An Emergency Treatment Hub-and-Spoke Model for by bmn61808


									Emergency Psychiatry

An Emergency Treatment Hub-and-Spoke
Model for Psychiatric Emergency Services
Tih-Shih Warren Lee, M.D.
Edwin F. Renaud, M.S.W.
Oscar F. Hills, M.D.

M      odern psychiatric emergency
       services can be traced back to
the Community Mental Health Cen-
                                            crisis stabilization, active initiation of
                                            treatment, and modification or rein-
                                            stitution of treatment, and the second
                                                                                          psychiatric emergency department is a
                                                                                          haven to turn to whether they need to
                                                                                          address their medical concerns or
ters Act of 1963, which mandated the        aspect focuses on hub-and-spoke in-           whether they experience suicidal or
provision of emergency psychiatric          teractions with medical, psychiatric,         homicidal ideation. In some cases the
treatment in all federally funded           and social services. Many institutions        psychiatric emergency department
community mental health centers             already practice this comprehensive           may be a helpful way to direct patients
(1,2). From 1963 to the early 1980s         and integrative model, although they          to other resources, which is especially
the prevalent model for treating psy-       may refer to the model by different           important given that mental illness can
chiatric emergencies in hospital set-       names. We refer to this model as the          make it difficult for patients to find
tings was one of psychiatric consulta-      emergency treatment hub-and-spoke             these services. In some circumstances
tion to the emergency department.           (ETHOS) model and characterize it             inpatient admissions are still indicated
   From the mid-1980s on, the dedi-         for future outcome studies.                   and most beneficial to patients, and an
cated psychiatric emergency depart-                                                       admission to inpatient service is not
ment became common in larger hos-           Hub-and-spoke paradigm                        construed as a failure of the emer-
pitals. Currently, the psychiatric          In the hub-and-spoke model, the psy-          gency team.
emergency department generally              chiatric emergency department acts
consists of a multidisciplinary team of     as a central agency, or hub, with             Emergency treatment paradigm
attending and resident psychiatrists,       spokes radiating to and from various          In the ETHOS model, the nature and
psychologists, social workers, nurses,      mental, medical, and social services.         cause of the patient’s acute decom-
and ancillary staff situated in a de-       The goal is to channel patients to the        pensation—for example, acute stres-
fined location. According to Rosen-         most efficacious and efficient treat-         sors, family discord, homelessness, or
berg and Sulkowicz (3), some psychi-        ment, depending on the circum-                treatment disruption—is comprehen-
atric emergency departments operate         stances affecting patients, such as           sively evaluated. The crisis that
as triage services, with the primary        their diagnosis, specific stressors, so-      brought the patient to the psychiatric
goal of providing the assessment and        cial circumstances, and phase of life.        emergency department is viewed as
care necessary to place the patient in      The spokes are bidirectional, because         an opportunity to engage the patient
another setting.                            many patients are referred to the psy-        and to allow the patient to experience
   Psychiatric emergency services con-      chiatric emergency department by              the crisis in a positive therapeutic
tinue to evolve, driven by treatment        other services for acute stabilization.       manner.
advances, fiscal constraints, and           The key spokes radiate to all outpa-             Clinicians are encouraged and ex-
changes in mental health paradigms.         tient clinics, day centers, and case          pected to delve more deeply into the
We characterize here a psychiatric          management systems and to transi-             biological, psychological, and social
emergency department model that             tional housing, work therapy, and             aspects of the patients’ problems by
emphasizes two key aspects: the first       substance abuse treatment programs.           making repeated assessments and ob-
aspect focuses on in-depth evaluation,      The mere presence of a receptive and          taining collateral information from
                                            helpful psychiatric emergency de-             multiple sources and over a longer
                                            partment is often a tremendous relief         time frame, if necessary. In some cas-
Dr. Lee and Dr. Hills are affiliated with
                                            to the other services and their pa-           es, the patient may be evaluated and
the department of psychiatry at Yale Uni-
versity, 25 Park Street, New Haven, Con-
                                            tients. Thus the psychiatric emer-            treated for 24 hours or more.
necticut 06519 (e-mail, warren.lee@yale.    gency department is able to facilitate           In addition to providing respite and
edu). All authors are with the Department   patients’ connecting or reconnecting          a safe environment for the patient,
of Veterans Affairs Medical Center in       with various services without the             the psychiatric department conducts
West Haven, Connecticut. Douglas H.         complexity of an inpatient admission.         a range of interventions. Pharmaco-
Hughes, M.D., is editor of this column.        From the patients’ point of view, the      logical interventions, beyond those
1590                                         PSYCHIATRIC SERVICES   ♦ ♦ December 2003 Vol. 54 No. 12
used for behavioral control, include           tion with the patient’s outpatient cli-      patients were discharged once they
initiation or change of antidepres-            nician and other services. The med-          were assessed to be sober or “safe,” it
sants, mood stabilizers, and antipsy-          ical center’s outpatient services in-        could lead staff members to feel as
chotics. Among the psychological in-           clude mental health and medical clin-        though their work were futile, and
terventions provided are supportive            ics; inpatient units; a “quarterway          they could become burned-out,
therapy, such as affirmation, advice,          house,” which provides temporary             which might adversely affect the
and empathic validation; motivational          shelter and proximity to treatment;          quality of care future patients receive.
interviewing; and family meetings.             day centers; substance abuse day pro-        It is our experience that a hub-and-
Behavioral, cognitive, and dynamic             grams; programs for the homeless;            spoke model, because of its proactive
