Discharging patients from ED in middle of the night

[1edyfirel]

I'm a psych resident and cover the ED at a couple hospitals. We don't have a dedicated psychiatric ED, or even space for these patients in the ED. At Hospital One: psych and ED have a great relationship; we do not d/c psych patients from the ED in the middle of the night, as it's thought to not be a safe dispo (these are ppl w/SI contingent on housing or intoxicated but will clear by morning). Night team will s/o these patients to day attending and resident, and they will lay eyes, touch base w/SW, and then make final dispo. And often whatever crisis brought them in passes in light of day and patient can contract for safety.

At Hospital Two, the situation is much different. The ED attendings put a lot of pressure on the psych residents to dispo the psych pts ASAP and get them out. This means we *are* d/c'ing people in the middle of the night and then asking them to come back in the morning to speak to SW abt housing or some other psychosocial stressor. (Again, these are patients who aren't appropriate for inpatient psych and again SI contingent on housing or passive SI w/no plan in setting of psychosocial stressors SW can help with, but not until the morning). This feels like an unsafe dispo to me and many of my co-residents (especially in light of our experience at Hospital One): there's also no guarantee they will get some kind of housing/shelter in the morning. I won't go into specifics but I did have a bad outcome w/a pt I d/c'ed in the middle of night (staffed with attending, of course). In the morning he did not get housing, and then made a suicidal gesture.

The alternative is resident getting into argument w/ED attending over having the pt stay thru night in ED to see SW, and then calling psych attending at 3 a.m. to let them figure it out. And we can totally do this, but it's wearing to have to do this repeatedly, is terrible for resident morale (esp when we spend several weeks working w/these ED attendings), makes relations between the depts. terrible. And of course there's the power dynamic of resident-attending at play. Or we could also try to admit, though it's often a very soft one and would take a bed that someone in acute psych decompensation needs.

I'd love to hear people's thoughts about the situation and have a million questions, as I don't really know many other psych residents at other programs. Is the situation I have at Hospital One (where policy is to NOT d/c psych patients in middle of the night) unique? Do you guys d/c (or recommend d/c, as I guess most of you are technically consultants) psych pts in the middle of the night from the ED (and again, ones deemed low acute risk for suicide and not necessarily warranting inpatient psych admission, but w/ some acute stressor, be it housing or something else)? Do you feel safe doing it? And how is your system set up--does your ED put pressure on you to dispo these patients ASAP? Also--does anyone know of any papers that explore this? I've been digging around but can't find anything on this topic specifically.

Finally--thanks SO much in advance for your thoughts.

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[Merovinge]

What you are describing is a really common and really tough situation, so firstly congratulate yourself that you are tackling the situation logically, seeking expert opinion and journal articles. ED psychiatry is awesome because you are tackling both the acute psychiatric stressors but also acute psychosocial changes, interfacing with other doctors, and doing it all by the seat of your pants so to speak.

ED policy for psychiatric patients vary wildly so I am not sure there will be the commonality you are searching for. As a resident I worked at an ED where every patient who had "psych" as chief complaint was an expected admission, and it was considered a huge accomplishment to discharge someone (even if they were not seeking admission). I would say among those seeking admission the rate was about 95% (this is a VA). This is a very risk-adverse (at least liability adverse) strategy pushed from the higher ups over the years after a patient discharged from the ED committed suicide. It was also very demoralizing for residents to admit for weak SI and personality disorders; in fact we had a gentleman with >100 admissions in the past 8 years.

Conversely many EDs operate like your hospital number 2, as some ED docs are financially incentivized to get patients out fast (the GOMER starts to flow in these ED's). The infrastructure may be such that it cannot support the care that patients in hospital 1 receive.

The ideal situation is really a psychiatric ED that can hold folks briefly and get help with psychosocial needs but certainly the majority of places do not have those.

So what does this mean to you? I would consider a few things:
1) If it is a tough call, your attending absolutely needs to be involved, including advocating for your treatment plan to the ED attending. As an intern, I had my psych attending voluntarily drive in to see the patient himself then support our treatment plan to a very mean ED attending (who had yelled at me for being an idiot) and I cannot tell you how much that 1 experience changed my confidence in my program, myself, and doing the right thing for the patient.

2) It is okay to have different practice models at different sites. Residency is a chance to see how medicine is practiced and learn what you think works well and what does not work out. You will not always be able to do what you think is best, but that is okay, because you are a trainee and it ultimately up to the attending. If there is something clearly egregious happening threatening patient safety, you should put your foot down, put for most grey-area things in medicine it is okay to let go of feeling 100% responsible (particularly as a resident).

 

[smalltownpsych]

I don't like to discharge any intoxicated people who present to ED and I am consulted on merely because of the unpredictability of behavior and increased agitation as the BAL lowers. Mainly concerned with potential danger to others more so than themselves. I don't want us to be the hospital that let some crazy drunk out while still inebriated and they killed some innocent folks. No one has ever really argued with me on that one.

