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Shelter from the storm: New unit cares for patients in psychiatric crisis

A young woman enters the room and chooses a reclining chair along the far wall. A few minutes after she settles in, a nurse walks over, pulls up a chair next to her, and begins asking questions: How are you feeling? What happened today? Others in the room watch television or visit quietly. A man in his 40s carries a laundry basket half-full of clothes across the room.

This is the Crisis Stabilization Unit (CSU) at University of Iowa Hospitals & Clinics, specifically designed for people experiencing an emotional or psychiatric emergency. The only facility of its kind in Iowa, it is based on a unique model of care featuring comfortable chairs instead of hospital beds and amenities like laundry facilities and a snack room, all in a calm and inviting space.

The CSU operates round-the-clock, and patients typically stay there for 24 hours, which allows their care team time to develop an appropriate treatment plan that may include medications, therapy, arranging follow-up appointments, or getting connected to community resources. After a solid treatment plan is developed, nearly 75 percent of patients are able to go home from the CSU rather than be admitted to an inpatient unit.

“I’ve been a psychiatrist for over 20 years and I feel like this is some of the best care that I’ve been able to provide,” says Jodi Tate, MD (00R), UI clinical professor of psychiatry and medical director of the CSU. “We’re there when the person needs it, it’s interdisciplinary, and it’s very patient-centered.”

Jodi Tate, MD

Emergency room not ‘ideal space’ for patients in psychiatric crisis

Since the CSU opened in October 2018, the wait time for patients to receive intensive psychiatric care has decreased by nearly 80 percent. Additionally, the number of patients opting to leave the hospital without being seen has declined by more than half.

Leaders in psychiatry and emergency medicine worked to open the unit last year in order to create a more suitable setting for adult patients in crisis. There were typically 10 people experiencing a psychiatric issue waiting in the UI Hospitals & Clinics emergency department (ED) at any given time. And as the number of state-funded psychiatric beds has shrunk, some patients were staying in emergency for extended periods of time, according to Paul Van Heukelom (08MD, 11R), clinical medical director of the ED.

Now that those individuals can go to the CSU, Van Heukelom says it’s been a “complete game-changer for our patients.”

“From the emergency department’s perspective, the CSU has been very successful,” he says. Not only have patients requiring psychiatric care been spending significantly less time in the ED waiting for appropriate treatment, but it has also reduced wait times for patients with other medical emergencies.

Van Heukelom says the intense environment of the ED, which receives about 58,000 patient visits annually, is not the ideal space for a patient experiencing a psychiatric crisis. The CSU accommodates patients in a more therapeutic environment with more specialized care, he adds.

Prompt care in a healing environment

During their stay in the CSU, patients work with a physician or an advanced practice provider, a team of social workers, and security officers who are trained as psychiatric medical assistants and peer supports. Calming rooms are available for those who need space or time alone, but patients are encouraged to interact with one another. The unit can serve 12 patients at a time and is usually at capacity.

The CSU mimics the design of an evidence-based care model known as an “emPATH unit.” The name means emergency Psychiatric Assessment, Treatment & Healing, and it is a system developed by Scott Zeller, MD, vice president of acute psychiatric medicine at Vituity (previously known as CEP America) and former chief of psychiatric emergency services for the Alameda Health System in Oakland, California.

Zeller served as a consultant during the planning phase of the CSU at UI Hospitals & Clinics and has been involved with opening over 15 units around the country, initially along the West Coast and now throughout the Midwest. He says the care model has shown tremendous success, enabling 75 to 80 percent of patients to avoid inpatient admission, and less than 1 percent are put into physical restraints. The CSU at UI Hospitals & Clinics is seeing similar outcomes six months since its inception.

“It’s ironic that in most health care systems across the country, the patients with the highest acuity of psychiatric symptoms are traditionally the most underserved, often languishing in ERs for days. It makes no sense at all,” Zeller says. “We know we can help them, we know we can make them feel better in a collaborative rather than a coercive way. UI Hospitals & Clinics is really showing the nation how to provide timely, compassionate, and successful care for this patient population with this Crisis Stabilization Unit.”

Some patients may need more care and will be admitted to an inpatient unit, but providers are finding that most just need a short-term stay in the CSU. Taylor Ford, MSW, LISW, a social worker and assistant clinical director of the CSU, says it’s nice to have a new care option that gives her a better chance to get to know a patient before deciding on the best treatment approach.

“We used to be really quick to say we have to admit or discharge a patient (from the ED), and now we’re trying not to do that,” she says. “You can’t really get to know somebody in 20 minutes.”

For the most part, she says the team is seeing people who can get stabilized and return to their daily lives in a short amount of time. For example, finals week brought in a number of students reporting high stress and low social support who needed solid resources and a bit of guidance.

“We see a lot of people who don’t need admission but need support right now because they’re in crisis,” Ford says. “We get them a really good plan and then they’re able to go home in 48 hours or less. The most rewarding part is not having people sit in the ER for days at the worst time of their life.”

Ford and Tate are now working on incorporating more group therapy and daily activities to create more structure for patients between visits with clinicians. They also hope to add more staff to serve as peer supports. For now, the team is pleased to provide prompt care and a space that’s safe, comforting, and inviting.

“I can’t tell you how many patients have personally told me that this is the best that they’ve ever been treated in a mental health care setting, which is why we opened this unit,” Ford says.

Monday, April 8, 2019