WHAT TO EXPECT WHEN YOU GO TO THE EMERGENCY ROOM - DR. JUSTIN DELWO MEDICAL LEAD, MENTAL HEALTH EMERGENCY SERVICES UNIVERSITY HEALTH NETWORK 8 ...
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WHAT TO EXPECT WHEN YOU GO TO THE EMERGENCY ROOM DR. JUSTIN DELWO MEDICAL LEAD, MENTAL HEALTH EMERGENCY SERVICES UNIVERSITY HEALTH NETWORK 8 FEBRUARY 2020
SOME IMPORTANT INFORMATION TO START… I have no conflicts to declare to you – I have no relationships with pharmaceutical companies, medical equipment manufacturers, or any companies that make money from health care.
WHAT DO YOU WANT TO KNOW ABOUT EMERGENCY MENTAL HEALTH CARE AT UHN?
LET’S GET STARTED! What is the process for someone to be assessed from start to finish? What happens if someone does not want to come in or does not want to stay? What if someone would prefer to get care outside of UHN? How long will someone need to wait to be seen? As family members, how involved can we expect to be? What types of people does UHN treat?
ARRIVING IN THE EMERGENCY DEPARTMENT AT
TORONTO GENERAL HOSPITAL (TGH)
Options:
Crisis Worker Discharge,
Triage Nurse ED Physician
(optional) Consult
Psychiatry
If Consult
Psychiatry -
If Admit - Options:
Psychiatry Transfer to
Transfer to Discharge,
Team Toronto
TGH Hold, Admit
Western
Hospital
ARRIVING IN THE EMERGENCY DEPARTMENT AT
TORONTO WESTERN HOSPITAL (TWH)
Options:
Crisis Worker Discharge,
Triage Nurse ED Physician
(optional) Consult
Psychiatry
If Consult
Psychiatry -
If Admit - Options:
Psychiatry Transfer to
Transfer to Discharge,
Team Toronto
TGH Hold, Admit
Western
Hospital
ONCE AT TORONTO WESTERN HOSPITAL Frequently within the Psychiatric Emergency Services Unit (PESU)
ONCE AT TORONTO WESTERN HOSPITAL
PESU is staffed by:
3 mental health nurses at all times
ED physicians at all times
A crisis worker for 12-15 hours daily
A staff psychiatrist (who may not be in the hospital)
A psychiatry resident (almost always, occasionally they are away during the day
due to teaching)
Medical students (at times)
Nursing students (at times)
Security guards (when necessary)
WHY SO MANY
PEOPLE?
Often get asked why
many people will
interview one person
Skill levels are different
Patient comfort may vary
with different staff
Assesses reliability of the
story
Educational purposes
TRANSFERS BETWEEN UHN HOSPITALS
Voluntary Patients Involuntary Patients
Usually by taxi with a staff member By transport ambulance (not the
Very rare cases patients will be
same as the emergency kind) with a
allowed to be transported by family staff member
– this is not actually our protocol as
we should be ensuring patients
arrive
Back to Topics
This Photo by Unknown Author is licensed under CC BY-SATHE LAW &
EMERGENCY
MENTAL HEALTH
CARE
Several laws impact on mental
health care in Ontario
Mental Health Act
Health Care Consent Act
Substitute Decisions Act
Personal Health Information
Protection Act
Federal Criminal Code Specifies a person’s rights when receiving
treatment for a mental disorder and the
legal requirements for health care providers
to suspend those rights
MENTAL HEALTH
It focuses on involuntary assessment,
ACT admission, and treatment but also includes
directions on the assessment of capacity
with respect to finances and health
informationMENTAL HEALTH
ACT
Involves a large number of forms
To get someone to hospital for
assessment:
Form 1 – Application for Psychiatric
Assessment by a physician (patient
is given a Form 42)
Form 2 – Application for Psychiatric
Assessment by a Justice of the
Peace
Section 17 – police apprehension for
assessment without a form being
issuedMENTAL HEALTH
ACT
To keep someone in
hospital:
Form 3 – Involuntary
Admission (patient is given
a Form 30)
Form 4 – Renewal of
Involuntary Admission
(patient is given a Form
30)
Form 4A– Continuation of
Involuntary Admission
(patient is given a Form
30)MENTAL
HEALTH ACT
To make decisions
for someone:
Form 33 – Incapacity
to Manage Finances,
Make Treatment
Decisions, or
Disclose Health
Information (patient
is given the Form 33)HEALTH CARE
CONSENT ACT
Dictates physician requirements in
determining if someone can give
consent to treatment
Can be used to:
Access health information in an
emergency assessment
Provide emergency treatment without
consent from the patient or substitute
decision maker
Hold patients in a particular setting
against their will for treatment that
cannot be obtained elsewhere Specifies who may make decisions on behalf of a person
determined to be incapable
There is a specific hierarchy outlined in the Act that must
be followed
Substitute Decision Makers (SDMs) must:
SUBSTITUTE Be capable under the same definition found in the Health
DECISIONS Care Consent Act
ACT Be willing and available
Make decisions based on what they believe the incapable
person would have wished when they were previously
capable
If no relative or legally appointed SDM is available or
willing, the Office of the Public Guardian and Trustee will
become the SDMConfidentiality has been part of the patient-physician relationship
for longer than it has been a legal requirement
Adverse events have resulted in laws requiring physicians to
disclose information when certain risks are present
PERSONAL
HEALTH When those risks are not present, not imminent, or not specific it
is very difficult for health care providers to provide information
INFORMATION without patient consent
PROTECTION ACT
PHIPA describes the legal responsibilities of health care providers
(PHIPA) with respect to personal health information (PHI)
Discussing PHI on the phone can be difficult even with consent,
as anyone could call and claim to be someone else
This is FRUSTRATING for families Obviously not something we hope for anyone seeking help
Can complicate assessment in the emergency department and
ongoing treatment
Pending charges means police may choose to stay with the
patient
THE CRIMINAL Patients can come with Corrections Officers if already in the
CODE OF prison system
Judges can send people to hospital for assessment from court
CANADA If someone is released from jail and the in-house doctor is
concerned about their mental health, they may issue a Form 1
Patients who are Not Criminally Responsible (NCR) may be
brought to UHN (usually for medical clearance) but cannot
remain for mental health treatment as we are not a designated
facility
Back to TopicsI’M IN PESU BUT I REALLY WANT TO BE ADMITTED TO ANOTHER HOSPITAL…IS THAT POSSIBLE?
