News from the Johns Hopkins Department of Psychiatry and Behavioral Sciences
A corner of the main Hopkins ED, home of emergency adult psychiatry, roughly covers the footage of a large living-room. The walls show a few impressive scars from the 3,000 or so psychiatric patients who’ve passed through each year for the past quarter-century: walk-ins from the neighborhood or several states away, referrals who deplane from Paris and take a cab to East Baltimore, and, from clinics across the street, outpatients deemed too precarious to go home.
“The area wasn’t designed for psychiatry,” says Patrick Triplett, M.D., who directs Psychiatric Emergency Services at Hopkins Hospital, “so privacy can be a challenge.” And like the Holland Tunnel, traffic rarely stops. But it’s a healing, fascinating, necessary place, Triplett maintains. His years as director have made him both wise and pragmatic, and under his watch, the small and occasionally tumultuous-appearing spot is one of the best-run psychiatric emergency facilities anywhere.
Some ED issues are generic—tied to the overlap of psychiatry and emergency medicine. With Baltimore’s drug abuse problem, for example, staff often treat patients whose substance-dependence crises are layered atop other psychiatric disorders. “That makes diagnosis difficult,” says Triplett. “Somebody may come in hallucinating and tell us, ‘I have schizophrenia.’ But then a cocaine screen comes back lit up. Where does the truth lie? It may take days to find out, to let the drug wear off and see if there’s a persisting, underlying psychotic disorder.”
And questions of whether to discharge patients loom large. “It’s tremendously hard to predict what people will do when they walk out,” explains Triplett. “Our residents, especially, can feel uncomfortable with stay-or-go decisions. How do you teach that sort of thing? Collect data on patients, we tell them; see if the woman on the gurney has ‘informants.’ Sharpen your diagnosis and always err on the side of safety. I was shocked, for example, the first time I heard a man say, if you don’t admit me, I’ll kill myself.” Now, Triplett says, “I see that remark as something of a prototype and probe more deeply, for example, for mood, personality or substance use problems.”
It’s the issues imposed from outside, however, that trouble him. “We’re seeing more patients and they’re staying with us longer.” This isn’t unique to Hopkins; it’s nationwide and stems, in part, from shrinking inpatient psychiatric facilities. Maryland, for example, is considering closing its acute care beds in all of its state hospitals. “That’ll put the hurt on us,” says Triplett.
Insurance companies add insult, he says, as their preauthorization requirements for psychiatric patients and the other corporate hurdles slow patient admissions. The average psych ED stay before someone can transfer to Hopkins inpatient units has reached 13 hours—beyond what’s typically needed for comprehensive emergency care.
Improvements, however, are real. “We were able to get Maryland law changed to require at least some insurance companies to be available 24/7 for approval,” Triplett says. Residents are taught more nuanced emergency psychiatry and supervised more, he explains. In 2005, full-time psychiatric nursing was added. And recently, staff from psychiatry and emergency medicine, security, social work, Hopkins legal branches and those dedicated to patient innovation began meeting to make the ED safer. Already, a newly revamped triage system, with its five-tier rating of psychiatric patients on urgency of care, is becoming a model.
“Obviously, you know that someone who’s agitated, shouting and bleeding needs immediate help, while someone wanting a medication refill probably doesn’t,” Triplett comments. “But patients in-between are less clear; that’s where the system helps.”
As for Triplett, he seems to thrive. “I like the fact that not every day is the same.”