Balan Yener, Murrell Karen, Lentz Christopher Bryant. Big Book of Emergency Department Psychiatry

CRC Press, 2018. — 373 p. — ISBN13: 978-1-138-19807-4.If you are reading this, you understand the importance of the specialty of caring for patients with psychiatric needs in an emergency setting. Our clinical experience and mounting evidence of increasing demand suggest that the need for specialized care of patients in emergency departments across the United States is critical. We decided to write this book to delineate operational strategies, discuss treatment care modalities and methodologies, and share experiential stories of those of us caring for our fellow humans every day. In doing so, we strive to dissipate the stigma of caring for patients with emergency psychiatric needs, and to improve the overall quality of patient care.
This book was written for trainees, clinicians, hospital administrators, and, most importantly, our patients and their families and advocates. The content of the book is designed to complement other published, regimented treatment protocols, by ensuring that the human element is retained. The field of emergency psychiatry is on the cusp of a renaissance. With legislation, such as the Mental Health Parity Act, the subsequent Addiction Equity Act, and more recently the Affordable Care Act, patients are increasingly aware of the availability of treatment options, and have deservedly demanded a fair and similar level of standard of care for their mental health needs. Now, more than ever, we need to advocate for our patients. There is a need to create high quality, compassionate, low-cost healthcare for patients with behavioral health needs. In the uncertainty of today’s political climate, mental health providers need to be prepared to provide support to the patients that they are currently caring for and initiate a safe transition to alternative mental healthcare options if needed.
Hopefully, most clinicians will be able to act within high moral and ethical boundaries and consider pro bono work for their most needy patients. The authors of this book recommend that readers reach out to their local government officials and communicate the need to ensure that our patients’ mental health needs will continue to be met now and in the years to come. With the increase in patient care demand, and the numerous opportunities for improvement in daily emergency department operations, it is imperative that a sophisticated and humane approach is adopted for the care of patients with behavioral health needs. There is no other viable choice but to go in this direction. The other option, ignoring this renaissance in the field of emergency psychiatry, would result in worsening stigmatization, marginalization, avoidance, poor patient care, patient and staff injuries, burnout, and increased costs for hospital budgets and patients. Annually, over 2 million people seek emergency psychiatric care in U.S. hospital emergency departments, at a cost of over $4 billion. This equates to between 6% and 12% of all U.S. emergency department visits being related to psychiatric complaints. It is reflected in an average length of stay in the emergency department for patients with psychiatric needs that is double that of other patients. This in turn exacerbates emergency department overcrowding, which is a separate national issue with many repercussions.
Emergency department staff often feel burdened by patients with psychiatric needs — for no other reason than the variation in emergency department expertise and training in mental health. The anxiety of feeling underprepared as a clinician, coupled with decreased external resources for patients on disposition, can lead to inadequate care and negative patient and staff experiences. Following this seemingly dismal patient journey often leads to inpatient hospitalization subsequent to the emergency department visit. According to Agency for Healthcare Research and Quality (n.d.) analyses, one out of every five U.S. hospitalizations involves a mental health condition, either as a primary or secondary diagnosis. An American College of Emergency Physicians (2009) survey conducted in 2008 of 328 emergency room medical directors found that 79% of survey respondents believed psychiatric patients were “boarded” in their emergency department, with a third of patients boarded for 6 hours or more. Moreover, 62% of respondents indicated that these patients received no psychiatric services while they were being boarded. Patients are presenting to emergency departments with a plethora of psychiatric complaints and diagnoses. Over the past decade, this epidemic has led to a significant increase in patients utilizing the emergency department for quick access to treatment of psychiatric issues ranging from depression to acute psychosis. According to the Centers for Disease Control and Prevention (2009–2010), in 2009 and 2010, 24.2% of emergency department patients sought treatment for anxiety and mood disorders. In 2009 and 2010, patients sought treatment for acute psychotic episodes in U.S. emergency departments at a rate of 17.3%. Patients with substance use issues or comorbid substance use and mental disorders also add to the ever-expanding emergency department census; these patients presented to emergency departments in 2009 and 2010 at a rate of 27.7%. Given this national increase in psychiatric complaints presenting to emergency departments, and the apparent lack of a current standardized treatment protocol in emergency psychiatric care, a solid foundation is needed for practitioners tasked with building a treatment protocol within their own emergency department. Many of the building tasks that an emergency department administrator needs to consider in the development of an effective treatment protocol