Emergency department (ED) visits have increased substantially from 89 million in 1992 to more than 110 million in 2002, while the number of EDs decreased by about 15% during the same period.1,2 An estimated 1.7 million people rely entirely on EDs for all their health care needs.3 The demand for emergency services continues to increase while the availability of inpatient hospital beds and alternative sources of urgent care has decreased, resulting in widespread overcrowding.4-6 The consequences of overcrowding include increased ambulance diversion, longer hours of patient "boarding" in the ED, and increased numbers of patients who leave either before being evaluated or against medical advice.7 We suspect that another consequence of ED overcrowding is an increased tendency to disregard psychiatric problems, especially if the psychiatric problem is not the chief complaint.
The annual incidence rate of psychiatric problems in the United States is estimated to be between 20% and 28% for both children8 and adults.9 When the rates of specific mental disorders are studied in ED patients, the psychiatric rates are often much higher than the respective national rates,10-12 so it is reasonable to assume that the overall psychiatric rate in ED patients is at least 20% to 28%.
The CDC surveyed EDs to determine the number of patients who received a psychiatric diagnosis in these facilities.1 Our analysis of the CDC data indicates that the rates of psychiatric diagnosis are much lower in EDs than in the general population (see Box, "Analyzing the CDC Data"). The data indicate that the majority of severe psychiatric disorders among ED patients are being missed.
In our experience, the argument offered most frequently by ED physicians to justify ignoring or overlooking psychiatric disorders that are not the chief presenting complaint is that the scope of practice of emergency medicine should include only emergent or acute injuries and physical illnesses. However, adherence to that model is no longer tenable, since about half of ED visits are for conditions that are neither emergent nor acute.1 It is also important to note that many patients who experience health-threatening problems related to psychiatric issues--such as battered wives, sexually abused children, HIV/AIDS patients, and psychotic individuals who are relapsing or actively experiencing hallucinations--are reluctant to volunteer information about their problems because of fear of negative consequences.13-16 These patients need to be encouraged to disclose their problems, and the ED physician needs to initiate inquiries into psychosocial and psychiatric issues, otherwise lethal consequences may ensue.17
Many ED physicians believe that mental disorders, in general, are relatively minor threats to health. However, this view is not supported by public health research, which has shown that psychiatric illness, and depression in particular, is second only to cardiovascular disease as a major cause of lost years of productive life.18 The view that psychiatric disorders are relatively minor threats to health is a perspective that also is not shared by the Emergency Medicine Core Content Task Force.19
In this model of the clinical practice of emergency medicine, the task force listed 3 levels of acuity of common conditions presenting in EDs:
- Critical: life-threatening illness or injury with a high probability of mortality if not treated.
- Emergent: illness or injury that may progress in severity or result in complications with a high probability of morbidity if left untreated.
- Lower acuity: illness or injuries that have a low probability of progression to more serious complications.
Eighteen categories of medical conditions were described and one, psychobehavioral disorders, deals with psychiatric conditions. Of the 35 individual psychobehavioral disorders listed in these categories, 20 (57%) were designated as either emergent or critical problems.
The provisions of the Emergency Medical Treatment and Active Labor Act (EMTALA)20 are relevant to the issue of whether emergency medicine should include psychiatric issues within its scope of practice. EMTALA prevents hospitals from "dumping" unwanted patients and guarantees all ED patients the right to a medical examination to determine whether a medical emergency exists and to stabilize patients before transfer. EMTALA specifically includes psychiatric problems and substance abuse as part of the definition of a medical emergency. The central issue is whether it is legal or ethical for ED physicians to routinely ignore significant psychiatric issues that are not the chief presenting complaint.
A 65-year-old white man presented to the ED with a fractured metatarsal as a result of a motor vehicle accident. The ED physician appropriately diagnosed and treated the fracture, gave the patient pain medication, and scheduled an orthopedic appointment for the patient. Just prior to discharge, the physician asked the patient how he was feeling, and the patient said he had been feeling "somewhat down and tired for a while." When asked about the pain in his foot, the patient said the pain medication seemed to be working. The patient arranged a ride home and the physician discharged the patient.
The physician did not inquire further about the nature of the accident or what the patient meant by "somewhat down and tired for a while," and the patient did not volunteer any additional information. Later that night, the patient committed suicide. If the physician had asked the patient about the circumstances surrounding the accident, the physician would have learned that the patient recently had been drinking heavily because of an emotionally troubling divorce and that he was depressed and having suicidal thoughts. Collectively, the sociodemographic characteristics of this patient (age, race, marital status, depressed, excessive alcohol use, retired) are strong indicators of potential suicide.21,22
Did this physician violate EMTALA? Is he guilty of medical malpractice? Would the physician be found "not culpable" because the patient did not initiate a discussion of psychiatric issues? EMTALA requires that the hospital must provide for an "appropriate medical screening examination to determine if an emergency medical condition exists." An appropriate medical examination should have included additional questions about the patient's emotional status. The heart of EMTALA is the concern with transferring a medically unstable patient to another facility--and sending a patient home can be considered a transfer. Therefore, the physician placed the hospital at risk for having violated EMTALA and increased his risk of being subject to a medical malpractice suit.
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