Organizing Emergency Services in Psychiatry: The University Health

Network Experience

Jodi Lofchy MD FRCPC

Director Psychiatric Emergency Services

University Health Network,

Associate Professor,

University of Toronto

Central LHIN Emergency Department

Quality Collaborative, Toronto

June 14, 2012

Overview

Models of best practice

The way we were…

Psychiatric Emergency Services Unit

[PESU]- the model

Systems and supports

Evaluation- what works and what doesn’t

A work in progress

Models of best practice

Goals:

Timely rendering of psychiatric emergency

care

Access to care

Safety/stabilization and assessment

Continuity of care

(Breslow R., Structure and Function of Psychiatric Emergency Services from Emergency Psychiatry,

ed Allen M., 2002)

Models of {best} practice

{Consultation}

Psychiatric Emergency Services in Medical Emergency Settings

Psychiatric Emergency Service Facility

Crisis hospitalization

Crisis outpatient follow-up

Mobile teams

Crisis residences

Breslow, 2002

APA Task Force on Psychiatric Emergency Services 2002

Shifting Objectives in Emergency Psychiatry

Triage Model

– Rapid

evaluation

– Containment

– Rapid Referral

Treatment Model

– Comprehensive

assessment

– Broad range of

effective services.

“An Organizationally Unique Treatment Facility”

Gerson and Bassuk 1980

Organization and function of academic psychiatric emergency services: Currier and Allen, General Hosp Psych 25 (2003) 124-129

Survey AAEP PES medical directors US- 51/56 (91%) response

77% (39/51) PES in general hospital– 64% (25/39) separate PES; 21% (8/39) component of med

ED; 13% (5/39) consultation

– 96% Ψ > 8 hr/d [26% Ψ 24/d]

– 77% had locked area in PES

– 69% (35/51) informal crisis beds; x = 9.2 beds

Admission rates: approx 1/3 (34%) admitted inpt Ψ

Length of stay [LOS]: x = 9.0 hrs (SD = 11.3 hr)

Hospital Based Services

Key System Components

Space Takes into account the needs of many, varied patients

Core Staff Nursing and other professional staff

Security officers

Psychiatric assistants

Psychiatrists and other medical specialists

Students

Support Services Toxicology

Therapeutic drug levels

Laboratory assays and imaging capability

The Views of the Client

Initial in-community contact

Alternatives to traditional services

More hopeful first contact

Intake and Waiting

– Comfortable physical environment

– Interpersonal emotional support

– Availability of peer advocate support

Assessment and Service Planning

– Respected person orientation

– Improved staff training

Treatment Interventions

– Patient-practitioner partnerships

Allen, M., (2003) What do Consumers Say they Want and Needs During a

Psychiatric Emergency Journal of Psychiatric Practice Vol 9, No. 1.

Emergency Psychiatry at UHN

University Health Network [UHN] =

Toronto General Hospital [TGH] +

Toronto Western Hospital [TWH] +

Princess Margaret Hospital [PMH] +

Toronto Rehabilitation Institute [TRI]

ER Ψ at TWH

Inpatient Ψ at TGH:

– 18 general psych beds

– 6 acute care [ACU]

Outpatient Ψ at TWH, TGH, PMH

http://images.google.com/imgres?imgurl=http://www.cghr.org/images/UofT_logo.jpg&imgrefurl=http://www.cghr.org/events.htm&usg=__uv6WtnDyneRJ-aqWbL_6Wvg85QI=&h=1103&w=633&sz=91&hl=en&start=47&tbnid=FiZrvNVUxxdu2M:&tbnh=150&tbnw=86&prev=/images%3Fq%3DUNIVERSITY%2BHEALTH%2BNETWORK%2BLOGO%2BTORONTO%26start%3D40%26gbv%3D2%26ndsp%3D20%26hl%3Den%26sa%3DNhttp://images.google.com/imgres?imgurl=http://tubs.sa.utoronto.ca/2002/speakers_macgregor/index_files/logo.gif&imgrefurl=http://tubs.sa.utoronto.ca/2002/speakers_macgregor/index.htm&usg=__5zOy4On48CyQCE5liU1YIE83YQM=&h=94&w=90&sz=1&hl=en&start=61&tbnid=uQWzWwtghoCGvM:&tbnh=80&tbnw=77&prev=/images%3Fq%3DUNIVERSITY%2BHEALTH%2BNETWORK%2BLOGO%2BTORONTO%26start%3D60%26gbv%3D2%26ndsp%3D20%26hl%3Den%26sa%3DN

