Am I wrong or is the EMPATH (Alameda model) psych ED just a psych unit in the ED

[nexus73]

You've got psychiatrists (or nps, or telepsych), you've got social workers, you've got psych RNs, you've got therapists. Outside of no groups, and everyone in one big room instead of several single rooms, this sounds an awful lot like an inpatient psych unit. So why not just build a bigger psych unit?

Or if you already have a social work triage team in the ED to assess need for admit vs discharge, what does the Alameda model (which is expensive and labor intensive) do for you really?

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[1edyfirel]

I've worked in a model really similar to this and enjoyed it. (No therapist though.) At my place it was honestly mainly just people on meth who need to crash, or very soft SI, or just poor coping skills. The biggest thing it does is get the ED off our backs and prevent ****ty admits. (I also controlled who could be admitted to our psych ED from the regular ED ; if someone needed IP, they either go straight from ED to IP, or wait until they get a bed.)

At my hospital, the ED docs (and admin) would force every meth-induced psychosis to be admitted to IP vs letting them metabolize overnight in the ED. Those patients don't need to be taking up a valuable inpatient beds, but when they are actively psychotic and agitated, they are also not appropriate for d/c from the ED. I found it to be a nice middle ground. I've also worked in places where there is not a psych ED and I hated the constant tension between psych and ED re: these patients. I would never do that work again in a million years.

 

[Merovinge]

I've also worked in places where there is not a psych ED and I hated the constant tension between psych and ED re: these patients. I would never do that work again in a million years.

ED vs psych tension is easily the worst possible interface/interactions to have in the entire field of psychiatry. Particularly when the ED doctors are actually paid more for how fast their throughput is, combining a distain for mental health and it costing them money is a truly wicked combination.

 

[Mad Jack]

ED vs psych tension is easily the worst possible interface/interactions to have in the entire field of psychiatry. Particularly when the ED doctors are actually paid more for how fast their throughput is, combining a distain for mental health and it costing them money is a truly wicked combination.

Concur. The worst working situations in psychiatry are when you're dealing with an ER that has significant incentive to move patients quickly and thus fails to properly evaluate or disposition psych patients and when you've got hospitalist services with similar incentives which push for admissions to psychiatric floors for inappropriate patients simply to clear their beds. In both cases administration seems to side with the other providers and push hard for choices that are not in the best interest of patients.

 

[nexus73]

I've worked in a model really similar to this and enjoyed it. (No therapist though.) At my place it was honestly mainly just people on meth who need to crash, or very soft SI, or just poor coping skills. The biggest thing it does is get the ED off our backs and prevent ****ty admits. (I also controlled who could be admitted to our psych ED from the regular ED ; if someone needed IP, they either go straight from ED to IP, or wait until they get a bed.)

At my hospital, the ED docs (and admin) would force every meth-induced psychosis to be admitted to IP vs letting them metabolize overnight in the ED. Those patients don't need to be taking up a valuable inpatient beds, but when they are actively psychotic and agitated, they are also not appropriate for d/c from the ED. I found it to be a nice middle ground. I've also worked in places where there is not a psych ED and I hated the constant tension between psych and ED re: these patients. I would never do that work again in a million years.

Your psych ED didn't take the boarded patients awaiting an inpatient psych bed?

 

[1edyfirel]

Nope. There was a clear difference (as clear as you can be, I guess) with which patients are appropriate for IP and which for the psych ED (those we could get out in 24-48H, though some did convert to IP.) Our psych ED was a large room with these weird recliners/beds. It wasn't appropriate for patients who might need IMs, restraints, etc. I never got pushback from the ED about bringing in a boarded patient waiting for IP. I assume that is something admins had worked out before.

 

[nexus73]

Nope. There was a clear difference (as clear as you can be, I guess) with which patients are appropriate for IP and which for the psych ED (those we could get out in 24-48H, though some did convert to IP.) Our psych ED was a large room with these weird recliners/beds. It wasn't appropriate for patients who might need IMs, restraints, etc. I never got pushback from the ED about bringing in a boarded patient waiting for IP. I assume that is something admins had worked out before.

was that psych ED staffed 24/7 with psychiatry?

 

[1edyfirel]

7a to 7p. Any possible admits after 7p unit were discussed with whatever doctor was on call (by phone only), and he/she would give yay or nay. Nursing staff also excellent about making sure patients go to the right place.

