Emergency Psychiatry: An Emergency Treatment Hub-and-Spoke Model for Psychiatric Emergency Services

Modern psychiatric emergency services can be traced back to the Community Mental Health Centers Act of 1963, which mandated the provision of emergency psychiatric treatment in all federally funded community mental health centers (1,2). From 1963 to the early 1980s the prevalent model for treating psychiatric emergencies in hospital settings was one of psychiatric consultation to the emergency department.

From the mid-1980s on, the dedicated psychiatric emergency department became common in larger hospitals. Currently, the psychiatric emergency department generally consists of a multidisciplinary team of attending and resident psychiatrists, psychologists, social workers, nurses, and ancillary staff situated in a defined location. According to Rosenberg and Sulkowicz (3), some psychiatric emergency departments operate as triage services, with the primary goal of providing the assessment and care necessary to place the patient in another setting.

Psychiatric emergency services continue to evolve, driven by treatment advances, fiscal constraints, and changes in mental health paradigms. We characterize here a psychiatric emergency department model that emphasizes two key aspects: the first aspect focuses on in-depth evaluation, crisis stabilization, active initiation of treatment, and modification or reinstitution of treatment, and the second aspect focuses on hub-and-spoke interactions with medical, psychiatric, and social services. Many institutions already practice this comprehensive and integrative model, although they may refer to the model by different names. We refer to this model as the emergency treatment hub-and-spoke (ETHOS) model and characterize it for future outcome studies.

Hub-and-spoke paradigm

In the hub-and-spoke model, the psychiatric emergency department acts as a central agency, or hub, with spokes radiating to and from various mental, medical, and social services. The goal is to channel patients to the most efficacious and efficient treatment, depending on the circumstances affecting patients, such as their diagnosis, specific stressors, social circumstances, and phase of life. The spokes are bidirectional, because many patients are referred to the psychiatric emergency department by other services for acute stabilization. The key spokes radiate to all outpatient clinics, day centers, and case management systems and to transitional housing, work therapy, and substance abuse treatment programs. The mere presence of a receptive and helpful psychiatric emergency department is often a tremendous relief to the other services and their patients. Thus the psychiatric emergency department is able to facilitate patients' connecting or reconnecting with various services without the complexity of an inpatient admission.

From the patients' point of view, the psychiatric emergency department is a haven to turn to whether they need to address their medical concerns or whether they experience suicidal or homicidal ideation. In some cases the psychiatric emergency department may be a helpful way to direct patients to other resources, which is especially important given that mental illness can make it difficult for patients to find these services. In some circumstances inpatient admissions are still indicated and most beneficial to patients, and an admission to inpatient service is not construed as a failure of the emergency team.

Emergency treatment paradigm

In the ETHOS model, the nature and cause of the patient's acute decompensation—for example, acute stressors, family discord, homelessness, or treatment disruption—is comprehensively evaluated. The crisis that brought the patient to the psychiatric emergency department is viewed as an opportunity to engage the patient and to allow the patient to experience the crisis in a positive therapeutic manner.

Clinicians are encouraged and expected to delve more deeply into the biological, psychological, and social aspects of the patients' problems by making repeated assessments and obtaining collateral information from multiple sources and over a longer time frame, if necessary. In some cases, the patient may be evaluated and treated for 24 hours or more.

In addition to providing respite and a safe environment for the patient, the psychiatric department conducts a range of interventions. Pharmacological interventions, beyond those used for behavioral control, include initiation or change of antidepressants, mood stabilizers, and antipsychotics. Among the psychological interventions provided are supportive therapy, such as affirmation, advice, and empathic validation; motivational interviewing; and family meetings. Behavioral, cognitive, and dynamic approaches might also be selectively employed in an emergency setting (3). Social interventions include assistance with housing, transport, welfare benefits, and access to medical treatment.

In emergency psychiatry, clinicians focus on brief intervention and stabilization while directly interacting with outpatient facilities and other services. If patients are new to the system, treatment may be initiated in the psychiatric emergency department before patients are referred to outpatient psychiatric and other services. For patients already in treatment, emergency department personnel immediately reconnect with the patients' clinicians; the clinicians then become actively involved in decisions about patients' treatment, medication, and placement. In some cases, clinicians are the ones who bring patients to the psychiatric emergency department and continue to play a key role. In all of these instances, the psychiatric emergency room facilitates optimal continuity of care. This aggressive, intense, and continuous two-way active involvement is referred to as the hub-and-spoke paradigm.

