This article was originally published in #CrisisTalk on May 7, 2019.
Emergency medicine has made remarkable strides in every specialty area except for mental health
Sandra Schneider, MD, FACEP, a past President of the American College of Emergency Physicians (ACEP), says current-day emergency mental health is reminiscent of the 1950s Emergency Department. A throwback, she says, in dire need of an upgrade.
What we know of today as the Emergency Department, shortened to ED by those in the field, began to take shape immediately after World War II. The climate in the United States at the time held lingering remnants of recent conflict and economic depression. At the same time, the innovation of the interstate highway made opportunity boundless, offering Americans a fresh start and quickly changing the face of medicine. Specialists who used large equipment they couldn’t transport replaced family doctors and their small, black bags. These doctors had office hours and didn’t make house calls. If an emergency arose, people went to the hospital. The ED started as a room in a hospital basement called ‘The Pit.’ It was overcrowded and run by some of the least experienced physicians treating the most dangerous situations, often resulting in grave consequences. [1] Dr. Schneider says that since then, emergency medicine has made remarkable strides in every specialty area except mental health. The reasons for stagnancy, she says, are vague diagnostic criteria, challenges in case follow-up, lack of warm handoffs, and unlike with all other specialties, emergency medicine physicians and psychiatrists haven’t had decades of collaboration.
Partnerships and the Golden Period of Intervention
While the direst situations were brought to the ED in the 1950s, specialists often failed to give patients timely care because they were on call for their practices. In 1961, Dr. James D. Mills realized that emergency medicine needed to be a specialization in and of itself. He convinced three of his coworkers to leave private practice to develop an ED alongside him in Alexandria, Virginia, becoming full-time emergency physicians working 12-hour shifts 5 days a week. Simultaneously, a group of 23 doctors in Pontiac, Michigan, did the same, working part-time to staff the ED at Pontiac General Hospital 24 hours a day. “Dr. Mills and his colleagues were the first to do this full time and say, ‘Hey, this works for patients and us.’” Dr. Mills would call in a surgeon to do surgery or a pediatrician if the patient was young, fostering a partnership between ED physicians and specialists. Patients spent about the first 30 minutes with the ED physician and the next half-hour with a specialist, allowing emergency medicine physicians to learn: first through observation, then consult with specialists on the phone, and finally, they could generally handle the cases themselves. Today, Emergency Department physicians often do procedures and no longer need specialists to come in and perform them. For example, says Dr. Schneider, ED physicians do far more intubations than many physicians in internal medicine or even anesthesiology who predominantly do outpatient work. No such leaps have happened in psychiatric emergency medicine. She says the result is that ED staff often don’t identify and fail to treat mental health crises during critical intervention periods. Emergency medicine physicians believe the first 30 minutes to an hour to be the most critical for outcomes, calling it the golden hour of intervention. For example, if a person has a stroke, ED staff have about three hours to get the clot-busting drug tPA (tissue Plasminogen Activator) into the patient. “If that doesn’t happen, the person is out-of-luck.” In the case of a heart attack, doctors have a 90-minute window to intervene. Partnerships with specialists have allowed ED physicians to fully utilize the golden hour of intervention, improving outcomes and mortality and allowing patients a far better chance of leading normal lives. Dr. Schneider says that in mental health, she and her colleagues understand that the longer a person is in psychosis, the more challenging it is to reverse. “It may not be a golden hour but more like golden days or even a week, but there is a critical window for intervention, especially in high acuity suicidality and psychosis.”
Pattern Recognition and Follow-up
Emergency medicine physicians have learned through patterns, and, with the help of specialists, what’s best to do during the golden hour of intervention. The field has developed through partnership, follow-up, and pattern recognition. That’s not the case for psychiatry, which Dr. Schneider says is the least rote specialty. She can look at an EKG and see that the patient is experiencing a heart attack, or, if a patient comes in and can’t lift his arm and isn’t using his leg, he might have a seven on the Stroke Scale, or the person’s blood count is low, so he may need a blood transfusion. Through pattern recognition, training, and established intervention, Dr. Schneider can determine a person’s critical needs. Psychiatry is not as transparent. “I may have a patient who isn’t making sense or is depressed, but there is no serum delirium or depression score for me to determine the level of acuity. We’ve not been trained and, as a result, never figured out the pattern recognition like we have in all other specialties. For many of us, our background is the month we spent on psychiatry in residency, so we feel out of our comfort zone.” She says this is compounded by vague psychiatric diagnostic criteria, the components of which most emergency medicine physicians don’t understand, and the minimal feedback after a handoff, if any. Pattern recognition, says Dr. Schneider, isn’t just developed by working alongside specialists but also through follow-up. Dr. Schneider says that doesn’t happen with psychiatric patients. If a patient has a rash that the ED physician suspects is a melanoma, she can follow up and find out if she was correct, which helps to improve pattern recognition. On the other hand, if she wants to know whether she was right about the acuity of a patient’s suicidality, it isn’t accessible. “The result is we don’t gain critical follow-up knowledge on psychiatric crisis.”
