In recent years, there have been increasing complaints that people with chronic mental illnesses impede access to care and contribute to ED overcrowding. Somewhere, the argument goes, there must be a more appropriate place for these patients. But there isn't. Because of difficulties in obtaining same-day or after-hours appointments with regular providers, many people with acute exacerbations of chronic conditions go to the ED for care. This is true whether the cause is noncompliance with dietary restrictions for congestive heart failure, failure to perform routine self-care for diabetes, or not taking antipsychotic medication as prescribed.
ED nurses have said to me that they didn't choose to be psychiatric nurses. True. But neither did ED nurses choose to be nurses in orthopedics, cardiology, gynecology, or neurology-and every day we perform care within these and other specialties. No matter what patients' diagnoses are, our role is to care for, treat, educate, and advocate on their behalf.
Too often, we ED nurses minimize the concerns of patients with acute exacerbations of psychiatric illnesses. Patients may say they are depressed or anxious or hearing voices. They sometimes have difficulty describing their concerns, saying only that they "need to be admitted to the hospital." We tend to believe that such concerns don't require specialized services, or else that the problems are caused by behaviors that could be resolved by the patient taking more responsibility. We don't feel this way about patients with other chronic conditions-perhaps we are more comfortable with and less judgmental about people with physical illnesses.
Every day, ED nurses treat patients with chronic medical conditions, such as diabetes or hypertension. Somehow, treating sequelae of these conditions seems appropriate to our role. Although we know that patients who successfully manage chronic conditions always benefit, we don't question our role in caring for patients whose efforts have failed-for example, a patient who's having acute exacerbations of asthma because he neglected to refill his corticosteroid inhaler.
It can be difficult to manage admissions or transfers of patients with mental illnesses. In many communities, resources are limited. There are also often multiple providers, and patients may be covered by a variety of private or public insurance plans. Deciding where to admit patients with mental illnesses may be complicated by their developmental disabilities, dementia, or drug and alcohol abuse. Because rapid disposition is essential to the smooth functioning of any ED, delays in arranging for admission or transfer can be frustrating.
Perhaps we're less judgmental about physical illnesses.
We can deal with this frustration, first, by providing good clinical care, as always, which can involve taking continuing education classes, reading articles or books on psychiatric nursing, and getting advice from colleagues with psychiatric experience. Second, we must communicate clearly with patients and families, keeping everyone informed of the treatment plan. Finally, we should treat patients with mental illness with respect-as we should all patients. Our legitimate frustration with a fragmented system shouldn't be expressed as irritation with patients.
Deinstitutionalization represented a major advance in civilization. With it, we acknowledged that psychiatric illnesses are chronic conditions that can be managed medically. Yet like other chronic conditions, mental illnesses require periodic treatment for acute exacerbations. In our society, the ED is the way into the health care system for many people with chronic illnesses, including mental illnesses.
Once we accept the fact that people with chronic mental illnesses have legitimate reasons to come to the ED, our work in caring for them will proceed more smoothly-as smoothly as anything in the ED can proceed, that is.