By Stacey Kusterbeck
Vanderbilt University Hospital is trying to manage a surge of patients with mental health and/or substance use issues, but that is a challenge when there is not an attending psychiatrist present at all times.
Alan Lewis, MD, PhD, is an attending psychiatrist at Vanderbilt University Medical Center who frequently provides consults for these patients. Treating addiction is a core component of psychiatry, and many patients with substance use disorder also present with other psychiatric diagnoses. “For these ‘dual diagnosis’ patients, it can be challenging to know what type of post-hospital care would be most helpful,” Lewis says.
Not every patient with a mental health or substance abuse issue needs a formal psychiatry consult. Lewis wanted to know what factors led ED providers to request consults. For emergency clinicians, obtaining psychiatry consults can be particularly challenging during off-hours.
In other cases, some emergency physicians (EPs) might obtain formal psychiatric consults because they are uncomfortable managing treatment alone. On the other hand, EPs might need consults because they struggle to access proper resources at all. Once a formal consult is underway, it triggers the involvement of social workers and other personnel who can help with referrals to inpatient hospitalization or detox facilities.
“I reasoned that if there were specific challenges that could be alleviated — either through highly targeted educational interventions or the reallocation of logistical resources — emergency medicine practitioners might be able to provide the same high level of care, without the added time to obtain consultation,” Lewis says.
Lewis wanted to know if there were differences in attitudes about caring for these patients between resident trainees and attendings — and if physicians believed developing a skill set in emergency psychiatry warranted a formal rotation (either mandatory or elective). Lewis surveyed 97 ED clinicians, including residents and attendings, about these issues.1
Most participants said improving care for patients with mental health or substance abuse issues would have an outsized effect on ED efficiency overall. Respondents indicated they felt at least moderately comfortable caring for common presenting complaints among these patients.
Many respondents believed resident trainees should be exposed to a formal emergency psychiatry rotation. Emergency medicine residents only have a few years to learn about almost all areas of medicine and surgery. “That they felt this area warranted several weeks of their time illustrates how important improving care for these patients is to the field of emergency medicine,” Lewis observes.
There were a few factors that motivated EDs to formally involve consultant psychiatrists:
• Difficulty in identifying the “right” level of care for patients. For example, providers struggled with determining if a patient required inpatient psychiatric hospitalization vs. partial hospitalization, or inpatient detox vs. rehabilitation.
• Understanding how the patient’s insurance plays a major role in their post-ED care options. “Insurance plays less of a role for most other presenting complaints in EDs,” Lewis notes.
Psychiatrists can help EPs understand what is, and is not, available to a patient based on insurance status. “It is unfortunate that this is the case,” Lewis laments. “But knowing what services a patient can get plays a role in clinical decision-making and safety planning.”
• Needing help with the actual operational process of making referrals to outside treatment facilities. Social workers, case managers, or behavioral health nurses can help with these logistical issues during consults. “To me, these findings were exciting because they are addressable,” Lewis says.
Overall, the survey findings showed EPs believe improving efficiency and quality of care for these patients was important. Respondents agreed providing psychiatric and substance treatment is part of the job description in emergency medicine.
“As such, I am extremely optimistic that psychiatry can support emergency medicine through highly focused, brief educational experiences,” Lewis says.
Focused training, conducted either in the classroom or the simulator lab, can, for example, cover how to identify appropriate levels of care. In other cases, ED providers know exactly what level of care a patient requires, but just need some help placing the patient in the right place. “Psychiatrists can work with social work and case management resources in those cases,” Lewis offers.
All emergency clinicians want to feel as though they are within their scope, practicing in a logical, reasonable, and reproducible manner. For patients with psychiatric disorders, it is not as clear how to do this.
“The presentations of emergency psychiatry patients seem to differ so much from the presentation of patients with acute MI or sepsis that it might seem impossible to practice in a standardized fashion,” Lewis explains.
However, for most psychiatric or substance abuse patients, Lewis says standardized practices are possible. Psychiatrists can work with EDs to develop a plan according to the patient’s history and current presentation based on interviews with the patient, family, or other clinicians. Next, clinicians can document a strong rationale for why a specific disposition was chosen.
For instance, EPs can document specific subjective and objective findings, and explain how those findings support an overall determination of risk to the patient or others. “From there, it is critically important to document how that risk is best mitigated,” Lewis stresses.
That might mean safety planning with the patient and family, referring the patient to an intensive outpatient program, or hospitalizing the patient. “Psychiatric consultation should still be obtained for patients with more complex presentations,” Lewis notes.
Emergency clinicians should consider requesting a consult for patients with catatonia, or patients requiring an adjustment of psychotropic medications that are not commonly encountered in EDs — which might produce side effects if prescribed at the wrong dose. Criteria on which psychiatric patients require a consult will vary depending on an ED’s personnel and community resources.
“There is a role for protocols in guiding when to think about consultation. But these protocols must be developed by each ED,” Lewis says.
REFERENCE
1. Lewis AS. Emergency medicine practitioner perspectives on caring for patients with psychiatric and substance use disorders in a large academic medical center. Gen Hosp Psychiatry 2023;80:68-70.
Difficulty identifying the “right” level of care for patients, understanding how insurance plays a major role in post-ED care options, and needing help with the operational process of making referrals to outside treatment facilities all are administrative and bureaucratic headaches with which clinicians could use assistance.
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