If wellness is a country, then the Psychiatric Emergency Department (ED) sits on the border. For the undiagnosed mental health patient, it is the crossing point from a free state at risk to a managed place of total support and loss of agency.
The Psychiatric ED, intended to function as an extension of psychiatric treatment, is dependent on engagement. Yet it suffers from the problems of most liminal spaces that are tasked with evaluating an unknown arrival; the individual’s dignity and autonomy are compromised by a reductive, checklist process of assessment and treatment. This is a consequence of the Psychiatric ED operating in the mimetic image of the Acute ED in which its praxis was traditionally embedded.
The fabric of the Acute ED is shaped by the need to assess, triage and respond to the unknown acute medical condition and its potential for hazardous infection under the pressures of time, risk and cost. The environment it creates, however, is inconsistent with the needs of chronic illness, which mental health and substance abuse qualifies as. It contributes to the trauma carried by the incoming patient and positions the institution as an aggressor despite the care that it can offer.
This article considers two recent hospital projects – the re-planning of an existing urban Psychiatric ED at the Centre of Addiction and Mental Health (CAMH) in Toronto and the visioning of a suburban Psychiatric Emergency Service at Ontario Shores in Whitby. It also asks, does a radical departure from the acute emergency department to a more specialized centralized service, such as a psychiatric emergency service, results in a new set of problems when looking at the broader health system? Are there negative consequences to decoupling the medical care of the body from the care of the mind, particularly with regards to marginalized communities?
Recent data from multiple jurisdictions indicates that psychiatric related visits to the ED are rising at a greater volume than the rate of non-psychiatric visits. In many Canadian hospitals, the response to this disproportionate increase in Psychiatric ED visits relative to the increase in non-psychiatric visits has been the creation of a sequestered psychiatric assessment unit adjacent to the existing Acute ED. In these units, the typology of the single occupant, acute ED exam/assessment room persists as does the centralized team station and double-loaded dead-end corridors, all with a heightened layer of security and observation.
Given that psychiatric diagnosis is typically longer than their acute counterparts and is often complicated by comorbidities or a lack of familiarity with mental health conditions, the problems with this plan are self-evident. When psychiatric patients are sequestered for extended periods of time without any sense of agency and the staffs’ capacity to identify emerging negative situations is limited, incidents of self-harm or violence invariably increase (Connellan et al., 148). Further barriers to engagement, including physical isolation and remote observation, are then instituted and the cycle is perpetuated.
This process of treatment through disempowerment often begins before the patient’s arrival. A patient transferred by police is mandated to arrive in handcuffs, irrespective of their behaviour. In this way, the patients’ health condition is effectively criminalized.
The Centre of Addiction and Mental Health (CAMH) and the Ontario Shores Centre for Mental Health Sciences sought to challenge this paradigm in a number of ways.
A Learned Design Evolution: The Emergency Department at the Centre for Addiction and Mental Health
In 2014, CAMH made the operational decision to open a dedicated Psychiatric Emergency Department (PED) focused entirely on psychiatric assessment.
The PED’s initial iteration, operating out of a satellite site, resembled an Acute ED in terms of access and patient isolation. It also compromised on sightlines and access to daylight. Facing dramatic increases in visits, levels of acuity, incidents of violence and self-harm and direct intake to an Inpatient Unit, CAMH elected to build a new PED on their main campus.
Operationally, the most significant change in the new PED is the limit on the patients’ length of stay. Any patient still under assessment after 23 hours is transferred directly to a recovery-focused inpatient environment.
Physically, the essential distribution of space remains the same with some improvements. The new PED provides a separate entrance for EMS so that the incoming patient retains a sense of privacy even if they arrive in restraints. The design also establishes different patient zones targeted at different levels of acuity in order to reduce the amount of disruption and agitation a higher acuity population might generate. All patient zones are larger and more advantageously configured with access to natural light where possible. Staff zones are smaller to encourage staff presence in patient and triage areas. Although security and liability are still primary design drivers, private patient spaces are camera-less to preserve patient dignity and reinforce a care model focused on direct patient-staff engagement. It is anticipated that this ‘revised’ design will result in reduced incidents of violence and or self-harm and that direct adjacencies between the PED and the main CAMH hospital will help support patients in their recovery journey.
