Importance of Psych ED?

[BobA]

Many programs I've looked at boast about having a psych ED. Since my home program does not have one of these, I don't really understand what that means exactly. What is a Psych ED? Why is it a good thing to have at a training program?

Thanks!

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[strangeglove]

Are you talking about a CPEP (Comprehensive Psychiatric Emergency Program)? This is distinct from a regular emergency room in that you can hold patients there for up to 72 hours for observation/stabilization. This requires a special dispensation from the state, so only some states have this , e.g. NY. Otherwise, having a psych ED also has benefits of segregating psychiatric patients from the medical patients in the ED, which may be better for management of violent and agitated patients and may also reduce some of the anxiety associated with being in an emergency room.

 

[masterofmonkeys]

Also implies a good support staff (i.e. 24 hr social work). But there are programs out there that don't have CPEPs that also have good emergency psych support staff.

 

[whopper]

I'm assuming you mean a psychiatric emergency department?

The names vary depending on the region. In south Jersey, in the hospital I worked at it was called PIP (psychiatric intervention program). Another place it was called PID, whatever.

The best advantage of this, education wise is you get to see patients in their most raw state. Several patients transferred to such as setting often times have just or are about to decompensate. Often times in inpatient, you've seen a patient that's already been given big doses of antipsychotic in the ER or medical floor before they've been transferred.

It also frequently tests your diagnostic skills because all day long you'll be getting new patients & diagnosing them. You'll be doing frequent H&Ps.

 

[BobA]

OK, that all makes sense. It seems like it implies high volume, good social work support (all of which we have at our ED even without a dedicated psych area).

Beyond that, it seems like the real benefit is for the patient who can be in a more quiet room.

 

[dianamd]

I have seen Psych ERs and CPEPs -- both are different than just the medical ER experience.

When I say Psych ER, I mean a separate area, locked, yes, with all the support staff, glass wall, etc. Some have a few rooms and otherwise a big open space, I saw one with 10+ rooms and a smaller open space. The main decision is admit or discharge, and you won't really keep someone for over 24 hours (maybe you could, but it's just uncommon, I don't know).

For CPEPs, they are also separate, but you can basically admit for observation for 72 hours -- right there in the CPEP. It's the ideal thing for many of the patients, and for learning.

Then there are just those "psych ERs" that are cordoned off by tape or a hallway from the medical ER. I put it in quotes because it is not locked down... I saw one on the interview trail that had a kind of room/area to work, but otherwise looked like a medical ER -- and they frequently kept patients for over 24 hours.

Great to see first encounters, to be the one guessing about the dx, you can learn a lot. And if you like shift work.....

 

[Faebinder]

The new PIP we got that Whopper is talking about is quit amazing and patients from far regions come to it and it sends patients all over NJ when necessary.

12 rooms total... 6 not yet medically cleared and 6 are for cleared patients for psychiatry to see them. Camera watched with a lot of space. I was pretty impressed when I saw it after I saw the old PIP (which was still way nicer than the Psych ED I trained in in NY). Patients can be admitted to the rooms over night after medical clearance till they are seen by a psychiatrist.

Having an official psych ER truly makes a difference in the program... it cuts down on a lot of social work and leg work you'd have to do if there was none. Unfortunately, I can't see a true psych ER surviving long without a nearby Involuntary unit, which many programs are lacking now a days as the trend to go away from those style of units is increasing.

 

[whopper]

The one you mentioned Faebinder is perhaps the best one in the state of NJ, which spends one of the most amounts of money per capita for mental health purposes. The PIP at ARMC is the main psyche crisis intervention center in all of south Jersey.

Its brand new & was designed quite well from what I hear. I'd venture to say its possibly one of the best in terms of physical design in dozens of states.

Another benefit is it teaches you to triage quite well. You'll have patients coming in, fully decompensating, and you'll have to haldol them, then you got someone in another room who just wants to be referred to outpatient.

 

[BobA]

All the points about psych ER's being great for learning I'm not sure I follow. We just have a large, busy, high-volume, old-fashioned, open ED. There's 24hr social work. There are usually 2-4 adult, 1-2 child psych patients there at any time. The psych consult team sees them in the ED - that's where you see the undiagnosed patients. Of course, usually after the ED doc has given some IM geodon or abilify.

Can't you see undiagnosed psych patients in a traditional ED? What's so great about having a dedicated psych ED? Are psych residents there 24/7?

 

[Faebinder]

All the points about psych ER's being great for learning I'm not sure I follow. We just have a large, busy, high-volume, old-fashioned, open ED. There's 24hr social work. There are usually 2-4 adult, 1-2 child psych patients there at any time. The psych consult team sees them in the ED - that's where you see the undiagnosed patients. Of course, usually after the ED doc has given some IM geodon or abilify.

Can't you see undiagnosed psych patients in a traditional ED? What's so great about having a dedicated psych ED? Are psych residents there 24/7?

Having a psych ER produces a zone where you can hold patients for a day and make your decision after they cleared up... e.g.

a) Borderline came in psychotic at 2 am....do you need to admit? Really? Hold till the morning...she feels better, ready to go home with outpatient followup... you can't do this in a regular ER.

b) Cocaine user, had only a couple of drinks (so a low BAL) and withdrew from cocaine and got suicidal. Held till the morning... felt better... not suicidal actively... done this a couple of times before infact... you can send him home in the morning, otherwise you would have admitted him at night.

c) and so on....

It's a good filter for people who wont benefit from inpatient psych much and require more of an outpatient txt.

Our PIP has oncall coverage 24/7 but does not require physical presence.... Telepsych is nice and saves careers.

 

[OldPsychDoc]

...
Can't you see undiagnosed psych patients in a traditional ED?
What's so great about having a dedicated psych ED?
Are psych residents there 24/7?

--yes, many hospitals do.
--it is hardly optimal for stressed out psychiatric patients, whether depressed or psychotic, axis 1 or 2, to be waiting out their crisis and experiencing florid symptoms in one of the most stressful, least-controlled settings in the hospital, if not in society as a whole. Most are not in need of the acute medical services of a standard ED, and for those that do, it's a short trip down the hall.
--some programs will station a resident in their psych emergency service (whatever it's called...) full time. Where I trained, this was a 2 month rotation, 1 month working noon-10 pm 5 days/week, and 1 month 10 pm to 8 am. As a learning experience, it is unparalled for seeing a wide variety of acute presentations and having to make management decisions on the fly. I wouldn't want to go back there...but in retrospect, it was great.

 

[kcrd]

My program has a PES separate from the ED (2 floors up), housed in our hospital of several psychiatric inpatient units and one medical unit. Ours is one of the busiest in the country (up to 900 patients per month). We do our call in the PES as upper years and it is not uncommon to evaluate 15-20 patients overnight, see a variety of psychopathology ranging from floridly psychotic patients escorted by police to people who want an outpatient referral for anxiety. If the OP is asking how this differs from going down to consult in the ED on a few patients that come in on your call, I think it is a world of difference. In the PES overnight the resident in most cases is the front line, making all treatment decisions, and in our case having to manage a very heavy workload. All said, I actually cannot stand working in our PES, but I think it has given me clinical confidence.