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Fast Treatment for Mental Health Patients in the ER: A start
November 13, 2012
Dr. Brian Goldman
Twenty percent of Canadians will experience a mental illness during their lifetime. Many of them will wind up in the Emergency Room. In the past, "make them wait" seemed the unspoken approach to caring for patients with psychiatric issues. But a surprising new study published in the Canadian Medical Association Journal suggests we're making progress.
Researchers from the Institute for Clinical Evaluative Sciences in Toronto looked at more than fifty thousand emergency room visits in Ontario by people with depression, bipolar affective disorders including mania, and psychotic disorders including schizophrenia. They found that patients with mental health issues waited a median of ten minutes longer to see the doctor than patients who did not have emotional problems. That's despite the fact that on average, patients with mental health problems were given a more urgent triage score than the patients who didn't have mental health issues.
True, ten minutes is an eternity to a patient who is in distress and whose agitation is escalating. However, in the context of an entire ER visit that could span many hours, ten minutes is nothing.
But the results get even better. Knowing what I know about the culture of modern medicine, I might have expected that patients with psychiatric issues would wait disproportionately longer than non-psychiatric patients when the ER is both busy and overcrowded. The result was the exact opposite. When the ER was more crowded, patients with mental illness actually waited less time than other patients to see the doctor.
The busier the ER, the more pronounced the effect. When there was mild crowding in the ER, patients with mental health issues waited fourteen minutes less to see the doctor. With severe crowding, they waited forty-eight minutes less. It's not that psychiatric patients were seen faster when the ER was crowded, but that patients with non-psychiatric problems waited disproportionately longer.
There are several reasons to explain the study's findings. First, it's easier to see and treat psychiatric patients compared to to non-psychiatric patients during times of overcrowding because there are fewer psychiatric patients. Second, non-psychiatric patients, those with emotional issues can usually be put into chairs instead of onto stretchers. Since stretchers are always at a premium in overcrowded ERs, you can immediately see why non-psychiatric patients wait longer at those times.
All of that overlooks the sea change that has occurred in the culture of emergency medicine. Triage nurses - the people who decide how quickly patients get through the sliding doors - have been given extra training to assess and treat patients with mental health issues as quickly as possible. Where I work, there's been a huge culture shift from letting people with psychiatric problems wait, to seeing them as quickly as possible so their behaviour doesn't escalate into a full blown emergency that endangers themselves, staff and bystanders. Quick intervention has also been shown to de-escalate the tension and to reduce the need to physically or chemically restrain violent patients.
Then there are factors that are beyond the control of the ER. As the study authors suggested, psychiatric wards do a better job than the internists of admitting their patients to a bed upstairs instead of making them stay in a hallway in the ER.
The study is important because it breaks from the usual findings. In a 2008 report, the Schizophrenia Society of Ontario recommended adding a psychiatric wait times' component to the province's Emergency Room Wait Times Strategy because they said it was their experience that psychiatric patients waited longer and were assigned a lower priority than non-psychiatric patients.
You may remember the Kirby senate report Transforming Mental Health, Mental Illness and Addition Services in Canada; it cited regional differences in ER care for people with mental illness.
Patients who present to the ER with a heart attack are given a lower priority if they also have a history of depression. People with schizophrenia and personality disorders generally have their cancers diagnosed later in the course of the disease because ER staff only sees the emotional issues and not the whole patient.
What's the take home lesson? I think Ontario's performance regarding psychiatric patients is quite good but I think it reflects the fact that the province put serious money into getting wait times down. I worry about what will happen to the 'wait times' money as Ontario deals with a fourteen billion dollar deficit. The other take home point is that the study's authors believe the system works best when ERs that see a high volume of psychiatric patients have dedicated psychiatric teams with special expertise in handling people with emotional issues. I saw that approach up close when I toured the dedicated psychiatric ER at the Royal Jubilee Hospital in Victoria.
November 13, 2012
Dr. Brian Goldman
Twenty percent of Canadians will experience a mental illness during their lifetime. Many of them will wind up in the Emergency Room. In the past, "make them wait" seemed the unspoken approach to caring for patients with psychiatric issues. But a surprising new study published in the Canadian Medical Association Journal suggests we're making progress.
Researchers from the Institute for Clinical Evaluative Sciences in Toronto looked at more than fifty thousand emergency room visits in Ontario by people with depression, bipolar affective disorders including mania, and psychotic disorders including schizophrenia. They found that patients with mental health issues waited a median of ten minutes longer to see the doctor than patients who did not have emotional problems. That's despite the fact that on average, patients with mental health problems were given a more urgent triage score than the patients who didn't have mental health issues.
True, ten minutes is an eternity to a patient who is in distress and whose agitation is escalating. However, in the context of an entire ER visit that could span many hours, ten minutes is nothing.
But the results get even better. Knowing what I know about the culture of modern medicine, I might have expected that patients with psychiatric issues would wait disproportionately longer than non-psychiatric patients when the ER is both busy and overcrowded. The result was the exact opposite. When the ER was more crowded, patients with mental illness actually waited less time than other patients to see the doctor.
The busier the ER, the more pronounced the effect. When there was mild crowding in the ER, patients with mental health issues waited fourteen minutes less to see the doctor. With severe crowding, they waited forty-eight minutes less. It's not that psychiatric patients were seen faster when the ER was crowded, but that patients with non-psychiatric problems waited disproportionately longer.
There are several reasons to explain the study's findings. First, it's easier to see and treat psychiatric patients compared to to non-psychiatric patients during times of overcrowding because there are fewer psychiatric patients. Second, non-psychiatric patients, those with emotional issues can usually be put into chairs instead of onto stretchers. Since stretchers are always at a premium in overcrowded ERs, you can immediately see why non-psychiatric patients wait longer at those times.
All of that overlooks the sea change that has occurred in the culture of emergency medicine. Triage nurses - the people who decide how quickly patients get through the sliding doors - have been given extra training to assess and treat patients with mental health issues as quickly as possible. Where I work, there's been a huge culture shift from letting people with psychiatric problems wait, to seeing them as quickly as possible so their behaviour doesn't escalate into a full blown emergency that endangers themselves, staff and bystanders. Quick intervention has also been shown to de-escalate the tension and to reduce the need to physically or chemically restrain violent patients.
Then there are factors that are beyond the control of the ER. As the study authors suggested, psychiatric wards do a better job than the internists of admitting their patients to a bed upstairs instead of making them stay in a hallway in the ER.
The study is important because it breaks from the usual findings. In a 2008 report, the Schizophrenia Society of Ontario recommended adding a psychiatric wait times' component to the province's Emergency Room Wait Times Strategy because they said it was their experience that psychiatric patients waited longer and were assigned a lower priority than non-psychiatric patients.
You may remember the Kirby senate report Transforming Mental Health, Mental Illness and Addition Services in Canada; it cited regional differences in ER care for people with mental illness.
Patients who present to the ER with a heart attack are given a lower priority if they also have a history of depression. People with schizophrenia and personality disorders generally have their cancers diagnosed later in the course of the disease because ER staff only sees the emotional issues and not the whole patient.
What's the take home lesson? I think Ontario's performance regarding psychiatric patients is quite good but I think it reflects the fact that the province put serious money into getting wait times down. I worry about what will happen to the 'wait times' money as Ontario deals with a fourteen billion dollar deficit. The other take home point is that the study's authors believe the system works best when ERs that see a high volume of psychiatric patients have dedicated psychiatric teams with special expertise in handling people with emotional issues. I saw that approach up close when I toured the dedicated psychiatric ER at the Royal Jubilee Hospital in Victoria.
