Psych Boarding in the Emergency Department
Transcript
0:47
All right.So Tyler.What are you obsessed with this week?All right.Well, I'm obsessed with this specific topic that I've been doing some little bit of research and reading about, and actually, in the process of writing a A with two of my favorite colleagues and I have a surprise for you.
1:04
Okay, the surprise is I brought in a guest who knows way more about this than I do.Alright, so who is it?All right, so this is dr.Catherine Kate reading, ER, who is an emergency medicine doc here at Western Michigan.
1:24
And also she is the assistant Dean for tell me again.Clinical application clinical applications.So basically the third and fourth year of medical school, okay?So and you may know her as the spouse of one of our dear friends, Mike reading here.
1:42
Never heard of them.Yeah, just kidding.The Bears and the podcast.So he, oh, yeah, he doesn't listen to the podcast so we can say whatever you want to about him.Okay cool.Okay, so well.Hey thank you, thanks for having me.
1:59
Yeah, so dr.Kate tell us about psychiatric boarding in emergency departments.What is that?Yeah.So psychiatric boarding is probably something that a lot of people would know about or think about For emergency physicians, it's become kind of a Mainstay of our day-to-day.
2:19
So boarding itself in the emergency department is not exclusive to psychiatric patients, but it happens when a patient will come in and they have been seen and treated and stabilized by the Emergency Physician, but there's essentially no room at the end.
2:36
There's nowhere for them to go.So they physically stay in the emergency department room.And it has a lot of negative safety issues, overall care.It's pretty distressing for the Emergency Physicians involved, because that room is being tied up and it's less room for new patients to come in.
3:01
So the waiting room will fill up.So it's a, it's a big problem for us nationally, but lately because of the reduced psychiatric beds.We've had a real increase in the number of mental health patients who are essentially living sometimes for days to months in our emergency department months.
3:23
Oh my gosh, I I mean, I don't know what the emergency department at your hospital looks like, but ours doesn't even have like walls.It's like curtains.So how could you possibly live there for months?Yeah, it's a huge problem.So emergency departments in general, like we barge designed and built on efficiency, See and getting people in and out quickly and and to where they need to be.
3:48
And so a lot of our metrics are based around the idea that our average length of stay is less than three hours.So they're not built for people to stay a long period of time.So like you said, sometimes it'll have walls, they don't have Windows, most emergency departments, don't have windows.
4:04
So a lot of times we have patients, who have literally not seen the light of day for four weeks.So just so I'm clear that they Patients who are experiencing a mental health crisis.They come through the emergency department because that's typically where you go or they're being referred there, but there's no psychiatric beds for them and so they just but we can't ask them to leave because they're in a crisis and we have this emtala law that says we have to stabilize people, but we can't stabilize them because the emergency department isn't set up to stabilize people in a mental health crisis.
4:39
And so they just end up staying in the emergency.Apartment.And then we don't know what to do with them.I mean this is the sounds terrible.Yeah, and for me personally, you know, obviously being married to an ethicist in a psychiatrist.
4:56
We talked about this a lot, it contributes to this idea of burnout and what some people refer to more as like moral distress of the physician.Right?You come in and you want to take care of patients.But then you actually wonder if you're like, you're able to do that.
5:14
To the best of your ability and whether their rights are being violated because you're not able to provide the care that you want to, but you also have a duty to them that you, they have a reasonably safe discharge plan, so if they're not able to go home back to that environment safely, then you do have to keep them.
5:32
So, yeah, we have a, I have a lot of different examples of how this plays out of the ethical and kind of legal challenges.So so so Say that I am experiencing or one of my loved ones is experiencing a mental health crisis.
5:48
Say, somebody is suicidal or they're psychotic.Obviously I want them to get the care that they need.So I'm going to take them to the emergency department of my local hospital and when I do that they get admitted, they enter the healthcare infrastructure and They get stuck in limbo, in the emergency department is that?