The ETHOS model in practice

The psychiatry department at the Department of Veterans Affairs (VA) Medical Center in West Haven, Connecticut, has continuously expanded its outpatient services. Even though the number of patients admitted for inpatient treatment has decreased, tremendous growth has occurred in the variety and scale of outpatient services the center offers.

In this environment, the psychiatric emergency department plays an increasingly active role in engaging patients, educating them on the variety of services available, initiating changes to or reinstituting pharmacotherapy, engaging in psychological interventions, and making referrals to other services, all done in close collaboration with the patient's outpatient clinician and other services. The medical center's outpatient services include mental health and medical clinics; inpatient units; a "quarterway house," which provides temporary shelter and proximity to treatment; day centers; substance abuse day programs; programs for the homeless; and work programs.

For purposes of illustration, there were a total of 2,296 evaluations in the VA psychiatric emergency department in 2002. Of all the patients evaluated, 503 (22 percent) were admitted to the inpatient psychiatry service.

Skill set, education, and staff morale

The primary assessment task for psychiatric emergency departments is risk and safety evaluation. Other requisite skills include data collection, diagnostic assessment, disposition planning, process negotiation, and a working knowledge of community resources and legal issues. Clinicians in the psychiatric emergency department need a direct and active interviewing style to elicit information from the patient and from a wide range of informants. Clinicians rely on narration, formal mental status examination, and laboratory testing to formulate a diagnosis and a plan.

Moreover, the psychiatric emergency department is an optimal setting for training residents in psychiatry, emergency medicine, primary care, and neurology; psychology and social work interns; and medical students. In the psychiatric emergency department setting, trainees work with patients in crisis. Through this process, trainees learn to conceptualize the patient's problem and plan for long-term treatment as well as employ psychological, social, and pharmacologic interventions in the brief time they have to see the patient. The quick turnover of patients means that the trainee will see patients who present a wide variety of symptoms and problems.

Every psychiatric emergency department has patients who come in or are brought in acutely intoxicated just to "dry out" or for "food and shelter" and who are not willing or able to engage in treatment. If these kinds of patients were discharged once they were assessed to be sober or "safe," it could lead staff members to feel as though their work were futile, and they could become burned-out, which might adversely affect the quality of care future patients receive. It is our experience that a hub-and-spoke model, because of its proactive engagement, evaluation, and treatment approach, mitigates staff burnout by humanizing the efforts of working toward patients' recovery.

Conclusions and future directions

Given fiscal and resource constraints, the most ethical and prudent way to serve patients' needs may be to broaden and deepen the scope of services and interventions that a psychiatric emergency department can provide. ETHOS is one of the available paradigms that focuses on in-depth evaluation, active treatment initiation, and reinstitution or change of pharmacologic interventions and that emphasizes close collaboration with other mental heath, medical, and social services.

It is conceivable that in the future some psychiatric interventions will be done in brief, intense, and repeated bursts in settings similar to psychiatric emergency departments, which would allow the patient to move to various services and treatment modalities. One logical extension of the ETHOS model is for an extended observation service that allows the patient to be evaluated and treated further.

On the other hand, fiscal constraints may lead to emergency psychiatric services' being marginalized even further. It is not inconceivable that some psychiatric emergency departments may be shut down completely and their patients seen in the medical emergency department with consulting psychiatrists. Under that scenario, however, the medical emergency department would again be saddled with behavioral dyscontrol, substance abuse, and the task of dealing with a variety of social services for persons with mental illness. Moreover, if psychiatric emergency departments are shut down, the medical emergency department will likely adopt psychopharmacologic interventions with less emphasis on the psychological and social interventions that may also be beneficial to the patient.

Ultimately, implementing the ETHOS model depends on the current needs and future projections of the psychiatric emergency department in terms of patient's demographic characteristics, patient's use patterns, community expectations, and fiscal policies for these services.

Dr. Lee and Dr. Hills are affiliated with the department of psychiatry at Yale University, 25 Park Street, New Haven, Connecticut 06519 (e-mail, [email protected]). All authors are with the Department of Veterans Affairs Medical Center in West Haven, Connecticut. Douglas H. Hughes, M.D., is editor of this column.