An Innovative, Nurse-Led Service for Appropriate Management of Psychiatric Emergencies: Initial Findings

The French mental health care system comprises both a public and a private network. The former is provided free of charge, is organized into sectors depending on a patient’s address, and encompasses outpatient services known as medical-psychological centers (known as CMPs in French). CMPs provide access to various mental health professionals, including nurses, psychiatrists, social workers, and psychologists, as well as access to inpatient wards, including for individuals requiring hospitalization without their consent.

Some French regions have additional arrangements in the public network, and these include both a crisis element that organizes reactive outpatient appointments, and structures known as Dispositif de Soins Partagés en Psychiatrie (DSPP, or shared care system in psychiatry), which help general practitioners to manage psychiatric care in the community, give advice on treatment, and, if required, arrange a timely appointment with a psychiatrist. Beyond these public wards, a private network, which sometimes requires patients to pay for treatment, also offers in- and outpatient care (mostly voluntary hospitalizations) (1).

Psychiatric emergency departments (PEDs) are public wards within the health care landscape. Their high visibility and possible role as the gateway to accessing the public network mean that they play a strategic role within the system (2, 3). In France, as well as globally, there has been a steady increase in the number of cases referred to emergency departments (EDs) for psychiatric reasons (4, 5). This increase may be due to reasons that are both positive (e.g., lack of resistance to seeking help for mental distress) and negative (e.g., reductions in the quality of available care and a lack of access to nonscheduled care). Of note, it is estimated that 20%–40% of PED admissions are avoidable (6).

The PED at our institution, Toulouse University Hospital, covers an area with a population of 1.4 million people and is open 24/7. A patient can be referred for a psychiatric consultation (i.e., outpatient care) or initially to the general ED (for inpatient care in cases of intoxication or to eliminate differential diagnoses) and then to a psychiatric team for evaluation. Our PED has experienced a major increase in the number of referred patients: from 2,927 psychiatric consultations in 2014 to 4,220 in 2018, representing an annual increase of 10%. This increase has affected the quality of care and the assessments conducted on the ward, meaning that PEDs cannot fully comply with national guidelines (7, 8). In our PED, outpatients arrive via two major pathways: 59% are admitted after self-referral and 41% after calling “15” (the French 911 service). These “911” departments are managed by the emergency medical aid ward Service d'Aide Medicale d'Urgence (SAMU) (9). An online supplement to this column describes the psychiatric referrals to Toulouse University Hospital’s PED.

The flow of patients who spontaneously present at the PED is difficult to regulate, requiring long-term public information campaigns to provide guidance to the general public. SAMU services for individuals who call for purely psychiatric or psychological reasons, however, can be improved. Indeed, using a retrospective analysis, we found that the physicians conducting triage for SAMU arranged transportation to the PED for 84% of such callers and for only 20% of those calling for any other health issue. Moreover, 73% of the patients referred by SAMU to the PED were sent home after a psychiatric evaluation.

Patients seek PED services for various reasons: they do not know where to find help elsewhere, have no follow-up arranged after an earlier appointment or cannot find an available appointment, are in the throes of a psychological or suicidal crisis, or are referred by their families, the police, or via SAMU when they are displaying psychotic decompensation or agitation. In cases of intoxication from alcohol or other substances, and associated suicidal ideation, psychotic symptoms, agitation or psychological distress, patients are initially referred to the general ED for medical monitoring until detoxification; a psychiatric evaluation is then performed. Optimal care organization should lead to attendance at the PED only for psychiatric evaluation. We have, therefore, attempted to address issues related to avoidable referrals by SAMU by designing a new psychiatric nurse–led psychiatric assessment service, known in French as Dispositif Infirmier de Régulation Psychiatrique au SAMU (DIRPS). This column describes how DIRPS was set up and our findings after 2 months of operation. Our study used data available under the French legislation MR-004. This legislation does not require institutional review board approval but requires a data protection law evaluation.

The SAMU Service

Calls to the medical emergency number 15 are answered by a medical referral assistant, who obtains initial information, including patient location, the reason for the call, and degree of emergency. The call is then referred to a trained emergency physician working for SAMU, who decides on the most appropriate care pathway.

Our assessment of this service revealed that the skill sets of the SAMU physicians enabled them to carefully evaluate calls for nonpsychiatric reasons, for example, cardiac emergencies, with referrals based on a patient’s medical history and clinical symptoms. This led to transportation to the ED in 20% of cases. After taking a medical history and conducting a clinical interview revealing psychiatric issues, however, SAMU physicians reported being uncomfortable with referring patients to the general ED, and instead usually decided to arrange transportation to the PED for nearly all of these patients.

A South African study of the management of psychiatric emergencies reported that 87% of the emergency physicians surveyed disclosed a lack of skills and knowledge of psychiatric illness, 64% felt unable to conduct a psychiatric examination, and 73% were unaware of the principles of crisis intervention (10). However, in our analysis, we also noted that even if the SAMU physicians attempted to improve their skills, they would not have enough time to apply them. SAMU referrals are based on very brief interviews, typically averaging 3 minutes, which is not long enough to assess calls made for psychiatric or psychological issues.