While more humane in its interpretation, however, the CAMH PED is essentially still modeled on an acute care environment. A patient arrives, is triaged, enters a secure area where staff are separate from patients – a space dominated by doors to small rooms in which assessment is initiated and completed – and is then discharged back to the community or transferred to an inpatient unit.
In recognition of this problematic legacy, Ontario Shores, a Psychiatric Inpatient facility is proposing a completely different physical and operational PED milieu.
Recovery in a shared milieu: The Psychiatric Emergency Service at Ontario Shores
A tertiary service provider, Ontario Shores has long recognized that psychiatric patients were underserved by acute hospitals. In developing its 2017 Master Plan, the hospital envisioned a new, dedicated PED model focused on assessment, disposition and discharge. This PED would receive transfers from nearby acute Emergency Departments as well as direct intake from EMS services.
The Ontario Shores vision aligns with the Emergency Psychiatric Assessment, Treatment & Healing (EMPATH) model developed by Dr. Scott Zeller. Pioneered at the John George Psychiatric Hospital, part of the Alameda Health System in California, the EMPATH model does away with the ‘acute’ layout of the PED. It favours a single, common milieu with individual reclining chairs and about 10 square metres of space per patient. Patients have access to a small kitchen, linens and a quiet room. The team station is almost nonexistent; staff and peer support workers all work within the patient environment. And psychiatric triage is done away with as a doctor undertakes a preliminary assessment with the patient immediately upon arrival. The maximum length of stay is, as with CAMH, 23 hours and medical triage is performed prior to arrival either by a partner AED or by EMS. The intent of the EMPATH model is to prioritize alternate, outpatient paths of disposition and discharge. And without the infrastructure or boarding times of an Acute ED, it is also cost effective.
Beyond the typical EMPATH features, Ontario Shores’ larger, greenfield site also allows for the addition of a secure courtyard and the opportunity for patients to go outside during their stay. In addition, the colocation of the EMPATH unit with an outpatient services facility provides a more comprehensive and integrated system of follow up and support.
Still, the EMPATH unit does present some challenges. Despite being less deterministic and hierarchical in its plan, the environment it creates is largely homogenous. Recognizing this, Ontario Shores is attempting to restrict their intake to a select patient profile, namely by excluding walks-ins and substance abuse visits.
Implications of Condition Specific Centralization
At both CAMH and Ontario Shores, the ED environment has been transformed into one more suited to a chronic condition. The system level response, however, remains the same. And if the ultimate goal in mental healthcare is wellness and long-standing recovery, then decoupling the psychiatric from the medical to create stand-alone facilities will result in limitations.
For the provider, these limitations include increased transfer times, potential service bottle necks and issues of exceeding service capacity without a reasonable alternative.
For the patient, these limitations are in large part about access. Centralized, stand-alone facilities have large catchment areas, making access, particularly for marginalized communities without private transport and who typically represent a disproportionate number of visits, difficult. Only when levels of acuity demand intervention by EMS are these individuals able to gain access to these facilities. This can be especially traumatic for persons in communities who have, historically, been targeted by police and who are more often subjects of involuntary psychiatric care (Barnett et al., 314). Centralized facilities also tend to ignore the relationship between mental health, food security and housing.
Given this, we can assume that a centralized facility with a limited scope of care will likely reinforce patterns of recidivism and system bias.
Is there an approach that can provide emergency psychiatric service in a humane environment while still addressing medical comorbidities? Architecturally, can we envision a project that sits at the intersection of physical and system level planning in its deference to local community needs? What does a project look like when it seeks to prioritize equity, local access and wellness in addition to base efficient service delivery? What does a design look like when it addresses, not just the effects of a chronic condition but the root causes that escalate its acuity?