The Way we Were…. Early 1990’s until 2005

24 hr psychiatric consultation to the TGH and TWH EDs

Crisis Response Service 1996-2005 Multidisciplinary clinicians

– 16 hrs/day 7 days/week Psychiatry assistants

– information collection, collateral, monitoring/escorting patients

Emergency Psychiatry Assessment Unit [EPAU] – 8 bed secure unit NOT in ED

Urgent Care Clinic [UCC]– patients mostly referred through the ED’s– 3 clinics/week – appointments within 1 week of referral

What We Struggled with….

Responsiveness to Psychiatric consultation in ED

Lack of space in the ED for psychiatric assessment

– 2 designated beds

– Long waiting times

– ↑ frequency of ‘LWBS’ [left without being seen], agitation, prolonged police stays

Length of Stay [LOS] on the inpatient unit

EPAU as satellite acute care unit– Form 3’s, 4’s!

– Review boards

– Inpatient charts, discharge summaries

– Too many beds (2/8 → Impact)

What We Struggled with….

Excessive use of resources to manage agitation– security – codes– chemical & mechanical restraint

UCC– beyond brief therapy– 50% f/u visits > 20 session guideline– Goal: 95% pts < 20 sessions

Insufficient time and resources to apply principles of crisis intervention in the ED

PESU- the evolution 2005-07

CTAS modification [Canadian Triage and Acuity Scale*]

Development of the PES Model

PES/ED Integration Committee

Training and education

New unit design/function* *

Maintenance of the consultation model within the ED-based PESU

*Beveridge R et al. Canadian Emergency Department Triage and Acuity Scale

Can J Emerg Med 1999; 1(3 suppl):S2-28

PES MODEL – Triage Level

TRIAGEDirect to Psych (Physician to Physician)

ER Psychiatrist on call = MRP

MENTAL HEALTH

ISSUE ONLY

NO YES

As identified by ER Triage

Assistance can be provided by

ER Psych RN

ER

MENTAL HEALTH

CONSULT REQUIRED

All patients should have basic

physical assessment, i.e. vital signs

CONSULTATION

CRISIS

CONSULT

PSYCHIATRIC

CONSULT

PES MODEL – Consult Level

Emergency Psychiatry remains a

consultative model. Crisis consultation

still available independent of

psychiatric consultation

CRISIS

CONSULT

PSYCHIATRIC

CONSULT

May refer to Psychiatry prior to

complete assessment if:

- presenting complaint

Psychiatric in origin

- No obvious or acute medical

issues are present

- ED physician engages with

crisis clinician for input to

expedite an early referral

Involvement in referral

will be at psychiatrist’s

discretion

Psych will ask ED

physician reason for

psychiatric referral

PES Clinician

(Mon.-Sun. 0800-

2300) discusses

case with ER MD

DISCHARGEHOLDADMIT

PESU

PESU

Physically situated in the TWH Emergency Department

Safe, secure setting with a capacity for 8 patients, 4 stretchers, 2 lounges, 2 wait spaces

Dedicated psychiatric nursing staff, psychiatry assistants, crisis clinicians and on-site resident and staff psychiatrists

PES Model supports decisions made by the team

ADMIT HOLD DISCHARGE

Decision to admit made,

patient transferred to bed

“Admit no bed” will

automatically trigger a

“psych bed alert”. ER MD no

longer responsible for

patient while in ER

Medical issues to be referred

to Medical consults

Decision to hold would be

based on clinical decision,

i.e.: patient’s condition, need

for collateral in an after

hours situation, awaiting

acceptance to another

facility (no longer than 12

hours)

If any acute decompensation

in a patient’s condition, ER

will be notified and respond

Refer to Urgent

Care Clinic, Clerk

Crisis Clinic or

Crisis follow up

Reconnect with

community support

Refer on to other

services

Considerations

Six hours post-consult, ER Psych becomes MRP

If patient requires medical attention, Medical Consults will be

consulted

PESU

PES MODEL - Disposition

PESU: who are the patients in our unit?