approaches might also be selectively           and work programs.                           engagement, evaluation, and treat-
employed in an emergency setting (3).             For purposes of illustration, there       ment approach, mitigates staff burn-
Social interventions include assistance        were a total of 2,296 evaluations in the     out by humanizing the efforts of
with housing, transport, welfare bene-         VA psychiatric emergency department          working toward patients’ recovery.
fits, and access to medical treatment.         in 2002. Of all the patients evaluated,
   In emergency psychiatry, clinicians         503 (22 percent) were admitted to the        Conclusions and
focus on brief intervention and stabi-         inpatient psychiatry service.                future directions
lization while directly interacting with                                                    Given fiscal and resource constraints,
outpatient facilities and other servic-        Skill set, education,                        the most ethical and prudent way to
es. If patients are new to the system,         and staff morale                             serve patients’ needs may be to
treatment may be initiated in the psy-         The primary assessment task for psy-         broaden and deepen the scope of
chiatric emergency department be-              chiatric emergency departments is            services and interventions that a psy-
fore patients are referred to outpa-           risk and safety evaluation. Other req-       chiatric emergency department can
tient psychiatric and other services.          uisite skills include data collection, di-   provide. ETHOS is one of the avail-
For patients already in treatment,             agnostic assessment, disposition plan-       able paradigms that focuses on in-
emergency department personnel im-             ning, process negotiation, and a work-       depth evaluation, active treatment
mediately reconnect with the patients’         ing knowledge of community re-               initiation, and reinstitution or change
clinicians; the clinicians then become         sources and legal issues. Clinicians in      of pharmacologic interventions and
actively involved in decisions about           the psychiatric emergency depart-            that emphasizes close collaboration
patients’ treatment, medication, and           ment need a direct and active inter-         with other mental heath, medical,
placement. In some cases, clinicians           viewing style to elicit information          and social services.
are the ones who bring patients to the         from the patient and from a wide                It is conceivable that in the future
psychiatric emergency department               range of informants. Clinicians rely         some psychiatric interventions will be
and continue to play a key role. In all        on narration, formal mental status ex-       done in brief, intense, and repeated
of these instances, the psychiatric            amination, and laboratory testing to         bursts in settings similar to psychiatric
emergency room facilitates optimal             formulate a diagnosis and a plan.            emergency departments, which would
continuity of care. This aggressive, in-          Moreover, the psychiatric emer-           allow the patient to move to various
tense, and continuous two-way active           gency department is an optimal set-          services and treatment modalities.
involvement is referred to as the hub-         ting for training residents in psychia-      One logical extension of the ETHOS
and-spoke paradigm.                            try, emergency medicine, primary             model is for an extended observation
                                               care, and neurology; psychology and          service that allows the patient to be
The ETHOS model in practice                    social work interns; and medical stu-        evaluated and treated further.
The psychiatry department at the De-           dents. In the psychiatric emergency             On the other hand, fiscal constraints
partment of Veterans Affairs (VA)              department setting, trainees work            may lead to emergency psychiatric
Medical Center in West Haven, Con-             with patients in crisis. Through this        services’ being marginalized even fur-
necticut, has continuously expanded            process, trainees learn to conceptual-       ther. It is not inconceivable that some
its outpatient services. Even though           ize the patient’s problem and plan for       psychiatric emergency departments
the number of patients admitted for            long-term treatment as well as em-           may be shut down completely and
inpatient treatment has decreased,             ploy psychological, social, and phar-        their patients seen in the medical
tremendous growth has occurred in              macologic interventions in the brief         emergency department with consult-
the variety and scale of outpatient            time they have to see the patient.           ing psychiatrists. Under that scenario,
services the center offers.                    The quick turnover of patients means         however, the medical emergency de-
   In this environment, the psychiatric        that the trainee will see patients who       partment would again be saddled with
emergency department plays an in-              present a wide variety of symptoms           behavioral dyscontrol, substance
creasingly active role in engaging pa-         and problems.                                abuse, and the task of dealing with a
tients, educating them on the variety             Every psychiatric emergency de-           variety of social services for persons
of services available, initiating changes      partment has patients who come in or         with mental illness. Moreover, if psy-
to or reinstituting pharmacotherapy,           are brought in acutely intoxicated just      chiatric emergency departments are
engaging in psychological interven-            to “dry out” or for “food and shelter”       shut down, the medical emergency de-
tions, and making referrals to other           and who are not willing or able to en-
services, all done in close collabora-         gage in treatment. If these kinds of                            Continues on page 1594

PSYCHIATRIC SERVICES   ♦ ♦ December 2003 Vol. 54 No. 12                                          1591
Continued from page 1591

partment will likely adopt psychophar-
macologic interventions with less em-
phasis on the psychological and social
interventions that may also be benefi-
cial to the patient.
   Ultimately, implementing the
ETHOS model depends on the cur-
rent needs and future projections of
the psychiatric emergency depart-
ment in terms of patient’s demo-
graphic characteristics, patient’s use
patterns, community expectations,
and fiscal policies for these services. ♦

1. Gerson S, Bassuk E: Psychiatric emergen-
   cies: an overview. American Journal of Psy-
   chiatry 137:1–10, 1980
2. Breslow R, Erikson B, Cavanaugh K: The
   psychiatric emergency service: where we’ve
   been and where we are going. Psychiatric
   Quarterly 71:101–121, 2000
3. Rosenberg R, Sulkowicz K: Psychosocial in-
   terventions in the psychiatric emergency
   service: a skills approach, in Emergency
   psychiatry. Review of Psychiatry, vol. 21.
   Edited by Allen M. Washington, DC,
   American Psychiatric Publishing, Inc, 2002

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