6:12
What's happening?Yes, that's exactly what could happen.If you're not at a facility that is adequately resource.With enough psychiatrists, and specifically psychiatric beds, a lot of times they end up being held in a limbo status and for a lot of patients, I think in the general population, they think when they come in, just through the front door of the hospital to the emergency department that they've somehow like been admitted to the hospital.
6:38
But it's way more complicated than that.They're still technically like, in an outpatient state in the emergency department and so until someone officially, like, accepts them to an inpatient bed, they're kind of in a limbo State.And so if there's not a psychiatric unit in that particular Hospital, what happens.
6:59
So, we have to look for the nearest safe discharge plan that we can come up with.So here we're in Southwest Michigan.Michigan will start contacting Regional hospitals, nearby Grand Rapids Battle Creek, will reach out to Detroit, sometimes Saginaw.
7:19
And then if we can't find anything in the state of Michigan, will start contacting States outside of Michigan.Indiana, tends to have some availability for us.So, yeah, you could come in and end up being transferred Far Far Away into another state.
7:38
So across the state or even to a different state and it seems to me and I get like I'm not a psychiatrist or an you know, medical doctor at all.So my loved one gets brought to the hospital there in a psychiatric distress, Mental Health crisis and they have to stay in the Ed, the emergency department until they get transferred to a place and that could be across the state.
8:05
It could be through a different state and it's not like that.Happens quickly, right?So they could have.It could be like, you said days weeks.Sometimes extreme cases.Maybe even several many weeks.What is happening to the patient while they're in this limbo status?
8:22
Are they being treated appropriately?So that's a great question and for a lot of us, we try really hard now to put processes in place that weren't typical of our emergency department setting and care to try to make sure we're addressing the problem as it as it grows.
8:43
Emergency physicians usually work in 8 to 12 hour shifts.So there's a lot of transitions of care and that has always been a place of significant.Patient safety, when we're in transitioning over, who's taking care of a patient.
9:00
And for someone whose total length of stay is now, an excess of 1,000 hours, you can only imagine how many handoffs and transitions of care that they've had.And that has to impact the care that they're receiving.
9:15
Because there's just no way to have that continuity.We're just not built for long-term care in that setting.So, and in other things that just basically, Means I have to remind myself like when I go in to see patients.Now I often have to make sure that I run through a mental checklist.
9:33
Like are you hungry?When was the last time you've eaten?Because I'm going to order a diet order, I don't normally order food for my patients.The cafeteria doesn't even come to the emergency department, sometimes because most people coming in that we're seeing, we don't let them eat for those three hours because they might need surgery or they're going to go home soon.
9:52
But patients, that might be living there.We don't have showers.An emergency department.So we have to think about how to get them.Bathed and clothed children who come in those are our most vulnerable patients, the children because there's far less fewer number of psychiatric beds available for children.
10:12
They end up with the longest length of stays, and those are the ones that, you know, break my heart, because they can't go outside, they're not going to school with.There's basically living in an Environment that it's not meant, not meant for children.
10:29
That can't be, I would think beneficial to their long-term mental health.It has to be a traumatic environment for them.So, what do we do?Can you dr.Redinger fix it for us, please.
10:45
What this sounds?The sounds terrible and I just was reading studies on how Windows help outcomes.And like the Arches you department is just not a place to stay.It's They going to be traumatic.So what should we be doing?And I think what also makes this heartbreaking is that everyone?
11:04
So the patient, if they brought themselves in or the family members, they're doing exactly what we would hope they do, they recognize the Mental Health crisis.They go and seek appropriate care and then they're being stuck in this, you know, terrible hole in the healthcare system.
11:20
So what do we do?So I think there's kind of two ways that you can look at this from from a societal standpoint.What do we do?Well, and like many things it comes down to funding, we need more funding for mental health.
11:37
We need more psychiatric beds for the patients to go and offload, the emergency departments.And that that's going to help in some we probably also need some funding to help with education and maybe restructuring the way that our emergency departments look.
11:55
So that we have here at Borgess, we've actually had some improvements made to our emergency department over the last several years to create basically like eight psychiatric, observation beds, if you will that have showers.
