Administration of Psychiatric Emergency Services
Avrim B. Fishkind
Scott Zeller
Mende Snodgress
The psychiatric emergency service (PES) has a unique position at the crossroads of medicine, mental health, law enforcement, and politics. The administration of such a service requires the ability to respond to many seemingly unrelated demands—which are often at cross purposes—while maintaining focus on the most important mission, patient care.
In 1986, Gail Barton (1) described the inherent challenge in the administration of PESs, saying “despite the clinical commitment, a complex emergency psychiatric care system has emerged piecemeal, without consistent administrative planning. The various scientific and political forces have left chaos in their wake.” She added that “services are poorly coordinated, resulting in gaps and overlap, and training programs assign low prestige to emergency rotations” (1).
It was noted as early as 1983 that administrative structures overseeing emergency services usually do not assist in creating the milieu necessary to allow intensive, noncoercive environments that can stress the assertive pharmacotherapy and psychosocial intervention necessary in crisis (2). In fact, even when such intensive intervention will create savings in time, money, and morbidity in the long run, administrative structures will rarely put in the money up front to see savings down the road.
To overcome these obstacles, and to provide the best service possible to their patients, a PES needs a cohesive, dedicated, and well-qualified administrative team.
MULTIDISCIPLINARY LEADERSHIPAND MODELS OF CARE
The very concept of multidisciplinary leadership in a PES is challenging. The PES, like other psychiatric inpatient and outpatient services, is usually characterized by a constant struggle to achieve equilibrium between biologic, psychological, and social domains. Parallel systems can develop within the PES, with the medical model on one side with physicians and nurses, and the psychosocial model on the other with psychologists and social workers. Each group may find themselves working in isolation, feeling frustrated, overworked, underpaid, and poorly heard. At times there are uneasy animosities between mental health disciplines. This produces an environment in which patients can easily split staff, and the staff lose the ability to work together as a team to prevent untoward outcomes. The solution to this scenario is the use of the multidisciplinary team.
Genuine multidisciplinary leadership has many advantages. First, the use of a multidisciplinary team helps ensure that the focus is on all functional domains of the patient, namely, biologic, psychological, and social. Second, the PES work environment is a great deal more satisfying when employees in all disciplines feel valued and recognized for their contributions to the service. Finally, PES workers need to feel that service delivery issues that are discipline specific are advocated for within PES administration.
A multidisciplinary approach to psychiatric emergency services promotes efficiency. Nurses, preferably master’s level (3), and social services workers, to whom patients are often well known, can triage and discharge individuals who are not acute or whose needs can be met without the use of scarce psychiatrist time. If the skills of each team member are apparent to staff psychiatrists as a result of the multidisciplinary team effort, physicians are usually comfortable with triaging patients out of the emergency service once the patient’s needs for psychosocial
supports have been addressed and ongoing therapy needs delineated.
supports have been addressed and ongoing therapy needs delineated.
Emergency psychiatrists set the tone for multidisciplinary leadership in the PES. Psychiatrists naturally become the team leaders in most psychiatric emergency services. This is generally true because of their ability to interface with other medical personnel, their diagnostic skills, and the ability to differentiate between psychiatric crises and organic disorders requiring a different course of treatment. Psychiatrists who recognize the clinical value of experienced nurses and social services workers can help create a team environment in which the skills of all disciplines are maximized in the service of patients who are often grossly underserved. However, in many PES environments, psychiatrists will find themselves being part physician, part psychologist, part nurse, and part social worker.
Perhaps the most common multidisciplinary model in psychiatric emergency services is the medical model, which is multidisciplinary because it includes other disciplines such as social workers, nurses, technicians, case workers, and chemical dependency workers in addition to psychiatrists. In this model, the psychiatrist is, by definition, the team leader, and uses his or her training to coordinate biologic, psychological, and social interventions. The psychiatrist must be careful to realize that lack of inclusion of a particular discipline will interfere with patient treatment and cause animosity among the team because members feel unimportant, overlooked, and unrecognized for their treatment successes. Perlman and Schwartz (3) described other multidisciplinary models in which cases are assigned to each team member in rotating order. Although this model helps keep all team members alert and sharp in all skill areas, it does not necessarily result in the team members being used to their fullest potential, and may result in either redundant assessments or assessments that are weak in some domains and strong in others.
Another model described by Perlman and Schwartz (3) has cases assigned to the psychiatric emergency care team according to the various skills of each team member. In this model, cases involving neurologic and endocrine crises, for example, would be assigned to psychiatrists, whereas cases involving floridly psychotic patients might be jointly assigned to a primary nurse. Social workers might handle cases in which homelessness, familial discord, and sexual or domestic violence or abuse are the primary or exacerbating factors in the crisis.
