A survey of Midwest physicians’ experiences with patients in psychiatric distress in the emergency department

Methods

This study was reviewed and deemed exempt category by the Michigan State University Institutional Review Board (MSU Study ID: STUDY00003520).

A 19 question anonymous survey (Supplementary Material) was sent via email to 55 emergency medicine residency directors throughout Michigan, Ohio, Indiana, and Illinois who were identified using an Internet search of residency programs in the region. Recipient program directors were asked to distribute the survey to their colleagues and residents. Responses were gathered from October 29, 2019 until January 16, 2020. The survey was administered using Qualtrics XM.

The intent of our data collection procedure was to use snowball sampling to generate as many survey responses as possible, while obscuring the identities of the respondents. As a result, certain demographic information was not collected, including the experience level of respondents (i.e., resident vs. attending) and the number of respondents from each individual residency program. Additionally, our survey tool was not capable of tracking responses and there were no linked questions allowing for attributed responses between earlier and later questions.

The survey (Supplementary Material) was developed by the authors. The survey was designed to assess respondents’ self-reported demographic data as well as their experiences with the boarding process, initial examination, final disposition, reevaluation of the patient, physician training and resources, and follow up care.

All respondents were notified that their responses to the survey indicated their consent to participate in research. Statistical analysis was performed using a Mann–Whitney U test [12, 13].

Results

Initial examination

Thirty four of 44 respondents (77.3%) reported that they perform the initial psychiatric examination on their patients, while 10 (22.7%) reported that this examination was carried out by either a nurse or a social worker (Figure 1A). Ten of 44 respondents (22.7%) reported that if they do not perform the initial psychiatric examination, they also do not perform their own examination to check the work of the nurse or social worker. Our survey did not differentiate between registered nurses (RNs) and nurse practitioners (NPs); we only provided options for “nurse” and “midlevel provider” on the survey among the options to answer the question “Who performs the initial psychiatric evaluation of a suicidal patient?” We did not provide a specific definition of midlevel providers, a term assumed to encompass NPs and physician assistants (PAs). Regardless, no respondents reported using a midlevel provider to perform the initial evaluation of ED patients in psychiatric distress.

Figure 1:

Respondents’ reported provider evaluation patterns for (A) initial psychiatric patient examination and (B) determination of final patient disposition.

Reevaluation

Twenty of 44 respondents (45.5%) reported that they reevaluate suicidal patients once per shift while the patient is being boarded in the ED and 14 (31.8%) reported that they do not reevaluate boarded patients at all (Figure 2). For comparison, respondents were asked about patients being boarded in the ED with cardiac pathology. Sixteen of 41 respondents (39.0%) reported reevaluating patients with cardiac pathology once every 2 h, while 11 of 41 respondents (26.8%) reported reevaluating them once every 4 h; eight of 41 (19.5%) reported that they do not reevaluate patients with cardiac pathology during the course of ED boarding. Based on this data, respondents reevaluated patients in psychiatric distress statistically significantly less often (p=0.01) compared with patients with cardiac pathology. However, this comparison between reevaluation patterns among respondents in their care of suicidal vs. cardiac patients in the ED is limited because the survey did not examine how often EM physicians utilized consultants for each group of patients; as lack of consultant support could significantly impact the frequency of reevaluation.

Figure 2:

Respondents’ reported frequency of reevaluation of patients who are being boarded in the ED. Mean frequency of evaluation for a suicidal patient was once per shift compared with a mean frequency of evaluation once every 4 h for cardiac patients (p=0.01).

Discussion

Although the majority of EM physician respondents in our study reported that they perform the initial psychiatric evaluation on their patients, 26.6% did not; the reasons EM physicians may defer the initial psychiatric examination of their patients are likely multifactorial and deserves further exploration. We hypothesize that this host of factors may include access to in-house psychiatrists, lack of psychiatric training/education, and increased ED crowding. Of note, four of 45 respondents (8.9%) did report that their ED is staffed by psychiatrists.

It is atypical for an EM physician to defer evaluation and determination of patient disposition to a nurse, social worker, or other nonphysician provider. However, our survey data indicate that this may be a fairly common practice in the treatment of psychiatric patients. According to our survey results, this could be in part due to EM physicians feeling insufficiently trained to handle psychiatric emergencies; 39.5% of our respondents indicated that they did not feel they were adequately trained in that area. This finding is supported by Bode and Jackson’s 2017 study [14], which confirmed that most EM residencies lack psychiatry rotations, and that psychiatry is underrepresented on EM board examinations [14]. This sentiment was echoed in a report [11] on focus group sessions with resident and attending physicians at a large teaching hospital, in which a number of EM physicians stated their discomfort and perceived lack of qualification to assess suicidality.

Our sample of EM physicians reported that they were less likely to reevaluate psychiatric patients who are being boarded in the ED when compared with cardiac patients; 14 respondents (31.8%) reported that they do not reevaluate psychiatric patients once boarded. This is a notable finding, as it suggests that patients with psychiatric illness may go many hours, or even days, without being reevaluated by a physician. This practice is inconsistent with the recommendations of the National Suicide Prevention Center, which advocates for physicians to treat suicidal patients the same as medical patients [15]. The National Suicidal Prevention Center’s guidelines also encourage EM physicians to evaluate suicidal patients frequently during their ED stays and emphasize the importance of building rapport with these patients [15]. We did not ask how often EM physicians utilize consultants in the care of suicidal patients; routine utilization of psychiatry or psychology consultants may explain the low reevaluation rates in our study population.

A 2017 study [16] of ED interventions identified post discharge follow up as a means of reducing suicidality in patients who present with acute suicidal ideation. Further research [17] has shown that ED screening accompanied by follow up intervention via telephone may reduce suicide attempts and deaths by 10% in the year following the initial ED presentation. This follow up activity then has the potential to reduce the number of suicides and suicide attempts by 39,500 and save $5.84 billion annually in the United States [18]. The National Suicide Prevention Center also advocates for EDs working with local crisis centers to ensure follow up for suicidal patients [15]. The results of our survey indicate that the majority (89.7%) of the ED staffed by the respondent physicians do not have follow up programs in place; we believe this may be attributed to lack of mental health resources in the ED and in the community.

Conclusions

Psychiatric care in the emergency department is challenging for EM physicians, staff, and patients. Lack of resources and professed lack of training impact the EM physician’s overall confidence in treating this group of patients. While EM physicians would not normally defer the evaluation and determination of disposition for patients to a nurse, social worker, or other nonphysician provider, our survey results indicated that this may be a fairly common occurrence in the management of psychiatric patients. According to our small survey this may potentially be in part due to EM physicians feeling insufficiently trained to handle psychiatric emergencies. Our finding regarding a perception of insufficient training is supported by the fact that most EM residencies lack psychiatry rotations, and that psychiatry is underrepresented on EM board examinations.

Further research is necessary to assess whether the results of this study are consistent with EM practice nationwide and to more critically assess practice patterns in EDs with and without access to psychiatry resources. Future studies are needed to explore barriers to care, improve physician comfort and education, and assist in the design of increased training opportunities. Increased collaboration between EM and psychiatry services may allow for the development of strategies that minimize ED boarding time for patients with suicidal ideation and psychiatric distress, as well as improve the quality of acute and follow-up care for this patient population.