No Warm Handoff
One challenge, says Dr. Schneider, is that while it’s impossible to see the level of acuity in mental health, ED physicians realize that just because a person isn’t bleeding doesn’t mean it’s not a high acuity case. The result is they often default to an assumption of high acuity, triggering numerous challenges for patients, including hospitalization and the corresponding trauma of institutionalization, stigma, and the detrimental impact on employment, finances, and personal life. Part of defaulting to high acuity is a result of an ‘it’s-better-to-be-safe-than-sorry’ mentality, but it’s also because ED physicians aren’t always confident that the patient will get the care she needs if discharged. Dr. Schneider says that more than any other specialty, there is a disconnect on what comes next for the patient. For example, if a patient comes in with appendicitis, the ED physician can call a surgeon. In the case of a rash, the ED has a roster of dermatologists and clinics, and in many cases, the physician can even make an appointment for the patient. These partnerships create confidence in the system and an appeals process if the ED doctor doesn’t agree with the specialist: the emergency medicine physician and specialist can get on the phone and discuss the case. Dr. Schneider says this communication doesn’t exist between most EDs and the mental health system, making navigating it incredibly difficult for ED staff. She says if she has a patient with depression who is feeling suicidal and needs mental health care in the next couple of days, she has no idea how to get them what they need. The same is true for substance abuse. “Let’s say a person with an opioid disorder comes in and has managed to withdraw but needs help for his addiction, all most ED physicians can do is hand him a list of addiction centers to start calling in the morning. Can you imagine if we did that with any other medical issue? If someone comes in with chest pain, I can get them set up with a stress test the next day, regardless if she has insurance. Why is it with mental health it’s okay to give patients a list and say, ‘Good luck’?” Emergency medicine physicians need to be able to do a handoff and have confidence in that handoff. “If there is someone to evaluate the patient, but I don’t know the person and whether he or she has made the right decision for the patient, that’s not a warm handoff.” Dr. Schneider says now is the time to improve the relationship between the ED and psychiatry because she believes emergency medicine physicians will soon be playing an increasingly critical role. The approved use of intervention medications, such as Ketamine and Brexanolone, for depression and postpartum depression, means that ED physicians will be able to decrease acuity with medication so that patients can go home and seek care within a week or so. She says it’s similar to how the ED addresses patients with atrial fibrillation (AFib) or a blood clot. Physicians diagnose, stop, and often reverse the emergency, before sending the patient to primary care. “We would acutely treat them and do a warm handoff.”
Replicating the Poison Center Model in Emergency Mental Health
Dr. Schneider recommends that mental health mirror the poison control center. Each center has a medical director and pharmacists, physicians, nurses, and toxicologists that answers the phone 24/7. If a physician is unfamiliar with the drug a patient took, the center will triage the call to a Specialist in Poison Information (the specialists are called SPIs, pronounced spies). For example, if a person took Banamine, a horse anti-inflammatory, the ED physician can call a poison control center and speak with a specialist: a poison expert who has access to a vast database that lists all chemicals and outcomes in previous exposures. The SPI would tell the ED physician what’s happened in previous cases such as: “Above this amount we’ve seen these problems so you should watch the person for kidney function.” If the situation is more complicated because the person took more than one drug, then the ED physician’s call would be forwarded to the toxicologist. (Typically, only 1 out of 100 calls escalate to the toxicologist.) The SPI also does follow-up and tracks outcomes. For example, if the person who took Banamine had a seizure, the SPI would add that to the database. They would also call the patient and ask how the person is doing and see if he or she needs an appointment. If a child drank bleach, the SPI would speak with the parents, telling them that they aren’t bad parents, and talking them through how to prevent the incident from happening again. They can even address more obscure poisonings. If a person eats a rare mushroom, the center will get the caller in touch with a mycologist (mushroom expert), local resources for dialysis, and the best hospital to care for the patient. The idea is that no matter where the person is at that moment, experts will be reached and local resources provided.
Psychiatric Triage with a Mental Health Center
Dr. Schneider says a similar structure for mental health would allow ED physicians to speak to experts and have strong confidence in their abilities. The call could be from an ED doctor who is uncomfortable giving Suboxone, a blockbuster medication that reduces symptoms of opiate addiction and withdrawal, for the first time. The mental health center would go through a checklist and then provide a dosage recommendation. If it doesn’t work, the ED doctor would call back, and the center would walk her through the next dose. They would also give guidance on more complex cases. Perhaps a patient had depression but no suicidal plan, a supportive family, and no lethal weapons. The mental health center expert might recommend the patient be discharged and meet with a mental health worker the next day. If the ED physician is not comfortable sending the patient home, a psychiatrist for the center can get on a video call. Dr. Schneider believes the escalation rate would be similar to that at poison centers: roughly 1 out of 100 calls would triage to the psychiatrist. After the video chat with the patient, the psychiatrist might recommend he be admitted, and help with the process, or say the patient can go home, but the center would call him in the morning to arrange an appointment. “ED physicians spend 15 minutes with a patient. We aren’t going to be able to add a 30-minute psychiatric evaluation, but the center would give us access to experts and a database of resources. It closes the loop of care and is the warm handoff that gives us confidence that patients will get the care they need.”
Sources:
[1] 24|7|365: The Evolution of Emergency Medicine. Retrieved March 11, 2019, from https://www.emra.org/about-emra/publications/legacy-documentary