TRANSFERS TO HOSPITALS OUTSIDE UHN
In Theory… In Reality…
Should be possible Psychiatric inpatient beds are difficult to
come by – your wait could be weeks
Care close to home makes sense:
Knowledge of resources in that area Finding an accepting psychiatrist is not
always straightforward
Closer to family and friends who can visit
Follow up could be with the same team as Sharing between hospitals is not required
treated you in hospital and it may be better for the accepting
hospital to take someone from their own
Patient preference would be nice to
emergency department (as this impacts
consider!
statistics)Many times the reason for a transfer request is
because patients and families want longer
admissions than is possible in acute care
hospitals
LONG-TERM
CARE VS. This is an excellent reason for transfer, but also
difficult with long wait times
ACUTE CARE
Not done from the emergency department in
almost all cases – longer stay programs want
proof there is a lack of improvement during this
stay before they will consider someone
Back to TopicsWAIT TIMES IN THE EMERGENCY DEPARTMENT
Wait Period Usual Time Maximum Time
Arrival to Triage
Legend
Triage to Being Assigned a
Location
Location Arrival to Physician
Min
Assessment
Assessment to Medical
Clearance
Hrs
Medical Clearance to Referral
Referral to Psychiatric
Assessment
Days
Psychiatric Assessment to
Disposition
Plan for a 4-hour minimum, Longest time to admission
Total: Back to Topics
rarely faster approx. 1 weekWAIT TIMES IN THE EMERGENCY DEPARTMENT
Wait Period Usual Time Maximum Time
Arrival to Triage
Legend
Triage to Being Assigned a
Location
Location Arrival to Physician
Assessment Min
Assessment to Medical
Clearance
Medical Clearance to Referral Hrs
Referral to Psychiatric
Assessment
Psychiatric Assessment to Days
Disposition
Plan for a 4-hour minimum, Longest time to admission
Total:
rarely faster approx. 1 week Back to TopicsFAMILY & EMERGENCY MENTAL HEALTH CARE
Complex for many reasons
Confidentiality
Family dynamics that may contribute to symptoms –
including family members who may themselves be ill
FAMILY & Disagreements about type of care needed/wanted
EMERGENCY Family burnout
MENTAL Busy departments
Need to consider all patients’ and visitors’ safety and
HEALTH CARE well-being in the unit
Amount of physical space available
Stigma
…and more Necessary for many reasons
Emotional and physical support that the care team
may not be able to provide
FAMILY & Assistance with remembering when illness impacts
retention of information
EMERGENCY Collateral on patients
MENTAL Help with taking home and/or bringing in belongings
and medications
HEALTH CARE Food and coffee from outside the hospital
A ride home
…and more As a result of these factors and more, family
involvement is incredibly variable
Advocate if you feel you need more involvement by
FAMILY & speaking with nurses and physicians, but important
to hear them if they inform you that it is the decision
EMERGENCY of your ill family member not to involve you
MENTAL In rare cases, if you feel staff have been
inappropriate you may wish to consider speaking
HEALTH CARE with Patient Relations at UHN who can help
advocate on your behalf
In extreme cases you can also speak to the college
responsible for licensing the health care provider
Back to TopicsWHAT PATIENTS CAN GET MENTAL HEALTH CARE AT UHN?
MENTAL HEALTH CARE AT UHN
UHN is a world leader in transplantation, cardiac, and cancer care, among others
As a result, we have developed particular expertise in providing mental health care to those with
complex medical needs
In the emergency department, we treat anyone – all ages, illnesses, genders, cultures, etc.
Some people may be served better elsewhere:
We cannot admit children/adolescents if that is what is needed, nor do we have outpatient services for
this age group (St. Joe’s, NYGH, or Sick Kids are options, Sunnybrook for teens 14+)
UHN does not have obstetrical services, so pregnant or post-partum women may choose to go to other
hospitals (St. Joe’s, Sunnybrook, or Mt. Sinai are options)
Our inpatient service does not specialize in treating concurrent disorders, so CAMH might be a better
option as they have specialized inpatient servicesQUESTIONS?
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