Innovative Care in the Emergency Department: Dedicated Psychiatric observation Areas

Many hospital medical centers that provide emergency services to the community at large contain a locked psychiatric treatment unit that serves as an extension of the ED. For EDs that do not have these units, the halls of the ED end up taking the place of the psychiatric treatment unit.

Many of the patients admitted to these EDs sit in the hallway for days without adequate treatment of their symptoms, which is one of the impetuses for writing this book.

In order to address this issue, we recommend the following restructuring of the way the ED team thinks about space allocation for patients with behavioral health needs. A model we suggest is to organize the placement of your patient population into three categories: high acuity, moderate acuity, and low acuity. Depending on the state that you provide treatment in, use of the term “acuity” can have implications for staffing ratio requirements.

Patients that are deemed to be loud, combative, requiring higher intensity of monitoring and care should be placed in an area that has better visibility, with potential access to video monitoring, or closer to a nursing station. The way to conceptualize the process, even within the ED, is as the higher acuity patient stabilizes, and is better controlled medically and psychiatrically, they can be moved to the moderate level acuity area, and then to the lower acuity areas of the ED. Patients that are placed in the higher acuity area should be “medically cleared.” The hope is that these patients have had substance intoxication or use ruled out of their diagnostic picture, but there may be occasions where this has been missed by the diagnosing ED clinician, so these patients may also end up being placed in the higher acuity psychiatric treatment area. Typical symptoms or diagnoses that may require a higher level of monitoring and care include acute psychosis, schizophrenia, schizoaffective disorders, and mania. Patients that have displayed a propensity for self-harm would also be placed in this area.

As the patient’s symptoms improve while being treated in the high acuity area, the treatment team can begin to develop a transitional plan for movement to the moderate or lower acuity areas. This depends on the level of improvement that the patient displays, and the continued expected length of stay in the ED.

Many EDs have adopted an innovative approach to developing a safe and therapeutic area for their patients with psychiatric needs to be treated in. A psychiatric “guesting area” has been created as an alternative treatment milieu for the psychiatric patient population in the ED (Waunch and Conley 2011; Winokur and Senteno 2009; Winokur and Waunch 2010). Some hospital systems have used a model in which the guesting area is within the ED walls, while others have utilized a designated space outside of the ED to house patients waiting for psychiatric beds (Levin-Epstein 2015).

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