Journal Article Annotations
2017, 4th Quarter
Annotation by Naomi Schmelzer, MD MPH
Type of study: Pre-/post-intervention study, clinical trial (non-randomized)
The finding: This study examined the impact of establishing a six-bed unit within the emergency department to provide specialized care to all patients presenting with acute behavioral emergencies, referred to as the Behavioral Assessment Unit (BAU). Following the implementation of the BAU, these patients experienced a significantly decreased length of stay in the ED (from 328 min to 180 min), as well as a reduction in median wait times to see both an ED clinician and an emergency mental health clinician. In addition, there were fewer security codes called on patients seen in the BAU intervention than the historical control group, as well as fewer episodes of mechanical restraint and therapeutic sedation, however this effect was smaller.
Strength and weaknesses: This study identifies that the BAU differs from a primary psych ED in that it treats all patients with behavioral emergencies, regardless of underlying cause, and recognizes that only a small percentage of patients treated there (13%) were identified as having a primary mental health problem. The treatment goals for this specialized unit, which include early and rapid care in a low stimulus environment, may differ from the psychiatric emergency cohort at large, and the results may not be generalizable. Other limitations to more universal application of this care model is that the BAU was set up under an inpatient cost recovery model that may be difficult in other healthcare settings, and that the availability of a 72-hour observation area may have also influenced care delivery in this system. In addition, it is possible that the effects observed in the study could be attributable to the increased allocation of resources alone.
Relevance: There are several delivery models of psychiatric emergency services and this article focused on the outcomes following the establishment of a hybrid model, an embedded behavioral assessment unit within – and operated by – an emergency department. The co-location model is known to have several advantages including access to an ED physician for medical interventions when indicated, yet typically also having less urgency for disposition to permit evaluations in a separate, calming environment with staff who have received additional training in management of behavioral emergencies. Known disadvantages include possible marginalization of these patients, and misuse of the space as an overflow site for the main ED. The article highlights that this model can be advantageous in providing overall improvements in patient throughput and care that emphasis a reduction in restrictive interventions, and may be appropriate especially in hospital EDs with moderate volumes that may not support a stand-alone psych ED.