include multiple factors. An effective treatment protocol may include considerations, such as patient flow and staffing models that draw from current Lean and queuing methodology and theory. Building and maintaining staff–patient rapport is especially important in working with psychiatric patients that may have extended boarding times in the emergency department. The standardization of protocols for medication management, taking into account both medical and psychiatric medications as well as proper medical clearance and methods to keep medical clearance costs down, is also important. Lastly, proper diagnostic criteria for diagnosing psychiatric disorders, ethical issues, and risk assessment are also key elements of the emergency department protocols. All these topics are discussed in this book in a patient-centric manner and with explanations of how stakeholders in the community and hospital systems benefit from this discussion. Patient flow through an emergency department is always at the forefront of management’s daily operational tasks. With the addition of a psychiatric patient population to the emergency department daily census, metrics like boarding times and average length of stay can be significantly impacted. It is here where the importance of utilizing Lean and queuing theories and methods in the ED setting becomes a key to minimizing increases in these vital metrics. Factors such as wait times in the emergency department lobby, triaging psychiatric patients, rooming them, and ultimately discharging them from the emergency department all come into play in the game of patient flow. The ultimate goal of using Lean and queuing methodologies in the ED is to reduce overall length of stay, thereby decreasing operating expenses and potentially increasing revenue. Patient flow has a positive or negative impact on overall length of stay in the emergency department setting, but length of stay can also be affected by early and proper treatment with medications. Many of the acute psychiatric complaints that present to the emergency department can be quickly addressed by the administration of psychiatric medication, especially in cases where the patient presents with acute psychosis or agitation. Medications used to treat comorbid chronic medical conditions that the psychiatric patient presents with must also be properly reconciled and prescribed by the treating physician. The goal is to avoid possible exacerbation of the comorbid medical condition and in turn exacerbation of the psychiatric condition that the patient is presenting with.
Length of stay in the emergency department can be significantly reduced when a solid discharge plan has been developed with the help of the patient. Once the psychiatric patient is admitted to the emergency department, discharge planning must start. Discharge planning is a multifaceted endeavor that includes multiple staff and support persons directly and indirectly involved in the patient’s care. Any discharge plan that is developed must be viable in order to reduce the chances that the patient ends up returning to the emergency department shortly after discharge. Emergency department staff may find it difficult to interact and engage with some patients that present with psychiatric complaints. The importance of effective rapport-building with this population cannot be stressed enough. It is vital that any emergency department develops and implements effective patient rapport-building education and training for all staff, with an emphasis on interactions with patients presenting with psychiatric illness. A strong rapport with the patient can go a long way in terms of reducing potential job stress for the direct care staff and the frustration levels in the patient, which can lead to a reduction in potential violent episodes and hence staff injuries occurring in the emergency department setting. What is it like, from the perspective of staff working in the emergency department setting, to interact with and treat individuals with psychiatric disorders? What do they experience on a daily basis? What do they feel and think about? What are the motivators and rewarding experiences that drive emergency department staff to work with this patient population? From the emergency department physician to the emergency department psychiatric social worker, we include chapters
in this book that address the differing and similar perspectives of various emergency department staff working with psychiatric patients.
The topics discussed previously are just a taste of what the following chapters in this Big Book of Emergency Department Psychiatry cover. We believe that the focus on Lean processes, queuing theory, metrics, and discharge planning as well as the various emergency department staff perspectives on working with the psychiatric patient presented herein set this book apart from others in the field.
As this book is written for patients, advocates, clinicians, physicians, and hospital administrators, the tone in this varies according to the applicable audience for each chapter. The authors deliberately shift the focus of the audience to enhance a sense of empathic awareness of other audience members’ experiences.
The authors of this book are here to make clear that the subspecialty of emergency psychiatric care has the same basic objectives and stages of care as the rest of medicine: establish a therapeutic relationship with the patient, treat for recovery, and ensure the maintenance of wellness. This renaissance in the field of emergency psychiatry begins with a cultural paradigm shift. We are proud when we see the fruits of our labor and the change we bring to patients and their families, and we know that the contents of this book coupled with the cultural shift in care delivery will lead to sustainable success!