 

[Jules A]

I'm surprised neither hospital has psych social work staff on overnight. All three of the hospitals where I take call do and they work with the ED docs on disposition.They are an inexpensive option as compared to either admitting patients who really don't meet criteria or housing them in the ED except in the cases of intoxication when we keep them until they are considered clinically sober. I'm almost never called overnight to consult on a discharge and in the rare cases I am its usually someone we end up admitting.

 

[splik]

I'm surprised neither hospital has psych social work staff on overnight.

why surprised? they have free (slave) labor in the form of residents to be the social workers. much cheaper. admitting patients is only going to happen if the hospital is going to make money of it. .

 

[hamstergang]

At Hospital Two [...] we *are* d/c'ing people in the middle of the night [...] who aren't appropriate for inpatient psych and again SI contingent on housing or passive SI w/no plan in setting of psychosocial stressors SW can help with, but not until the morning

I have no problem discharging these patients. They are in the Emergency Department of a hospital, not a shelter or a soup kitchen. If you are the psychiatrist and don't feel they need inpatient, then they need to be discharged. Some might try to manipulate you and threaten suicide if you don't fix their non-psychiatric, non-medical problem, but you don't have to feed into the manipulation.

Edit: while I say this, I don't know that I've run into such a case as an attending yet, and when I was a resident I don't know if I got to do what I felt was right, so be careful trying what I've written

 

[NickNaylor]

We do not cover EDs solo (there is always an attending on-site for our ED experiences), so I will freely admit that I have less difficulty in dealing with this since, in particularly contentious situations, the attendings will simply sort it out among themselves. However, I think seeing patients in the ED and the relationship between you and the ED staff very closely parallels the relationship between a psychiatric consultant and the primary team.

Ultimately, you are the expert with respect to these issues. It is not your problem that the ED attending wants to get the patient out. It is not your problem that they're worried about their LOS, dwell time, etc.. It is not your problem that they don't understand that psychiatric disposition planning often requires slightly more work than printing prescriptions and saying, "good day."

When I do consults - whether in the ED or on an inpatient floor - I see my role as making recommendations that I think are the most clinically appropriate for the patient. As a consultant, however, the primary team (be it the ED or whoever) is more than free to ignore my recommendations. They do so at their peril. If you document concerns about discharging the patient in the middle of the night and think that the appropriate thing to do is for the primary team to wait so that a social worker can do appropriate discharge planning (possibly requiring 4 hours of hanging out in the ED before that can happen), then you say as much to the ED team - both verbally and in your note. They are then free to do with that information what they will, including completely ignore it. I do not let the primary team pressure me into changing my recommendations or what I think is most appropriate for the patient or what I think is best for their care.

To be clear, I don't think this means that you can just tell the primary team to **** off if they decide to not follow your recommendations. As a consultant, I think it's your responsibility to do the best that you can with whatever plan the primary team develops. If the ED wants to discharge someone without waiting for SW intervention - for whatever reason - then fine, that's their choice. I will do my best to do everything I can for the patient within the limits of that plan. However, when I communicate with a primary team, I make it clear that this is not a plan that I think is in the best interests of the patient and explain why. Often a little explanation and teaching can go a long way, and you can get the primary team on board. Sometimes it doesn't and the primary team will do what they want to do.

Same thing when things go the other way - e.g., the ED/primary team thinks that inpatient psychiatric admission is indicated when it clearly is not. If they want to argue with me about that point, then I will happily explain my reasoning to them. It is neither their job nor their area of expertise to determine who needs psychiatric admission and who doesn't when they have asked a psychiatrist to specifically assess for that need. They can be all up in arms about it. It does not change my decision. Again, here I will try and work with them to develop a plan that they are comfortable with and is reasonable, but their discomfort with discharging a malingering patient or being told that a substance-induced mood disorder presenting with SI 8 hours after ingesting cocaine for the 10th time in the last 30 days is not an indication for inpatient admission is not my problem.

As a consultant - again, whether in the ED or elsewhere - working with primary teams that may have different thoughts about what to do with a patient, I think the key is 1) doing your best to satisfy the primary team and being as helpful as possible while 2) being comfortable with the fact that this is your field, you are the expert, and your word is what goes with respect to psychiatric issues. Sometimes this can be a tough balance. If you do too much of #1, you will get steamrolled by primary teams to do things that aren't, strictly speaking, appropriate. If you do too much of #2, then you come across as a dingus that doesn't play nice with others. I think the bridge between these two extremes is open communication. Ultimately, most people are reasonable, and I've found that clearly spelling out my reasoning gets people on board with my plan and recommendations. In the few cases where that doesn't work, though, then the primary team ultimately can choose to do whatever they want to do with the patient. That is part of the difficulty and frustration of being a consultant. You are ultimately there to advise the primary team on what is best based on your particular expertise. However, it is not your fault if they choose to completely ignore those recommendations.

