A Wisconsin colleague and friend had posed a question to the listserv last month, of which 20 of you provided some responses (thank you!).  The essence of the question was — do you have access to a specialized psychiatric crisis response center and/or do you interface with a general hospital’s crisis center.  Related questions sought to understand the good and the bad of each (e.g., we continue to move towards more integrated care and does specializing and isolating behavioral health/psychiatric crisis services undercut that effort? Or, are the needs so unique that having specialized psychiatric crisis services is really best care and coordination). 

  • 11 of you indicated that you only access emergency depts within general hospitals. 
  • 3 of you indicated that you only access specialized psych emergency depts/crisis stabilization units
  • 6 of you indicated that you have access to both.

Below are some questions and responses:

Does your area have problems with extensive emergency room department “boarding” – where the individual may sit for hours, even days, to access a bed and services?  16 (80%) responded YES.  Some clarified that it may be hours.  Here are some specific responses (with notation if they said general hospital, psych ED, or both above):

“Most all state hospitals in VA are over capacity following trickle down effects of “Bed of Last Resort”/Creigh Deeds incident.  Local, private hospitals deny admission for people that are aggressive, highly psychotic, etc. essentially sending them to state hospitals since they cannot deny admission.  It has created huge problems within the VA system which feels like it is nearing a breaking point.  ACT teams cannot get individuals hospitalized locally and if they do make it in the door and do not clear within a couple of weeks, they are generally discharged because there are no transfers to longer term care anymore.  Folks that are TDO’d for acute hospitalization are sitting in ER’s for days now waiting on a bed somewhere in the state.”  (BOTH)

“Our most recent experience involved a 22 year old held in the emergency room from Friday to Monday, then sent from (central Minnesota) to ND.  Put on 72 hour hold prior to transport, discharged after 2 days.  We scrambled for placement.  From there he went to an IRTS (very south-western MN).   That was a 16 hour trip to transport him.” (BOTH)

“Finding a bed for someone with significant psychosis AND physical health issues in the local area is impossible.  They have to go outside of our community.” (BOTH)

“Often clients can wait several hours to be seen by the Behavioral Health team at the hospital. If there is not a bed available on the Behavioral Health Unit they will be transferred to another hospital. This process could take upwards of 24-36 hours. During this time clients will become agitated, desire to leave, or become involuntarily hospitalized.” (General Hospital – but recently started a Crisis Intervention Team Assessment Center within the local hospital)

“The individual may sit for hours before being transported to the Psych “department” for that hospital; the other hospital is usually full and will keep individuals on a Psych hold in the general ER. The hold in the ER can last for days.”  (Gen Hosp)

“Clients will sit in holding for days waiting on a bed, and sometimes client get sent to hospitals quickly that don’t require an assessment but they don’t typically get the best care at those hospitals.”  (Gen Hosp)

“Many patients board regularly in the psych Ed while awaiting inpatient beds and or transfers within county to psych beds particularly in the weekend” (Psych ED)

“The certified pre-screener is responsible for typing up the assessment and collecting medical clearance. Sometimes medical clearance takes a long time if the client cannot pass urine or refuses labs. Both medical clearance and prescreen assessment are needed to start a bed search. The length of time to call each hospital, fax and follow up to see if the fax was reviewed can be extremely lengthy.” – ps this is in VA, similar to the first response above.  (BOTH)

“Hours, not necessarily days.” (BOTH)

“rarely, but it does happen. not for days, but to sit for a few hours waiting to get responses from hospitals for admission is common.” (Gen Hosp)

If you have access to a specialized psychiatric emergency department, or crisis stabilization unit, what has been helpful about how this has been designed?  Anything not so helpful (that could be better)?

“We have one regional Crisis Stabilization unit in our region (city of Richmond and surrounding counties) and they have provided excellent treatment, in many cases better than acute hospitalization with the requirement of active treatment vs being housed in a local hospital bed until the acute crisis passes.  They are also somewhat selective in who they accept and they are very reluctant to admit someone unless they have housing already in place or firmly lined up prior to admission.”

“There is a Crisis Unit in (MN).  We have to ensure that the individual brings their own meds and they will not prescribe/change medication.  Not changing the medication is a positive in cases where the individual was not taking meds.”

“Currently we just had a CITAC (Crisis Intervention Team Assessment Center) open at our local hospital. If someone is brought to the ED by police for evaluation they are met by a peer support, trained law enforcement, and mental health clinicians who support the client through the process. It has only been open a couple of months but we hope to see a positive impact with it.”

“It is helpful that we don’t always have to go through the hospital to do an admit if needed and we can just do a direct admit to the CSU.”  (CSU- crisis stabilization unit)

“The referral form is the pre-screening form, in the event they escalate to the level of need of a TDO (I think temporary detention order – Lorna) we are able to do this quite quickly.”

“We have access to state and privately ran crisis/triage hospitals and stabilization units.  It is most certainly easier on the clients to be in a facility that specializes in behavioral health.  The teams also develop great working relationships with consistent staff on the specialty units.    Those relationships have become tremendously helpful when collaborating during a hospitalization. Utilizing emergency departments was a procedure many many years ago and would, unfortunately, feel like going backwards if it were to occur in our area.    The facility that accepts mainly Medicaid has a unit with “23 hour beds”.  This becomes mainly an acute stabilization and if further care is needed, they will go to a “bed” on the longer term unit. We have a variety of resources, however, we still feel short of beds frequently.  When beds not available in our county, they will be driven, by sheriff deputies, to other county agencies in the state for treatment.”

Where did our respondents come from?  Virginia, Minnesota, Oklahoma, New York, North Carolina, Indiana, Florida, George, and Colorado

– Lorna


photo by Simon Matzinger

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