Breaking a Few Eggs


“Most EDs do not have separate secure areas in which psychiatric patients can be held. They typically don’t have a psychiatrist immediately available to evaluate the patient and provide guidance on management, and they do not have extra nursing staff to monitor often unpredictable patients.”

azmd, in a comment on one of my blog posts  on

Well, we have been talking for a few weeks now about the way psychiatric patients get to the ED and what happens or does not happen when they do. Many of you have lamented the lack of personnel, the dearth of services and the waits that these patients experience because of dwindling inpatient resources. What can be done about this deplorable set of circumstances?

First and foremost, I believe that hospitals are going to have to provide separate service areas for these patients.

The stark white room with only a gurney and a chair, with no television or magazines or anything stimulating to do, must go. Replace it with a hallway or a suite of rooms with a centrally located nurses station and a common area that give patients a little more room to walk, space to interact and even a special area for visitations from family. The lone guard outside the door, symbolizing both threat and security, must be replaced with trained mental health staff in this special area, staff who know about the signs of escalating agitation and potential for violence in these patients. A small emergency room within the main ED, this area could be secure and therapeutic at the same time, much as an inpatient psychiatric unit might be. This should become a standard for emergency departments who wish to receive mental health patients.

Psychiatric coverage is going to be needed for these service areas.

As many commenters have pointed out, both patients and providers alike, it seems that there are never enough psychiatrists around to see mental health patients when they do come to the ED for help. One criticism, spot on in some cases, is that psychiatrists do not respond in a timely manner to requests from the ED physician for consultation and help in the management of difficult psychiatric presentations. They do not come out in the middle of the night to see patients and they do not give timely input that would be helpful to the ED staff. In many rural areas, even if there  is a small community hospital, there are no psychiatrists anywhere. There are no mental health centers to send a screening clinician.

Services such as telepsychiatry may be the answer to psychiatrist shortages in the future.

Being able to see multiple patients in multiple hospital EDs over a regular or extended shift, without the hassle of driving from place to place, is one of the virtues of telepsychiatry. A patient who might have sat for days waiting for an inpatient admission because no mental health input was available to begin treatment in the ED, may be the beneficiary of a mental health consultation and initiation of services from the first day they are evaluated. A fair number of these patients, their treatment begun in the ED, may actually be improved enough to go home directly from the hospital after a few days.

Now, I know what is going to  happen as soon as these kinds of changes are proposed.

There will not be enough space. There will not be enough money (when is there ever enough money?). We can’t dedicate an entire area of precious emergency department real estate for a babysitting service for mental health patients. Psych patients will be running amok all over the department, threatening and yelling and getting into other patients’ business. We can’t spare staff for this in the ED. Psychiatrists will never come down to see these patients even if we do set them up in their own place. Telepsychiatry equipment is expensive and we’ll never be able to afford it.

The fact is, as my old mentor Everett Kuglar MD used to tell me, these patients are not going to go away. Someone is going to have to treat them.

No matter how much hospital administration tries to ignore their existence, no matter how little funding state legislatures provide for their care, people with schizophrenia and depression and substance abuse problems and other mental health problems are going to be with us.

We can choose to ignore them, but the problem will only get worse. We can choose to maintain the present day status quo, which in my opinion will only lead to more frustration for patient and provider alike.

We can choose to spend a little money, time and physical and human resources to turn this around.

Sometimes if you want to make an omelet, you have to break some eggs.

6 thoughts on “Breaking a Few Eggs

  1. A thought, from this outsider’s point of view: would it be possible where you are (and by that, really I mean ‘in the USA’) to get together with other doctors and psychiatrists in each area to found and run your own community psychiatric EDs? It would take time, but surely it could be done? Someone has to start somewhere and it looks like your government (regardless of what party is in office at any one time) isn’t about to do it for you… and if change needs to happen this badly, maybe the better way is to start again from scratch?


  2. I had hoped, some years ago, that this would be a place for APRNs within the psychiatric specialty to fill in where there is a shortage of psychiatrists. I haven’t seen that happen and now that the ANCC is no longer offering certification for Psychiatric Clinical Nurse Specialists I doubt it will ever be. I don’t know if resistance from the doctors or the relative scarcity of psych CNSs is the primary cause, but I think it is an unfortunate loss of potential care for psychiatric patients in crisis. Just sayin’…


  3. AMEN AND AMEN!!!!!! How about you and I just find some investors and start building the RIGHT kind of facilities?!? We could do so much better. We might go broke in the process (even though it appears that we will do that anyway!) but at the very least, patients would be taken care of. That is, far and away, the worst thing that has and is happening in the midst of all these “advancements” in healthcare…..patient care, the TOTAL patient, is being lost more and more each day!


  4. Susan,

    I absolutely agree.
    It is so very shortsighted of the doctors who tenaciously hold on to their turf and think that they are going to slide into irrelevance if they ask for, and receive, good, competent help from others who are not doctors but have a lot to offer.
    For me personally, I can see and feel the need to collaborate more the older I get. Not because I’m tired and burned out and want to offload some of my burden, but because I can see the value of collaboration and working as a team.
    Unfortunately, I think young doctors are still a fiercely independent breed by natural selection and then by training.


  5. Penny,

    A little fire in your eyes and money burning a hole on your pockets, eh?

    Of course you are absolutely right. It may come to that, but the question of funding is always the elephant in the room, isn’t it?


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