Edit: In terms of hospital policies, our county site as a policy similar to that of #1. In general, all patients must have a SAFE discharge plan that requires that they be able to get to wherever they are going, and that place must be an actual place beyond "the street." However, other sites that we work at do not have this requirement. In those cases, I do my best to work with them, but as discussed above they are free to ignore those recommendations if they are adamant about discharging a patient.

I should also add that all of the above assumes that the primary team doesn't do something clearly inappropriate - e.g., discharge a patient that is an imminent danger to themselves or others. In that case, you need to do what is clinically appropriate, including involuntary hospitalization if that's an option. This somewhat removes the ability of the ED team to discharge the patient and binds their hands. They may get upset about it, but again, that is not my problem. I cannot with good conscience allow a patient to be discharged when they are acutely dangerous and would benefit from further treatment. In my experience, though, this rarely happens, and it's usually the grey areas that are "contentious."

 

[Bartelby]

It sounds like you are convinced that having patients stay through to the morning is the right decision. A couple of thoughts:

1- If this is a regular issue for residents bring it up to your department and ask them to sit down and discuss the issue with the emergency department. Having an adult conversation about how to approach this recurring issue is better than arguing it out again and again, for everyone involved.

2- At the end of the day you are a consultant. The patient is the ER doctor's patient. Make your recommendation based on your own best medical judgment. Document it. If they choose not to follow it that is their right (and becomes their responsibility). It's always better to work out an agreed upon solution, but I wouldn't get pressured into signing my name to a plan that I felt fell below my own standard of care.

 

[jaymon]

Personally, I'm of the mind that if you don't need to be admitted then you don't need to stay in the ED, so the ED and I are usually on the same page. If I'm concerned enough about a patient to not want them leaving in the middle of the night, I usually admit them. I'm still a resident so all of this is of course dependent on the attending agreeing, but they almost always do. Our ED residents and attendings are pretty good for the most part. If a person is intoxicated, they're not going to let them leave anyway. So I can say in my note that the patient doesn't meet criteria for psychiatric admission and that they can be discharged once they're medically stable. They don't consider intoxicated medically stable so they wait. We have SW around the clock, but there's usually not much they can do at night anyway.

One thing I'll do if a patient is expressing suicidality contingent on finding a place to stay is recommend discharge and talking with SW for placement, but rather than them sitting in the ED, they discharge them to the waiting room. Then in the morning, when SW can actually find them a place to go, they'll see them. They're safe in the waiting room, but they're not affecting ED wait times or anything like that. Everybody wins.

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[FlowRate]

Is the situation I have at Hospital One (where policy is to NOT d/c psych patients in middle of the night) unique? Do you guys d/c (or recommend d/c, as I guess most of you are technically consultants) psych pts in the middle of the night from the ED (and again, ones deemed low acute risk for suicide and not necessarily warranting inpatient psych admission, but w/ some acute stressor, be it housing or something else)? Do you feel safe doing it? And how is your system set up--does your ED put pressure on you to dispo these patients ASAP? Also--does anyone know of any papers that explore this? I've been digging around but can't find anything on this topic specifically.

I would say that our situation is a mix of your two, more like hospital one. There is pressure to move patients by the ED. We do not discharge patients without a safe discharge plan. We do discharge patients overnight, but they are typically a clear-cut, virtually-zero risk of harm case (chronic group home developmental delay patient got in another shouting argument at group home and is back in the ED for literally the 26th time this year.) We must staff all overnight discharges/changes in legal status (does not meet criteria) with an attending first (that means waking them up.)

I don't like to discharge any intoxicated people who present to ED and I am consulted on merely because of the unpredictability of behavior and increased agitation as the BAL lowers. Mainly concerned with potential danger to others more so than themselves. I don't want us to be the hospital that let some crazy drunk out while still inebriated and they killed some innocent folks. No one has ever really argued with me on that one.

Our policy is that patients are not evaluated by psych until they are sober.

 

[Jules A]

I would say that our situation is a mix of your two, more like hospital one. There is pressure to move patients by the ED. We do not discharge patients without a safe discharge plan. We do discharge patients overnight, but they are typically a clear-cut, virtually-zero risk of harm case (chronic group home developmental delay patient got in another shouting argument at group home and is back in the ED for literally the 26th time this year.) We must staff all overnight discharges/changes in legal status (does not meet criteria) with an attending first (that means waking them up.)



Our policy is that patients are not evaluated by psych until they are sober.

"clinically sober" is our terminology, lol.

 

[smalltownpsych]

Our policy is that patients are not evaluated by psych until they are sober.

We don't have a strict policy on that here, although I have worked in a place where they did. Some of our folks try to hold the EM docs to that standard anyway, but I find that leads to more calls to evaluate a drunk at 2:00 am than does my stance of trying to work with and help out the EM docs. Working well with others is a valuable skill to have. Another side of it is I get a call right before I go to bed and the doc tells me that they are waiting on labs, but do you want to come in now instead of at 2:00 am. "Sure. I'm on my way."