A solution to both of these issues is to create an alternate department just for psychiatric care, a place with trained staff and a healing environment where psychiatric patients can have ongoing treatment for up to 24 hours. Such “psych EDs” are known by many names but most commonly as a Psychiatric Emergency Service (PES) or a Crisis Stabilization Unit (CSU).
Explore This IssueACEP Now: Vol 35 – No 07 – July 2016
Though there are about as many variations on these models as there are programs, a PES/CSU is essentially staffed with mental health professionals trained to work with emergency psychiatry patients. Coercive treatments such as forcible medication or physical restraints are avoided; instead, the focus is on collaborative engagement, with a goal of a community disposition rather than hospitalization when appropriate. There’s enough time allotted for medications to take effect, intoxications to detoxify, withdrawal symptoms to abate, or external issues to resolve before making a reevaluation to determine the most appropriate disposition. Staff members such as nurses, therapists, and even former patients known as peer counselors (in roles similar to Alcoholics Anonymous’ sponsors) are intermingled with the patients rather than behind a nursing station, conducting everything from organized group therapy to supportive chats or even talking about things over an impromptu game of checkers or dominoes.
With these approaches, it isn’t uncommon for a PES/CSU to help patients improve enough to avoid hospitalization in more than 70 percent of cases, patients who would have otherwise been hospitalized in the traditional system. Because only patients who truly have no alternative are admitted, psychiatric hospital beds become far more likely to be available than in systems where the default treatment is hospitalization.
PES/CSUs can be set up to accept transfers from a hospital emergency department or multiple area emergency departments or to directly receive patients from the community, thus avoiding a stop in the department altogether. Such designs greatly reduce boarding times for the surrounding departments. In a 2014 study, a regional PES reduced the psychiatric patient boarding time in local EDs by more than 80 percent below the state average, essentially eliminating the concept of boarding in the region.4
The per-patient cost of running a PES/CSU can be less than the cost of ED boarding, so operating a financially self-sufficient psychiatric emergency program can be of major benefit to hospitals and emergency departments. Further, insurers, HMOs, Medicaid, and other government payers will find tremendous savings by being able to avoid expensive psychiatric hospitalizations in a majority of their patients.