Residents’ Forum

Increasingly, tighter fiscal constraints challenge our ability to provide our patients with quality care. While these pressures often feel burdensome, they are also an opportunity for us to reevaluate and improve the care we deliver. In this essay, Sunil Chhibber, M.D., a child and adolescent psychiatry fellow in the department of psychiatry and behavioral sciences at the University of Kansas Medical Center, describes his experiences in a new system for crisis stabilization developed by his training program. Dr. Chhibber welcomes your questions about the program and can be reached via e-mail at us.chhibber@mci2000.com.

If you wish to submit a piece for the Residents’ Forum or contact me about member-in-training issues of concern to you, please send me a fax at (410) 614-5914 or e-mail at abbusch@erols.com. All submissions will be considered.

Alisa Busch, M.D.
Member-in-Training Trustee

New Solutions to Old Problems

As a fourth-year psychiatry resident, I have had the unique experience of working in two dramatically different emergency room (ER) settings at the same teaching hospital in Kansas. In the first, patients needing psychiatric care were processed through a general emergency care operation. In the second, patients in possible need of psychiatric care were immediately seen in a specialized crisis stabilization unit. The differences between the two settings were remarkable for me and, I believe, for the patients.

As a resident on call, evaluating psychiatric patients in the traditional emergency room was stressful to me and difficult for patients. Patients with physical trauma and other medical emergencies were typically seen more quickly than psychiatric patients. Nurses and other ER staff, accustomed to dealing with medical and surgical emergencies, had difficulty switching gears and calmly obtaining a psychiatric history while providing the support, comfort, and reassurance needed to deescalate patients and make them feel safe in the chaos and frustration of the ER.

The situation has now improved with the establishment of our Crisis Stabilization Center (CSC), a dedicated unit and staff that, although separate, is physically close to the ER. The CSC serves child, adolescent, adult, and geriatric patients who are experiencing significant crises that seriously impair their capacity to function.

In the CSC patients are evaluated by a team consisting of a social worker, psychiatric nurse and nurse’s aide, resident psychiatrist, medical student, and attending psychiatrist as back-up.

Upon entering the emergency service, the potential psychiatric patient is seen by the ER triage nurse and then immediately brought to the CSC, where he or she may receive a variety of services, including on-site psychiatric and medical assessment, crisis intervention, brief individual or family intervention, and pharmacotherapy. The patient may remain in the center for 23 hours to ensure effective stabilization before being admitted, discharged, or referred elsewhere. These services are provided 24 hours a day, seven days a week, regardless of a patient’s ability to pay. Children and adolescents in crisis do not stay in the CSC but instead are sent to the child and adolescent psychiatric inpatient unit for further observation and stabilization. There they can mingle with peers, work briefly with staff in occupational and recreational therapy, and attend school.

The therapeutic environment in the CSC has its own calming, deescalating effect. Often seemingly out-of-control crisis situations are managed quickly and effectively with the team approach. In the traditional ER, it was almost impossible to provide even minimal care when two patients arrived at the same time for emergency psychiatric services. In the CSC, while the resident sees one patient, the team members can help attend to the needs of others. The resident can now take the time to telephone a patient’s relative to obtain more information and request help in management if needed. The resident also is in a position to reassure and educate the patient and his or her family.

Social workers are a great help in locating resources for patients in need of detoxification, home shelter, or other community resources, as well as arranging appropriate outpatient care.

The following clinical examples illustrate the kind of crises handled effectively in the CSC:

• A patient with bipolar disorder and alcohol abuse discontinued his medications and relapsed in his alcohol use. He was clearly manic by history and exam, as well as suicidal and intoxicated. He was kept in the CSC for 23 hours and stabilized with Ativan for alcohol withdrawal and Depakote loading for mood stabilization. He was discharged the next day to his family and scheduled for follow-up in the outpatient clinic. The CSC avoided a hospitalization by stabilizing the patient faster and under less duress than usual. Both the patient and his family expressed their gratitude for this service.



• While observing a young child brought in by his mother for "out of control" behavior, it became clear that the mother was completely overwhelmed with multiple psychosocial stressors and had neuro-vegetative symptoms consistent with major depression. Both child and mother were offered an integrated outpatient treatment program, which would not have been possible in the traditional ER setting.

By utilizing a collaborative team approach, working with each patient’s strengths, and utilizing available social and community resources, the CSC provides a more efficient and cost-effective alternative to inpatient hospitalization. Patients now coming for emergency psychiatric services are more satisfied with the care they receive, particularly those patients who have experienced the prior treatment approach. They describe the new system as a more welcoming, efficient environment in which they feel respected and well served.

No one involved in psychiatric emergency care at the medical center can imagine going back to the old system. I certainly cannot. The changes in setting and philosophy make a world of difference to both me and my patients.