12:14
They're quieter.So they're away from the traumas that are coming in.They have their built kind of with more of a psychiatric unit in mind, but they still don't have.Toes but it's an improvement.So so those things can help from day-to-day standpoint though.
12:34
I think we also need to address it as the individual Physicians coming in.How do you best?Make sure that you're taking care of the patient in front of you and that's going to be a little bit different than there are typical emergency medicine mindset when we're taking care of a long-term patient.
12:53
So and I think we need to so, be mindful that Situations change.And so each day that we come in, we need to make sure that we're seeing those patients that are boarding.We need to re-evaluate the situation and if there is a different safe, discharge plan, make those changes and and come up with an alternative making sure that they're getting access to the food and water and showers that they need.
13:20
It's multifactorial problem, is there anything.So I'd hate for X2 think it would be worse to take somebody to the emergency department if they were in a crisis.Although for some of these patients that might be worse to exist in that limbo State than to have, maybe not taken them.
13:42
I don't know if I had a family member who I can imagine this happening to, what should I do?Should I drive them to a place where there's a psychiatric hospital nearby or what could I possibly do in a situation like this?Yeah so I mean with anything We all were the open doors of the hospital.
14:01
We want everyone to feel like the emergency department is the safety, net of the community.And that if you need help or you feel unsafe, we want you to come through our doors still.I think in an acute crisis, it is better to come in, then to try to go at it alone that that's not what we want for our patients.
14:25
So we do want them to still come in. and be seen, but I think it's also being proactive on the outpatient side.So maybe from a family standpoint, not waiting till the very end moment of Crisis.
14:45
But talking with primary care.Physicians may be getting in touch with mental health resources in the community sooner just broadening your network of resources.So that the emergency department is kind of more of a last resort option.
15:03
We have a really well connected.Wonderful group of people in our community that other hospitals don't have.So we're doing a lot here to make this more Equitable Fair solution for our mental health patients.
15:23
But it's even here it's a problem.So it's going to be a long roll dr.Iyengar, do you have potentially a case that illuminate?Some of this or illustrate, some points that you think are important from an Ethics perspective?Yeah, absolutely.
15:39
So a lot of this to comes down to the state that you practice in and live in because a lot of our mental health code is regulated, At a state level.And so here in Michigan, you can be admitted on a voluntary basis.
15:55
So basically, you are coming in but you're signing yourself into the hospital.For psychiatric treatment or you can be admitted on an involuntary basis.And the general thought is that we want our patients to maintain their autonomy as much as possible and participate in treatment, that that's a better outcome for them.
16:16
So we prefer if it's safe If they have the capacity to do so that they come in on a voluntary basis where this gets kind of tricky from an ethical standpoint is let's say a patient comes in their cooperative and they're on a voluntary basis and they're seeking admission because they're feeling suicidal and they're at a point where they're finally wanting to come to care there, haven't really told their family members this but it's pretty serious.
16:47
And they outline a Pretty active plan and your concerns, your glad that they're coming in, but you're concerned about their safety.In that case, I would want the patient to sign in, on a voluntary basis, because right now, they're Cooperative, they have capacity.
17:04
But I would feel unsafe based on all the information they told me about their detailed plan.Just letting them go if they change their mind.Well, what happens now is they get seen.Maybe the psychiatry With the social workers kind of sees them as well agrees.
17:22
And we start the process of trying to find a bed.If there's a delay, they often change their mind, I'll come back later or there's no beds available.I'll be okay.I really have this important appointment.
17:38
I can't miss.And then we get into a really tricky situation of whether I should hold them involuntarily based on the statements that they had made prior.Or let them go.And sometimes, again remember our ships are only 8 hours.
17:59
So if this whole process takes beyond that the next Doctor is having to deal with this conversation of this was not the change of plan.This was not what the first doctor told me and it becomes really ethically challenging on what to do.
18:17
The.Involuntary holds future.When you are saying they have the capacity to sign themselves in.You're also saying that they have the capacity to change their mind.And so that becomes really difficult when when they they don't, they feel the delay is causing a change in their and their willingness to seek treatment.
