ERP here from ER Stories.  I hope you enjoy my ramblings.  

You might also call these three diagnoses all together “The Bermuda Triagnle” or “Triple Threat”.  All I know is that when they all appear on the chart of an ER patient, you just gird your loins (like the two Roman references?)  before you go in.   You know it is going to be painful.

I experienced the wrath of the Triumvirite the other night – blindsided as I walked into the room.

The triage RN wrote:  50 year old woman c/o headache, vomiting, abdominal pain, body aches, and maliaise.  Fine, I thought, probably a viral syndrome or the flu.  Vitals were fine.    But then I looked down the triage sheet and saw them. Those three diagnoses staring me right in the  face.  My mood sank, dreading the fact that it was really busy and that I had been really hoping for a few quick, easy patient encounters.   The med list that followed confirmed my suspicions and I felt like the knife was being ground in a little further.

Past Medical History: Migraines, Fibromyalgia, Irritable Bowel Syndrome

Meds: Dilaudid, Imitrex, Topomax, Klonopin, Soma, Lyrica, Trazadone.

Allergies : Compazine, Reglan, Toradol, Steroids

It was a painful encounter.  Demands for narcotics, histrionics, exaggerated wretching, and constant pestering of the nurse and secretary.   I am ashamed to say, I lost my nerve.  I was really busy with sicker patients and threw in the flag. I called the patient’s PMD’s service and admitted her.  Sometimes you have to know which battles to fight. I will live to fight the triumvirate another day when I am emboldened with more energy.

As resources become more scarce and as more patients lose insurance funding, psychiatry beds for mentally ill patients are becoming harder and harder to secure. In turn, psychiatry patients who need further care are putting an increasing stress on emergency departments. Subtle financial cherry-picking of patients makes it extremely difficult to obtain necessary care for patients. When called for a potential transfer, psychiatric institutions require an informational “face sheet” containing demographic … and insurance … information to be faxed to them prior to releasing a bed. Then the fun begins.

Patient #1
A young lady with pre-existing psychiatric problems used a Ginsu knife to cut her throat after her boyfriend broke up with her. She had been drinking … a little. Her alcohol was 210. We did some testing to make sure that she didn’t hit any of the vessels in her neck and then closed the laceration. Then we went about transferring her to see a psychiatrist. The psychiatric triage nurse requested that we fax them a “face sheet.” The patient happened to have no insurance.
We get a call back 15 minutes later.
“We won’t accept the patient until her alcohol level is less than 80.”
Fine. We’ll play the game. Alcohol levels generally decrease at a rate of about 20mg/dl/hour, so we’ll keep her locked in a room for another 6 hours.
Six hours later we draw another alcohol level. It is 82. Call the psychiatric nurse back and ask to speak to the psychiatrist.
“Nope. Alcohol has to be less than 80.”
OK, Nurse Ratchet. Whatever.
Wait another hour just to make sure that alcohol will definitely be lower than 80 and re-draw the alcohol level for the third time. Ahhh 57. Great.
Call psychiatric nurse and get put on hold. Finally speak to her and she agrees to page the psychiatric attending for us.
Forty five minutes later, psychiatric attending calls back.
“Have you reassessed her?”
“Of course.”
“Is she still suicidal?”
“Right now she’s pissed off that she had to wait so long, so she wants to leave.”
“But is she still suicidal?”
“I didn’t specifically ask her that.”
“Ask her.”
“She nearly decapitated herself with a butcher knife and you’re wondering whether she was sincere in her intent?”
“Ask her.”
[Walk into room, ask patient is she is still feeling like harming herself]
“F*^& you. I’m getting the f*^& out of here.”
“Are you suicidal?”
“No”
[Back to phone]
“She says she’s not suicidal now.”
“Then I’m refusing the patient.”
“You’re refusing to take a patient who tried to kill herself by slitting her throat with a knife?”
“She’s not suicidal any more. What do you need me for? Have her follow up in an outpatient center.”
[Click]

Patient #2
Another young lady came by ambulance after hearing voices that were telling her to kill herself. There were superficial cut marks on her wrist. She had intermittent psychiatric problems in the past and was noncompliant with her medications. She also had a history of hypothyroidism. She had Medicaid for insurance.
We get all the usual labs and everything is normal except she has a few bacteria and a few epithelial cells in her urine.
Calls to several hospitals with psychiatric services were unhelpful since they all allegedly had full beds. They still make sure that you tell the story and fax them a face sheet first, but then they call you back and say that they’re full.
Finally we get a place that has beds available.
“Did you check magnesium, RPR (for syphilis), and thyroid levels?”
“Actually, no.”
“Call us back when you get those results.”
“RPR probably won’t come back until tomorrow.”
“The labs need to be sent.”
“Fine.”
[Labs sent and actually come back, including RPR, in a couple of hours. Call psych triage nurse back.]
“Everything is normal except that her TSH level is elevated.”
“You need to repeat the TSH level.”
“Why?”
“We won’t accept the patient until her TSH level is normal.”
“Whaaaat? That could take days or even weeks.”
“The doctors here don’t treat medical problems such as that. Until the patient is medically stable, we cannot accept transfer.”
“I’m saying that the patient is medically stable. You just have to give her thyroid medication that has already been prescribed to her.”
“Sorry, we’re not accepting her until her labs are normal.”

And people wonder why psychiatric transfers take so long.

We get what we pay for.
Psychiatric services are traditionally reimbursed at a very low level.
Therefore fewer and fewer facilities are remaining open to offer the services. For examples, see here and here.
The remaining facilities get overwhelmed and either cannot or will not provide care for the patients in need of help.
Patients often end up in the emergency department where they must be kept until they can get the treatment they need. Sometimes that makes days that patients are stuck in a room in the emergency department instead of getting the treatment they need.
That same room is unavailable to other emergencies that need to be treated.
The backups in patient flow and resulting emergency department overcrowding cost lives.

The new health care bill addresses psychiatric care by creating a “productivity adjustment” for psychiatric hospitals (page 379):

‘‘(2) PRODUCTIVITY ADJUSTMENT. In implementing the system described in paragraph (1) for days occurring during the rate year ending in 2011 or any subsequent rate year for a psychiatric hospital or unit described in such paragraph, to the extent that an annual percentage increase factor applies to a base rate for such days for the hospital or unit, respectively, such factor shall be subject to the productivity adjustment described in subsection (b)(3)(B)(iii)(II).’’

Here’s how the adjustment will be calculated (page 377):

‘‘(II) The productivity adjustment described in this subclause, with respect to an increase or change for a fiscal year or year or cost reporting period, or other annual period, is a productivity offset in the form of a reduction in such increase or change equal to the percentage change in the 10-year moving average of annual economy-wide private nonfarm business multi-factor productivity (as recently published in final form before the promulgation or publication of such increase for the year or period involved). Except as otherwise provided, any reference to the increase described in this clause shall be a reference to the percentage increase described in subclause (I) minus the percentage change under this subclause.’’

… which is precisely why we’ll have fewer and fewer psychiatric services available to us and why more and more emergency department overcrowding will occur.