In the emergency department, psychiatric patients can be particularly challenging. Evaluation in the ED is primarily based on history from many different sources–police, family, EMS, many times second hand or on a written report or petition.
Often, family does not accompany the patient to the ED. Patients can be unreliable, intoxicated or just plain unable or unwilling to answer questions. This presents opportunities for “information gaps” to occur for the care team.
The medical clearance is fairly routine. You certainly have to be suspicious of intoxication and ingestion. There are a few and not terribly common medical causes for psychiatric presentations that must be considered. Elderly patients may more commonly present with dementia or delirium mimicking psychiatric illness.
Once medical clearance is completed, however, determining the proper disposition is the goal.
A few years back we had an unexpected outcome with a psychiatric patient that had been discharged from the ED. When we looked into the issues surrounding the care, it mainly centered on communication. We found that different members of the ED team caring for the patient had different pieces of information and may have assumed others knew this information.
It is common for many people to interact with the patient, including the bedside sitter, nurse tech, nurse, charge nurse, triage nurse, physician and behavioral health employee who performs the psychiatric evaluation in the ED. This is in addition to the family, friend, officer, or EMT who all may have vital pieces of information. The sitter may witness a phone call between a patient and friend with information that no other team member is aware of. Questioning the officer who was at the scene can be very informative.
To bring every team member caring for the patient together to share information, we devised the “psych huddle” that we now perform with every potential psychiatric discharge. We bring the team together to compare notes, stories and exchange information.
We make sure to listen to any hesitation or concern with a plan for discharge by a team member. We attempt to clear up any concerns by obtaining more information, answering questions and having frank discussion. While the licensed provider is ultimately responsible for the discharge decision and it is not required for all to be in agreement, it is very rare for there not to be a unanimous decision when discharging a patient with this process.
Making sure we make decisions based on the entire body of information obtained by the team and eliminating the “information gaps” has vastly improved the safety of psychiatric patient discharges. The provider documents in the records that the “psych huddle” occurred so we can show the process was followed. This leads to more complete documentation of the medical decision-making process as well, creating a more understandable record of the thought process justifying the discharge.