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
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 All patients should have basic physical assessment, i.e. vital signs TRIAGE Direct to Psych (Physician to Physician) ER Psychiatrist on call = MRP As identified by ER Triage Assistance can be provided by ER Psych RN MENTAL HEALTH ISSUE ONLY NO YES ER MENTAL HEALTH CONSULT REQUIRED CONSULTATION CRISIS CONSULT PSYCHIATRIC CONSULT
PES MODEL Consult Level CRISIS CONSULT PES Clinician (Mon.-Sun. 0800-2300) discusses case with ER MD Emergency Psychiatry remains a consultative model. Crisis consultation still available independent of psychiatric consultation 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 PESU ADMIT HOLD DISCHARGE
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
PES MODEL - Disposition PESU Considerations Six hours post-consult, ER Psych becomes MRP If patient requires medical attention, Medical Consults will be consulted 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
PESU: who are the patients in our unit? Emergency Hold Admit ER MD = MRP* Ψ= MRP Ψ= 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 Pts referred to psychiatrydecision to hold as an emergency patient for following reasons: Crisis stabilization Risk assessment Further collateral required Not likely to require admission 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 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 64% 70% 83% 82% 81% 80% 83% 82% 82% 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 complaintless wait time Decrease in number of admits Increased overall volumes
PRE AND POST PESU COMPARISON 8,000 6,000 4,000 2,000 0 2004-2005 2005-2007 2008-2012 Tot. Visits 1,173 4,580 7,555 Tot. Admits 453 696 956 % 38.60% 15.50% 12.70% EPAU PESU 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 complaintless 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