described the communication differences that you have when you're working with patients with addictions - "You (as a counselor) say: 'you need to attend as many meetings as possible, develop coping skills to maintain sobriety and (if needed) take medication as prescribed and follow up with your individual therapist'. Upon hearing this, your patient usually interprets this as: 'you know everything you used to love to do? - well, you can't do it anymore'."

As practioners, we think we're helping our patients when what we really may be doing is scaring the heck out of them and increasing the vulnerability they already feel - which increases the potential for relapse.

I love listservs because of their ability to gather practitioners from all areas of medicine in all areas of the world in a manner which encourages and fosters dialogues about what really works in healthcare. The potential to develop innovative practices is phenomenal.

This is crucial in areas such as Addictions and Alcoholism. The book "The Disease Concept of Alcoholism" was published by EM Jellinek in 1965. It contains several defininitions of alcoholism - my favorite is "when one's drinking causes any damage to the individual, to society or both". I like this definition because it's very subjective. You never really know what is so damaging to someone that they make a decision that their life needs to change dramatically. Even now - in any Emergency Department in the country, healthcare practitioners see patients whose lives have been affected by alcohol - whether it is as a result of their own drinking or as a patient affected by an alcohol related accident or illness.

As the knowledge and understanding of Addictions and Alcoholism has come a long way since 1965, the need for innovative practices remains - if only because of the potential to assist those who are looking to regain their lives.

www.niaaa.gov
www.criticalS2.com

Monday, September 25, 2006

Legacy

I once came across an article written and incorporated at Minolta (the copier company). They were utilizing the topic of legacy to illustrate some of their leadership responsibilities and practices. One of these involved having the members of their company review their "Responsibility of Success".

The questions asked in the "Responsibility of Success" help define the legacy that Minolta's team leaves on their organization. While sometimes it's easy to think that these practices only apply to the organizations leadership, it is difficult not to see how these values or the answers to these questions can reflect the mission, attitudes and legacy of an entire organization.

"What will our legacy be?

What will yours be?

What mark will you make?

Years from now, will your team look back at this time and feel it was time well spent?

Or will they feel used?

When you tell your children what you accomplished here, will they be proud?

Will you be proud?

Did you help your community?

Were your business practices honorable?

What was stronger in your workplace, ideas or politics?

Was it all about the money?

If so, what did you end up doing with that money?

Were the sacrifices too great?

Were you committed to positive change?

Were you committed to providing opportunity?

Did your organization set an example for your industry?

Did people really want to work for your organization?

Did you have fun?

Did you make a difference?"

"Did you make a difference?" - Isn't that a great question? I love this and applaud Minolta for paying attention to the legacy that we all leave not only in our families but in our careers as well.

One of my favorite guys in the world was discussing the changes going on in healthcare and how these changes are being driven by changes in technology, patient care, insurance and pharmaceutical companies and the needs of the almost 47 million Americans in this country who are uninsured. He said "if you think that healthcare is going to change with a 450 page document sitting on the desk in Congress, you're gravely mistaken...healthcare is going to change by communicating best-pactices and evidenced based standards of care, cutting edge research and all that we do every day to provide the best care for our patients.

The question still applies for those of us in healthcare and is even more imperative today - what will be our legacy?

Saturday, September 16, 2006

Managing Stress in Fast-paced situations

Got Stress?

Who doesn't right?
When was the last time you were really stressed out? What happened? What was your response? When you think about your response, was it an appropriate response for the situation or did you just 'go off'? How many times have you heard the expression "going-postal" or "kirking out"? Are ya tired? Any idea how to manage any of it?

It amazes me that it seems like the amount of stress we're all taking on every day seems greater. Greater in such a way that when you sit quietly and listen to the wind blowing through the trees, it takes awhile to realize how beautiful and relaxing it is since you haven't been paying attention.

Consider this your wake-up call.
It's Fall here on the East Coast; time to get on the bike and go for a ride. Time to go apple picking. Time to go "fall-foliage peeping" as they say - yes 'they'. 'They' who know the importance of taking time and paying attention. 'They' say we need to be better at this...
We need more they; we need to become 'they'.

I think that the term "fall back and regroup" has some significance here, if only because it's the season to fall back and reflect.