Some multidisciplinary teams in psychiatric emergency settings (usually in community mental health organizations) are described as “truly egalitarian” in that cases are assigned and handled in a completely random fashion with no identified single accountable discipline (4). It is arguable that leaders will emerge anyway, and this model may require too much process and too little action to adequately serve the needs of a busy psychiatric emergency service.
Administrators in the PES can make a significant contribution to the efficiency and effectiveness of the multidisciplinary service. Conversely, ad-ministrators who operate in a vacuum, serving a system rather than its patients or staff, can detract from the difficult job of operating a multidisciplinary psychiatric emergency service. Anecdotal experience suggests that less is more when it comes to the administration of a PES. Cumbersome systems requiring many layers of administrative approval, paperwork, and compliance with ancillary requirements are not as clinically effective in responding to emergencies, adequately reassessing patients, and avoiding unnecessary hospitalizations.
A typical PES administrative structure will include a medical director, a program director, and a nurse manager.
Medical Director
In the ideal setting, the medical director oversees all clinical and quality assurance issues affecting the psychiatric emergency service. In collaboration with the program director and nurse manager, the medical director defines the role of each discipline represented in the service, and each clinical provider answers to the medical director for all clinical services provided. The medical director also defines the population served and the supporting services used to enhance the functioning of the PES.
In reality, medical directors usually have ultimate responsibility for the handling of each case in the emergency service, and they are generally responsible for hiring, management, and staffing of psychiatrists and psychiatric residents. It is too often the case that medical directors have little
real control over staffing patterns, budget, and other matters that directly affect the quality of services provided to patients. Too often, unreasonable demands are imposed on medical directors to provide a variety of other services not directly related to the clinical demands of the psychiatric emergency service.
real control over staffing patterns, budget, and other matters that directly affect the quality of services provided to patients. Too often, unreasonable demands are imposed on medical directors to provide a variety of other services not directly related to the clinical demands of the psychiatric emergency service.
Program Director
The program director, usually a social services worker or a nurse, handles the day-to-day operations of the emergency service. The program director addresses the myriad of staffing problems that invariably occur in a psychiatric emergency service, and usually devotes a great deal of time to hiring and managing the various disciplines represented. Under the direction of the medical director, the program director is involved in evaluating and improving the quality of ser-vices provided. In many respects, it is also the duty of the program director to advocate for patients to receive high-quality care despite conflicting bud-getary and administrative pressures to decrease the intensity of services provided and the frequent push to decrease staffing.
The program director has a special responsibility to support the multidisciplinary nature of the psychiatric emergency care team, attempting to ensure that the roles of all disciplines represented are clearly outlined and carried out by the team.
Nurse Manager
Nurses operate at the very front line of emergency psychiatry. They are often required to administer medications to highly agitated patients who are violent and unwilling participants. It is the challenging task of the PES nurse manager to hire, manage, and staff the majority of the PES positions, including registered nurses, licensed vocational nurses, and nurse extenders such as psychiatric technicians who have direct responsibility for managing the milieu. Identifying and hiring individuals suitable for this demanding work is an onerous task. The nurse manager also works to diminish the conflictual relationships that develop between nurses and physicians.
The nurse manager frequently works in close concert with the medical director, but it is equally important for the nurse manager and the program director to work together in a coordinated and harmonious manner. This is especially true because many duties of the nursing staff invariably overlap with the duties of social services workers. Overlapping tasks include assessment, therapeutic interventions, interactions with families, interactions with external providers, and discharge planning.
The clinical administrators of a psychiatric emergency service are critical to the quality of the service provided. Lack of coordination and cooperation between the medical director, program director, and nurse manager often contributes to putting the service itself in crisis and, in the end, produces a less favorable outcome for the patient. A clear definition of responsibilities, a generous flow of information, and abandonment of rigid discipline-bound duties can produce a psychiatric emergency service that is client centered and fundamental to any health care system.
RESPONSIBILITIES OF PSYCHIATRIC EMERGENCY SERVICES ADMINISTRATORS
Quality Assurance
UTILIZATION REVIEW
Utilization review (UR) refers to the efficiency of the clinical services provided by clinicians in a particular service (5). Managed care has further refined the definition as a mechanism to evaluate whether treatment options are appropriate, necessary, and of high quality. With regard to acute psychiatric services, UR may include admission preapproval, concurrent review for continuing treatment, discharge planning, and retrospective review (6). For many PESs, this is required by the Joint Council on Accreditation of Healthcare Organizations (JCAHO), although non-JCAHO-accredited facilities can use these standards as a model as well.
The structure developed by JCAHO contains four functions that apply to the PES. The first UR function is monitoring the medical necessity of admissions to the PES and extended observation, as well as the use, omission, or inappropriate use of support services such as laboratory, radiology, and medical consultation. Second, there must be clear admission criteria taking into account psychiatric diagnosis and concurrent medical, substance abuse, and developmental comorbidities.