DIRPS Goals and Services

The role of DIRPS was to help the SAMU physicians to better identify relevant psychiatric criteria before arranging for transport of a caller to the PED. The main objective of DIRPS was to prevent such admissions for those who would benefit from care elsewhere in the network. The new service was based on the skills of three psychiatric nurses who have worked in our PED for several years and had significant experience in handling psychiatric emergencies. The DIRPS service is located in the same room as the SAMU service and operates from 10 a.m. to 10 p.m. The nurses can help the SAMU physicians to triage calls made by individuals with only psychiatric or psychological problems.

The nurses can assess a caller’s psychiatric condition over the telephone. This psychiatric assessment includes a clinical interview and involves obtaining a medical history and, if applicable, accessing relevant psychiatric databases, including medical records from the department’s out- and inpatient files. Other databases, including those of the criminal justice system, however, are not accessible to the nurse. This assessment enables the nurses to determine whether the caller already has a psychiatric follow-up in place and whether redirecting the caller to the relevant department or physician is possible. The nurses also can perform suicide risk assessments to prevent PED referrals when such risk is low and may seek the support of a patient’s immediate family or other relatives. The nurses use specific psychiatric interview techniques to manage a caller’s distress or emotional arousal. If the nurses are uncertain about the caller’s psychiatric condition, they can refer the case to a PED psychiatrist, who makes the ultimate referral decision in collaboration with a SAMU physician. Patients who call the SAMU service under the influence of alcohol or other substances, or who request help with a medical emergency (after a suicide attempt), are not referred to the DIRPS nurses.

We collected data on calls to SAMU solely for psychiatric or psychological reasons over a 4-month period (between April and July 2019)—2 months before DIRPS was set up and 2 months thereafter. This enabled us to assess whether care referrals changed after DIRPS implementation. The referrals were categorized as follows: transportation arranged, leading to a transfer to the PED or for psychiatric inpatient care; transportation arranged, not leading to a PED transfer, either because the transportation was inapplicable (no patient at the address, transport refused) or because care at home was appropriate; and transportation not arranged, with advice instead given over the phone by a nurse or a physician, or a referral was made to outpatient care, with an appointment provided by phone. We conducted a descriptive analysis of these data by using numerical values and percentages, evaluating the changes by calculating the differences in the referral percentages. We also compared hospitalization rates relative to patients admitted to the PED before and after DIRPS became operational.

Calls to the SAMU service for psychiatric or psychological reasons led to PED referrals in 84% of cases before DIRPS implementation versus 38% thereafter. The DIRPS service reduced referrals arising from inadequate patient assessments and resulting in transportation to the PED in cases of no real psychiatric or psychological need. Moreover, the proportion of direct referrals to inpatient care without admission to the PED increased from 1% to 4%. Decisions about providing care at home remained stable, with advice for referral given over the phone by the DIRPS nurses rather than the SAMU physicians. At the same time, the rates of inpatient hospitalization after PED admittance following a referral by the SAMU service increased from 27% before DIRPS was established to 36% in the 2 months thereafter. This increase implies that patients sent to the PED via DIRPS had more serious problems and required inpatient care more often. The latter finding may indicate that the nurses are very skilled at identifying psychiatric emergencies requiring inpatient care, although further study is needed to confirm this observation. A summary of the referrals before and after DIRPS implementation is provided in Table 1.

Strikingly, unlike before DIRPS when no patients were directly referred to outpatient psychiatric care, whether for usual care at a CMP or to a private psychiatrist or a general practitioner (with the assistance of a DSPP, if required), 48% of callers were referred to such care after DIRPS was established. This increase in outpatient referrals may be explained by the skills of the psychiatric nurses. Indeed, before we established the DIRPS service, the SAMU physicians, having limited knowledge of psychiatry and the psychiatric network, out of an abundance of caution systematically referred individuals with psychiatric problems to the PED for psychiatric evaluation. These findings highlight the key role of the psychiatric nurses in coordinating appropriate care. In particular, along with their psychiatric assessment skills, the nurse-led service benefited from the nurses having access to specific psychiatric databases, their knowledge of the psychiatric network, and the longer time nurses had when making decisions.

The key limitation of this study was its focus on quantitative data obtained over only 4 months; a prospective study covering a longer period (which is currently planned and expected to begin later in 2021) is therefore required to validate our results, specifically in relation to diagnoses and their severity among the patients admitted to the PED after DIRPS was established. This extended study will again include data obtained both retrospectively (before DIRPS) and prospectively (after DIRPS). Randomization will not be used for ethical reasons; because the service has now been in operation for 2 years, we consider it inappropriate to prevent patients from accessing a DIRPS evaluation.

The extended study will specify the care referral and will include a cost-effectiveness analysis. Moreover, further work is required to determine whether the DIRPS service may have any negative effects on patients not referred to the PED. This is particularly important, given that inappropriate referral decisions could have severe consequences. We will also examine whether the patients referred for outpatient care honor the appointments made for them.

Conclusions

The preliminary results of our analyses of the new psychiatric nurse–led DIRPS service are encouraging with respect to the feasibility and benefits of this service. It has enabled referrals within the psychiatric care network that have prevented unnecessary admissions to the PED. However, further evaluations of DIRPS and its efficiency are required and will be undertaken in a planned extension of the current study.