Hey Tarek (and everyone else)
Mental health in the emergency department is one my my major interests, and I’m hoping to make contributions in this area here as time goes on.
For the last few months, Dawn Giffin and I have sat on a committee with players in psychiatry and internal medicine regarding the management of acute cognitive change in the elderly in the emergency department. As we have all seen working in the ER, sometimes these patients get referred to medicine and sometimes to psychiatry. The exact endpoint for each individual patient is not standardized, and depends on a combination of patient / provider / accepting service factors.
In discussions I’ve had with Dawn, our hope was, and still remains, to develop a standardized pathway for disposition of elderly patients with acute cognitive changes. The research project I completed during my EM year using data from LHSC found what I felt to be an unacceptably high rate of adverse medical outcomes in elderly patients referred to psychiatry from the ED, the majority of whom were “behaviour changes”……these are often referred to psychiatry as their behaviour issue is attributed to a psychiatric disorder, and not a delirium due to an undiscovered medical illness.
A roadblock we have run into in this committee is that medicine and psychiatry do not agree on which patients should end up in which service. We will continue to politely push them, as we feel strongly about standardizing these patient’s disposition. It would also make it much easier in the ER as we would not have to argue with residents defending why we feel a patient should be in psychiatry or medicine, the pathway would pre-determine that.
My gut feeling is that the safest place for elderly patients with acute cognitive changes is usually not the psychiatry ward, but the medicine ward. At least for a short observation period, to ensure that something sinister does not declare itself. Mental illness in the elderly can be a diagnosis of exclusion. That is just my two cents.
Regarding a discharge checklist for psychiatric patients, I have not done any work on this specific topic. I am always interested in improving patient flow and I would welcome an evidence-based approach to safely managing our patients with mental illness. A physician checklist is one way to go about this. I wonder about having a patient checklist, where patients may check off symptoms they are having and indicate risk factors that would portend a high risk situation (e.g. famhx suicide, access to lethal means, elderly, etc)………we could consider involving residents (both ER and psych) in developing this as well.
However, before I spend too much time developing checklists, I have heard through the grapevine that CEPS is planning on having one of their nurses in the front bubble on a fairly regular basis at some point in the near future - I don’t know the ER’s role in this, but this may impact throughput and help in our safe disposition planning. A worthwhile place to start may be engaging CEPS and our colleagues in psychiatry and utilizing their manpower to our, and our patient’s, advantage.
I am happy to reach out to them and see where we can help. Even starting a round table discussion with them would be beneficial.