Third, there should be measurable length-of-stay criteria for the PES units based on acuity, complexity of care, and needed psychosocial interventions. Fourth, there should be an established process for implementing corrective actions.
Third, there should be measurable length-of-stay criteria for the PES units based on acuity, complexity of care, and needed psychosocial interventions. Fourth, there should be an established process for implementing corrective actions.
Other areas are critical to review on an ongoing basis in the PES. These areas can include time from arrival to seeing a physician; appropriate level of care determinations; accuracy of triage determinations; use of seclusion, restraint, and forced medications; and the time police or ambulance crews spend waiting when they drop off patients. Medical necessity and meeting “continued stay” criteria are other common examples.
A PES can be a very expensive operation, and utilization review can be used by PES administration to ensure that medication choices, laboratory tests, and consults are appropriate and not excessive. Cost containment is a combination of the necessity of care weighed against the efficiency and cost. Medication monitoring is a good example. State department of mental health, pharmacologic best practices, and good risk management procedures require certain blood work (electrolytes, complete blood count) and procedures (electrocardiogram, pregnancy test) to be done prior to the initiation of medication. However, a PES may not have a sufficient lab budget or nearby stat lab. This leaves clinical staff in the difficult position of deciding between a reasonable risk of initiating a medication without laboratory availability or foregoing treatment and instead hospitalizing for initiation of medications.
Cost containment in the PES can also take other forms. One possibility is limiting formulary choices to control costs; generic versions of medications may be as effective as brand names, yet significantly less expensive. Another option, because patient cost is typically measured on a per-hour basis, is to have concurrent review that ensures that patients have the shortest possible length of stays based on presenting acuity. Some psychiatric emergency services contain costs by limiting ser-vices to patients who are not diagnosed with schizophrenia, bipolar disorder, major depression, or other severe mental illnesses; primary diagnoses of mental retardation or substance abuse, for example, may be excluded. Other PES units might have medical exclusion criteria to limit the number of physically ill patients present in the PES.
CLINICAL INDICATORS AND CONTINUOUS QUALITY IMPROVEMENT
Utilization review, however, needs to be balanced against the provision of effective, quality care. An administrative psychiatrist, or a quality committee including physicians, must closely monitor the biologic and psychological therapies dispensed in a PES.
In 1986, Comstock (7) described a set of quality assurance indicators for a PES. They included time required for the service itself, patient satisfaction, staff satisfaction, documentation of services, number of episodes of violent behavior, death rate, rate of return visits attributable to incomplete or ineffective treatment, and hospitalization rates.
Service delivery in different PES facilities can vary widely in scope. One of the best examples is a lack of standardization in defining what makes up a psychiatric emergency assessment, especially in areas as difficult to define as dangerousness, parasuicidality, and impulsivity. Even more bewilderment as to standards arises regarding what is an appropriate medical clearance and what nurse- and physician-to-patient ratios are optimal.
It is recommended that the medical director of a PES establish both peer review and quality review, which will aid in the definition of appropriate standards for a particular facility. In peer review, PES physicians analyze each other’s clinical performance on a regular basis. For example, physicians may review each other’s charts with an eye toward evaluating each other’s appropriateness in use of medications. In contrast to peer review, quality care review involves using specific and quantifiable measures of clinical care, which can be easily measured (8). The goal is to easily compare the delivery of care and clinical outcomes across institutions.
In an array of psychiatric emergency ser-vices, clinical indicators might include clinical processes (obtaining informed consent, administration of medication), outcomes (patient response to medication, drug usage evaluation), and resources (availability of medication, pharmacy services, and a laboratory for medication monitoring). The medical director should work closely with social work and nursing services to collect indicators for each discipline. Directors
should be aware that developing comprehensive indicators is less important than selecting high-yield indicators, which address difficult clinical domains—those susceptible to errors or untoward outcomes.
should be aware that developing comprehensive indicators is less important than selecting high-yield indicators, which address difficult clinical domains—those susceptible to errors or untoward outcomes.
Continuous quality improvement (CQI) is not just about having resources to provide care, nor is it solely concerned with meeting standards. It implies that there is always room for change and development. This is especially applicable in the PES to more severe untoward outcomes, such as assaults, needlesticks, elopements, suicide attempts, and adverse medication reactions. Other items such as successful linkage to aftercare and patient satisfaction are important to monitor.
Quality assurance indicators for psychiatric emergency include, among others, the standards published by the American Psychiatric Association, the American Association for Emergency Psychiatry, the American Association of Child and Adolescent Psychiatry, the American College of Emergency Physicians, and the New York State Office of Mental Health. The example indicators discussed in this chapter are a small fraction of the overall indicators that may be applied to psychiatric emergency services (Table 43.1).
TABLE 43.1 Indicator Domains from the APA Task Force on Psychiatric Emergency Services | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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