18:45
That that sounds really tricky.So are there.Rules of thumb?Is there a kind of statement that you have to take more seriously than another kind of statement?I mean, is it just a I feel in my gut, like this person really could hurt themselves or somebody else.
19:00
If I let them leave, like how do you negotiate then when it's appropriate to allow somebody who came in voluntarily to then voluntarily leave or when you need to make an involuntary?Hold, yeah, I mean, I don't know if there's a hard and fast rule.This is Where I think it's really helpful to go back and then like take a fresh look and redo the evaluation at that moment.
19:26
I always try to eight lean toward making sure that the patient is safe and being open to Alternative, safe discharge plans.So in that case, if the patient had a family member, they could contact.
19:45
And perhaps if the plan involved, specific weapon or something, if those have been removed from the house and we can get a follow-up appointment with the family doctor or Community, Mental Health provider in the next 24 to 48 hours, those sometimes can be alternatives to kind of activating an involuntary.
20:12
Hold.But ultimately It kind of comes down to whether you feel that that patient is able to keep themselves safe.So there are situations where the patient will come in voluntarily seeking help and they've said the right things are said the wrong things and you have concerns about them and then they try to change their mind and leave and you involuntarily hold them in and then they get stuck in this limbo.
20:44
So, They came in voluntarily.And then are stuck in this situation where they can't be transferred and they're being boarded in the emergency department for days weeks.Sometimes and that just sounds absolutely terrible for a lot of different reasons.
21:05
Yeah.And if we retired mom voluntary but patients who come in on an involuntary basis.So they've been petitioned by someone in the community, someone in the family and then we We do certify that.Yeah, we don't think they have capacity or they're acutely.
21:22
Dangerous.So we do go through that process in Michigan.That is supposed to trigger, basically a 72-hour, hold that.Within 72 hours, they can go and have their case heard before mental health court, be admitted to a psychiatric unit.
21:39
And have, you know, another evaluation done to kind of confirm, whether they still need to be admitted.And when we get past, Past those 72 hours, still in the emergency department without a hearing without a second psychiatrist evaluation, that's another kind of timeframe that it feels like that due process is being violated.
22:03
And and you want to get them to what they need, but it becomes prolonged.And this isn't just a problem in Southwest Michigan or Michigan or in the midwest.I mean, this is Nationwide.Yeah, and how I said the state's usually determined the individual laws for the mental health code, a lot of states have tried to address this for many years and have various proposed solutions that in theory sound great.
22:37
But again, if they don't come with the necessary funding to back them, don't work, for example, Virginia had this problem.And they proposed a law in which if at basically The 8 Hour Mark, if you hadn't find a found a bed State Hospital would have to take them.
22:57
Well, the state hospital is essentially got overrun because they weren't adequately resource and staffed and funded and it didn't really it just kind of pushed the burden from the emergency department to the state psychiatric hospitals.You could also the look at potential Solutions, Then but you're just ended up kind of Shifting the deck chairs.
23:20
If you just admitted them all to like an observation unit and a medical floor, you really have again.Haven't gotten them to the care.They needed their just shifted again out of your emergency department, but now it's the internal medicine departments problem.
23:39
Wow.Wow, any optimism, can we end up Nah, only do, I think with all ethical problems, the first start is awareness.So this is definitely on the radar of the National Emergency societies.
24:01
It's a big part of what we're advocating for at a state and National level with our with our lawmakers to get improved access to care.So I think that's really helpful.And then I also think that we're going to have to have a shift in education in general with in our Emergency Department training programs that we don't typically have much training in mental health.
24:31
It's not part of our typical board requirements but lately it seems that it's become a huge part of our jobs that you know, on any given day, I could actually have more psychiatric patients that I see car accidents.Broken arms.You know Stitches the typical bread and butter things, you think go to the emergency department just it's a much larger proportion of what we do.
24:55
Yeah.Well, we appreciate you talking about the topic and appreciate what.I'm sure is good advocacy and patient care.On this front.It sounds.It sounds tough.Yeah.So that's what that's what we're obsessed about this week.
25:11
The last several weeks.