An Inclusive Emergency Department
In Ontario, there has been success in a shift towards Urgent Care Centres (UCCs). Located outside of the traditional Acute Hospital, UCCs address a high volume of ED patients who are not in immediate need of critical care. The UCC is embedded within a larger facility that provides a range of outpatient clinical services from cardiac to mental health – a colocation that helps legitimize the diagnostic services required by the UCC.
In the United States we find another alternative with the development of new, stand-alone micro Emergency Rooms (ER). Spatially, these replicate the ED model in a smaller, more manageable footprint, one that is still successful despite being separated from a full Lab or Diagnostics Suite.
Both the UCC and the micro-ER demonstrate the viability of an emergency medical service outside of the acute hospital. But they are still focused on an acute model and the physical medical condition, and they fail to address disparities and inequities in service across multiple jurisdictions and within different patient populations. Can we envision a building that supports an operational model not solely centered on efficiency in the delivery of health but on the more holistic concept of wellness?
We revisited the George Street Revitalization project (GSR) to find out.
Made up of a 384-bed Long Term Care home, a 100-bed Emergency Shelter, 130-bed Transitional Living Program, 21 units of Affordable Housing and a Community Hub, GSR already meets the criteria for an integrated and community service-focused project. It offers clinical services through a family health team space in the Emergency Shelter, a safe injection site and a managed alcohol program based on the harm reduction model. And it provides horizontal pathways for clients between programs; for example, homeless men in the transitional living program may move on to residency in the long-term care facility.
What is more, GSR’s community hub space would readily accommodate the integration of a typical 6000 square foot micro-ER with a 1000 square foot psychiatric treatment space, similar to an EMPATH unit. The building’s existing infrastructure is already compatible with that of an ED with robust HVAC systems, designed to accommodate outbreaks of infectious disease, and 100% Emergency Power backup.
Integrating rapid response medical service in a project like GSR has many benefits. Firstly, it directly addresses the acute phase of chronic conditions that form the majority of psychiatric related emergency visits, including those related to substance abuse. Secondly, clients in the LTC and Transitional Living Divisions have rapid access to medical stabilization as needed through the micro-ER. Thirdly, the co-location of the ER with social and housing support services increases clients’ chances of recovery. And finally, an ‘in-community’ model addresses the geographic limitations of marginalized communities, reduces the likelihood of delayed intervention, including transfer by EMS, and allows for care options that better reflect the needs and culture of the local community as well as familiarity between staff and repeat users.
In removing both distance and division, a borderless condition is created where wellness, not the reductive concept of ‘health’, is the goal.
The concerns that CAMH and Ontario Shores sought to address with their centralized emergency models are real. The typical Acute ED psychiatric service is a hostile environment that is incompatible with PED/PES needs but these can be improved through increased daylight, views and general connectivity between staff and patients. In addition, the act of centralizing psychiatric care and separating it from medical care results in a more immediately efficient model: boarding times are reduced and a disposition can be determined within 24 hours.
Despites these benefits, that disposition can often only be a stop gap measure focused on stabilization and discharge if the ED remains isolated from support services including medical services and system navigation. The chronic nature of mental illness cannot be addressed in isolation, even if that isolation is done in the name of efficiency.
Connellan, Kathleen, Mads Gaardboe, Damien Riggs, Clemence Due, Amanda Reinschmidt, and Lauren Mustillo. “Stressed Spaces: Mental Health and Architecture.” HERD: Health Environments Research & Design Journal 6, no. 4 (2013): 127-68. Accessed November 23, 2016. doi:10.1177/193758671300600408.
Phoebe Barnett, Euan Mackay, Hannah Matthews, Rebecca Gate, Helen Greenwood, Kevin Ariyo, Kamaldeep Bhui, Kristoffer Halvorsru, Stephen Philling, and Shubulade Smith, “Ethnic Variations in Compulsory Detention under the Mental Health Act: A Systematic Review and Meta-analysis of International Data,” The Lancet Psychiatry 6, no. 4 (April 01, 2019), March 04, 2019: 314, accessed March 29, 2019, doi:10.1016/ S2215-0366(19)30027-6.