Organization and function of academic psychiatric emergency services☆

Abstract 

Psychiatric emergency services (PES) are evolving as freestanding, parallel components of emergency departments at many tertiary care medical centers in the U.S. While PES facilities provide an increasing percentage of first-line care for patients with psychiatric crises, the services they provide and their interactions with medical emergency services have not been systematically assessed. The purpose of this study was to examine PES structure, care processes, patient characteristics and relationship with medical emergency services by surveying PES directors with a 70-item questionnaire about PES facilities in 1998. This report presents information about staffing adequacy, medical evaluation and other procedures, length of stay, and aftercare. The response rate was 91% (n=51), and most sites (>90%) were academic training sites. A large percentage (92%) of PES sites were open 24 h a day, 7 days a week, and 94% had an attending psychiatrist present at least 8 h daily. PES psychiatrists performed initial medical evaluation at 55% of sites and were often responsible for medical clearance. Pharmacologic therapy was routinely initiated for patients being admitted in 92% of facilities and for patients being released in 70% of facilities. Mean (SD) length of stay in the PES was 9.0 (11.3) hours. The PES facilities were effective at referring patients to aftercare, and 51% of PES sites provided follow-up care. However, 69% of respondents reported inadequate referral options for patients with substance abuse. The mean recidivism rate was 18%, primarily attributed to substance abuse and medication noncompliance. The results of this survey show that PES facilities are organizationally complex units in which staff routinely perform medical clearance, initiate treatment, and coordinate aftercare. Our findings highlight the importance of adequate medical training for PES psychiatrists, the need for improved aftercare programming, and better access to substance abuse treatment for discharged patients.