Combining Recovery, Medical Models to Improve Emergency Psychiatry Outcomes

 

Avoiding coercion not only improves the patient experience and leads to more trust and alliance with caregivers but can result in a safer environment than restrain and sedate with fewer assaults and injuries, better outcomes, and improved throughput.4,5

Medical Approach: Better Parameters for Psychiatric Patient “Medical Clearance”

The concept of what constitutes appropriate “medical clearance” — when a patient is considered medically stable for psychiatric evaluation and treatment — has long been a sore spot between medical facilities and mental health programs.

Frequently there have been complaints about excessive, expensive and/or unnecessary test requirements causing delays, or being used as an excuse to prevent transfers.

Now evidence continues to accumulate that yields from broad screening laboratory tests without clear indications are very low.6 As a result, mental health programs are beginning to streamline screening guidelines using more evidence-based criteria, which is lowering costs and removing barriers to achieving a prompt admission process.

Recovery Approach: More Welcoming, Calming Treatment Environments

People in the midst of a mental health crisis respond best to a comfortable, non-threatening, friendly setting, which encourages healing, and limits cause for fear or agitation.

Many of the best recovery model programs have soft lighting, soothing music or ambient sounds, pleasant colors or nature murals on the walls, and inviting, cozy furniture. There is also the encouragement for open, nonjudgmental interaction, and engagement with peers and staff.

Compare this to more common clinical settings of busy medical EDs, which are hectic and noisy, have dangerous looking equipment and machinery everywhere, isolate people by cubicles or curtains, and staff that come and go at a rapid pace.

Is it no wonder that paranoid, anxious, or seriously dysphoric patients might feel worse in such settings? Even many dedicated psychiatric emergency programs too often isolate their patients in individual locked rooms at a time when interaction with other people might be far more therapeutic.

Medical model programs or medical settings that also see mental health emergencies should be encouraged to have more welcoming areas for those in crisis.

Even very crowded EDs could benefit from a diversion room near triage, where crisis patients are offered the option of a calm environment prior to placement in the main part of the ER. It should be understood that human interaction in a time of crisis can be very beneficial, and isolation should be discouraged.

Medical Approach: Taking All Comers

A criticism of some recovery model programs is that they can be too selective, excluding individuals because they “don’t meet our criteria,” because “they won’t benefit from our services,” or even worse because a person has gotten onto the “Do Not Accept” list.

Meanwhile, medical EDs, which are based on the medical model, are prohibited by federal law from declining to serve anyone who requests help. Recovery model programs would be better served by emulating this aspect of medical model programs, and should extend their reach to a broader set of those in need.

Scott Zeller, MD, is Chief of Psychiatric Emergency Services at Alameda Health System in Oakland, California, and past president of the American Association for Emergency Psychiatry. He is also a member of the Psychiatry Advisor editorial board.

References

  1. National Alliance on Mental Illness (NAMI). CIT Toolkit: CIT Facts. Accessed Jan 31 2015. Available at http://www.nami.org/Content/ContentGroups/Policy/CIT/CIT_Facts_4.11.12.pdf.
  2. Zeller SL.“Treatment of psychiatric patients in emergency settings.” Prim Psychiatry. 2010;17(6):35-41.
  3. Zibulewsky J. ”The Emergency Medical Treatment and Active Labor Act (EMTALA): what it is and what it means for physicians.” Proc (Bayl Univ Med Cent). 2001;14(4):339–346.
  4. Knox DK, Holloman GH. “Use and Avoidance of Seclusion and Restraint: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Seclusion and Restraint Workgroup.” Western Journal of Emergency Medicine. 2012;13(1):35–40.
  5. Cole R. “Reducing Restraint Use in a Trauma Center Emergency Room.” Nursing Clinics of North America.  2014; 49(3): 371-381.