Emergency Hold Admit

ER MD = MRP*

Pt. s/b ED Physician +/-

clinician or PESU nurse

1. Pt. discharged from ED

by ER MD

2. Pt referred to psychiatry

for consultation then d/c’d

by Ψ

Ψ= MRP

Pts referred to psychiatry-

decision to hold as an

emergency patient for

following reasons:

Crisis stabilization

Risk assessment

Further collateral

required

Not likely to require

admission

Ψ= MRP

Disposition after

psychiatric consultation:

Complex diagnosis

Known pt. with pattern

of high risk

decompensation

Will need further

stabilization and /or

treatment

*MRP= Most Responsible Physician

Systems and supports

Departmental

Emergency department

Hospital

ER Alliance

Computerization

Communication

– High risk pts: EMI’s

– Cross-site meetings

– ER/Psych meetings

– M&M ER/Psych rounds

– PALC

PESU Staffing (2012)

Days:

1 Staff Psychiatrist (0830-1700)

Resident and/or Clinical Clerk (0830-1700)

2 RNs (0730-1930)

2 Clinicians (0800-2000 and 1100-2300)

2 Psychiatric Assistants (0730-1930 and 1100-2300)

Nights: 1 Resident on call/Staff Psychiatrist

2 RNs (1930-0730)

1 Psychiatric Assistant (1930-0730)

What’s Working………

Patients are seen straight from triage if

presenting with a Mental Health

complaint- less wait time

Average Crisis Response Times Under 2 Hours

64%70%

83% 82% 81% 80% 83% 82% 82%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

2004 2005 2006 2007 2008 2009 2010 2011 2012

EPAU PESU

What’s Working………

Patients are seen straight from triage if

presenting with a Mental Health complaint-

less wait time

Decrease in number of admits

Increased overall volumes

PRE AND POST PESU COMPARISON

0

2,000

4,000

6,000

8,000

Tot. Visits 1,173 4,580 7,555

Tot. Admits 453 696 956

% 38.60% 15.50% 12.70%

2004-2005 2005-2007 2008-2012

PESUEPAU

Avg. % Admits

vs. Total Pts Seen

2004-2005

38.6%

2005-2012

13.6%*

*Currier & Allen,

2003: x = 34%

What’s Working………

Patients are seen straight from triage if

presenting with a Mental Health complaint-

less wait time

Decrease in number of admits

Increased overall volumes

Current average LOS in PESU 9.8 hrs

Less use of chemical restraint

Less use of security

Other variables….

Length of Stay

Pre-PESU/EPAU- 2005 Avg. LOS: 8 days

Post-PESU- 2006-2012 Avg. LOS: 10.4 hours*

- 2011-2012 Avg. LOS : 9.8 hours*

*Currier & Allen, 2003: x = 9 hrs

Chemical Restraint

PESU vs. EPAU: less chemical restraint - received fewer meds overall, less multiple medications, less Haldol used

Hypotheses:–Less wait time to see Ψ

–De-escalation by psychiatric staff

–Containment of a locked unit(Venos et al, 2006)

What’s Working………

Patients are seen straight from triage if presenting with a Mental Health complaint- less wait time

Current LOS in PESU @ approx 9.8 hrs

Decrease in number of admits

Increased overall volumes

Less use of chemical restraint

More capacity for crisis intervention work in the ER

More capacity for crisis f/u: 4 UCC clinics, max 10 sessions

Improved staff morale- recruitment/retention; consumer satisfaction

Increased communication, collegiality with ER

Rich educational venue

Morning report revised- resident driven

Increasing numbers of students:

– Medical student electives

2003-04: 20

2005-11: 61

– Resident electives:

2008-11: 13

– Nursing

– Social work

Sharing model with other centres across the country

– 13 Local

– 11 National

A Work in progress…

Inpatient beds located at TGH site

Challenges unique to UHN and PESU

Ongoing communication!

Model refinement

Medical consultation

Managing change

Outcome measures-best practices

HOLDING AND HELPING….

PESU TORONTO WESTERN HOSPITAL ED