 

[nexus73]

7a to 7p. Any possible admits after 7p unit were discussed with whatever doctor was on call (by phone only), and he/she would give yay or nay. Nursing staff also excellent about making sure patients go to the right place.

who was the attending in charge of the psych ED patients overnight, what would happen if someone wanted to d/c at 2am? and was the salary comparable to the inpatient unit psychiatrists...or was it a premium for ED work?

 

[comp1]

It sounds something like observation on the medical floors and sounds great. There are certain patients that are harmed by the fully tucked in setting of an inpatient unit and would benefit from something more transitory to move them quickly onto an appropriate outpatient level of care. A regular ED is not an ideal place for a person with meth psychosis to be for 24 hours, but it's also not necessary that be admitted inpatient to somewhere that has an average length of stay of 5-7 days. This is in between.

 

[1edyfirel]

Attending on-call (by phone) was responsible, and nobody was asking to leave at 2am. They are either on a hold or very much want to be there (and the issue is more getting them out in the morning). I guess if a pt was really demanding to leave at 2 am nurses could call the crisis team to eval and put the pt on a hold if appropriate. (But this is why the initial screening matters so much.) Salary was per hour and, at this hospital anyway, comparable to IP.

 

[NickNaylor]

Our PES gets absolutely steamrolled by the ED service. In fact, our PES service is organizationally managed by the ED (rather than by psychiatry), which leads to all kinds of fun things.

About a year ago, our PES service rolled out a new service line called the "extended observation unit." The idea was to basically provide somewhat intensive psychiatric services for patients that could not be discharged immediately but were unlikely to require inpatient admission. The unit was funded in part by the local government-funded "mental health authority" and was supposed to be focused on connecting patients with appropriate inpatient services.

Initially, this actually worked fairly well. There were several groups led by the social workers throughout the day. Case managers met regularly with the patients and allowed us easier access to more intensive outpatient services that were otherwise difficult to access. Patients were assessed twice a day by a "provider."

Now, it basically functions as an overflow for the main PED. Many patients are court-ordered for treatment and will be going to an inpatient unit when a bed becomes available (100+ hour dwell times are not unusual for us). The additional case management services that were available have slowly faded such that the case managers rarely meet with patients unless specifically asked to do so, and more extensive connection with outpatient services is non-existent. The unit tends to be enriched with people that are primarily malingering and/or intoxicated - not the most pleasant group to work with. This model has been so "successful" - and by that, I mean getting those damn psych patients out of the medical ED quickly - that we will be rolling out a similar unit of similar size.

It's a good idea in theory, but I've been soured on the whole model because of how miserable the experience of working on this unit has been at my institution.

 

[hallowmann]

Nope. There was a clear difference (as clear as you can be, I guess) with which patients are appropriate for IP and which for the psych ED (those we could get out in 24-48H, though some did convert to IP.) Our psych ED was a large room with these weird recliners/beds. It wasn't appropriate for patients who might need IMs, restraints, etc. I never got pushback from the ED about bringing in a boarded patient waiting for IP. I assume that is something admins had worked out before.

We have a very similar model of a psychiatric observation unit aimed at acute stabilization for crisis that was made like 3 years ago. Patients are supposed to be there for 24-72 hrs. Most end up discharging with outpatient services/plan. They are mainly seen by social work, nursing, and psychiatrist or mid-level during the day. Some stay until they get into residential SUD treatment without taking up an actual inpatient bed. It's basically a big room with chairs that lay flat into "beds". It has done wonders for boarding patients and admitting people to the units who really need it, but now, demand seems to have just increased. Still nice to have a good option for people who just need a little better discharge and outpatient follow up planning.

The actual roll out was crap though. Initially they told the residents it would in no way affect us, so they didn't include the residency in any planning, then right before it opened they said, oh, residents will cover the unit and do all admissions from 5pm-8am. They staffed the place mostly with ARNPs, and the quality of the initial evaluation, H&P, and management dropped significantly. That isn't an issue for most, but it was an issue for the ones that needed to be admitted to the inpatient units. It significantly increased our call work (because the turnover was insane) and something like 80% of the admissions to the unit in the first few months were done by residents, because the day provider would often leave people in the ED to be evaluated after 5pm (they weren't as efficient). They have finally increased staffing on that unit to have coverage until 8pm during the week, which has helped (just took a while).

We had a lot of trouble at first ironing our the rules for admissions, specifically who was appropriate depending on violence/level of care needed, and also making sure the ED actually evaluated patients and explained what the unit is like instead of just saying "hey, this person has a psych complaint, admit to this unit". It's still an issue at times from an ED standpoint, but at least now there are rules and guidelines to follow and point to.