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AbstrAct The Crisis Assessment and Psychiatric Emergency Services (CAPES) unit was designed to improve the quality of psychiatric treatment, contain costs, and provide relief to overburdened psychiatric inpatient and emergency services in Delaware. This innovative program is the result of collabo- ration between public and private agencies to treat individuals in crisis. The myriad factors that contributed to a broken system and instigated Delaware’s search for a solution are discussed in this article. The CAPES unit has resulted in improved communication among providers, decreased committal rates, better linkage to appropriate levels of care, increased safety, and improved coor- dination of services. Clinical implications for nursing practice include providing more holistic care in a safer environment.

Although a plethora of articles recount the mental health crisis in America, there is a paucity of research about innovative pro- grams that effectively address the psychiatric emer- gencies that contribute to this national crisis. This article outlines one state’s journey to implement an effective program that would respond to the mul- tiple issues plaguing its mental health and commu- nity service agencies.

In Delaware, public and private sectors formed a unique coalition, combined resources, and ulti- mately created the Crisis Assessment and Psychi- atric Emergency Services unit (CAPES). The State of Delaware’s Division of Substance Abuse and Mental Health united with Christiana Care Health

System (CCHS), the state’s primary medical facility that responds to psychiatric emergencies. Among the goals of this alliance was to develop a safe, se- cure unit that would meet the special needs of the psychiatric population who are in crisis, while al- leviating an overburdened system. Additional, but equally important objectives included:

l Improving communication among providers. l Decreasing costly voluntary and involuntary

psychiatric hospitalizations. l Increasing opportunities for timely patient

referrals to more appropriate levels of care, such as outpatient day treatment programs.

l Diminishing risks for patient, staff, and com- munity safety.

Michelle Lauer, RN, BSN, BC; and Rose Brownstein, RN II, BC

Earn

4.0 Contact Hours

Replacing the Revolving Door A Collaborative Approach to Treating Individuals in Crisis

JourNal of Psychosocial NursiNg • Vol. 46, No. 6, 2008 25

The journey to seek a resolu- tion to Delaware’s mental health crisis began with an exploration of programs around the country that had successfully addressed similar problems. Despite a profound gap in published results, the discovery of one emergency department- based behavioral health (EBH) unit was found in the nearby Le- high Valley Hospital and Health Network (LVHHN) (Lewis, Sier- zega, & Haines, 2005). Although this program had only started in 2002, its early outcomes were promising and thus were influen- tial in Delaware’s search for a rea- sonable solution.

Plans for Delaware’s EBH unit capitalized on the trial-and-error efforts of LVHHN through which strengths and weaknesses in their program had been considered. In addition, the CAPES unit ex-

panded on the LVHHN model by incorporating a strategy that derived special benefits from combining the resources of state agencies with those of CCHS. This proved to be a critical com- ponent for success.

This article reviews the myr- iad factors that contributed to a broken system and instigated Delaware’s search for a solution. The process of developing this unique program and a descrip- tion of features of the CAPES unit are provided. Preliminary evidence of benefits experienced by patients, staff, and the com- munity since the inception of the CAPES unit are examined, and new challenges are identi- fied. We hope this article will add valuable information to the cur-

rent body of knowledge regarding the implementation of an effec- tive program that addresses the mental health crisis.

bAckground History

History clearly reveals the catastrophic results of deinsti- tutionalization, a government policy that moved individuals with severe mental illness out of state institutions and into unprepared communities. Since this movement began in the mid 1950s, as many as 92% of those individuals who would have resided in institutions are now struggling to live in the commu- nity (Torrey, 1997). A backlash of poor planning has resulted in the ongoing lack of psychiatric resources, such as inconsistent provision of essential psychiat-

ric medications and inadequate outpatient services, which has led to a revolving door pattern of psychiatric hospitalizations.

One such devastating con- sequence is a profound influx of individuals experiencing men- tal health crises into emergency departments (EDs). This lack of stabilization has created a ripple effect that is evident in problems such as:

l Overcrowding of EDs, caus- ing serious delays in emergent medical and psychiatric treat- ment (National Mental Health Association, 2004).

l Patients being directed to inappropriate levels of care due to limitations in resources (Na- tional Mental Health Associa- tion, 2004).

l Dramatic increases in vio- lence in EDs (Emergency Nurses Association, 2006). In addition, these authors have frequently witnessed detainment of numerous police officers in the ED due to insufficient inpatient psychiatric beds. This creates a strain on law enforcement avail- ability in the community. Greater demand for psychiatric services continues to deplete community resources, which in turn increas- es the volume of patients experi- encing mental health crises.

diminished resources: overcrowded Eds

The exodus of psychiatric pa- tients from institutions in the 1950s dramatically increased the volume of homeless individuals in the community. The National Coalition for the Homeless (2006) estimated that approximately 20% to 25% of the single adult home- less population has some form of severe and persistent mental ill- ness. In addition, there is a high prevalence of medical comor- bidities in this population, such as diabetes, cardiovascular disease, gastrointestinal illness, skin in- fections, hepatic disorders, and acute respiratory ailments (Bar- tels, 2004). EDs are mandated to serve individuals who are indigent and, consequently, are commonly used by those who are homeless as primary care resources for both medical and psychiatric illnesses. Many psychiatric patients are un- insured or have exhausted their benefits, which creates financial burdens on institutions serving this population.

It has been found that prompt recognition and skillful interven- tion during a time of crisis can help individuals avoid the devel- opment of serious long-term dis- abilities (Aguilera, 1998). It may even contribute to the beginning of new coping patterns that can improve their overall functioning.

Prompt recognition and skillful intervention during a time of crisis can help individuals avoid the development of serious long-term disabilities.

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In light of the lack of urgent out- patient psychiatric care, psychiat- ric nurses in the ED can and do play a key role in the treatment of individuals in crisis by providing the immediate care required for clients to reestablish equilibrium. However, such interventions re- quire time, space, and adequate resources for nurses to gain a com- prehensive understanding of pa- tients’ current condition, level of functioning, and potential threats to safety of self or others.

The chaotic environment of an overcrowded ED is not con- ducive to establishing the above conditions and providing thera- peutic crisis intervention services. Crowley (2000) suggested that the culture of the ED, in which a high value is placed on technical pro- ficiency, quick movement through the system, and treatment of trauma cases, is incongruent with the delivery of mental health ser- vices that focus on the complex emotional needs of individuals in crisis. Crowley (2000) also advised that the open, noisy environment of the ED can make disturbed behavior difficult to contain and may lead to potential safety risks for patients and staff members.

safety concerns Risk of Violence. Violence in the

ED is on the rise (Emergency Nurs- es Association, 2006). Therefore, safety is a primary concern when treating behavioral health clients on an emergent basis. According to Quintal (2002), violence is of- ten linked to overcrowded condi- tions; therefore, assessing patients’ risk for violence and effectively managing their behavior is vital to averting injury. Quintal identi- fied precipitating factors of which nurses must be aware to take an active role in preventing violent episodes. These include the pa- tient’s history of violent behavior, his or her age and diagnosis, and staff attitudes toward the patient.

Although conducted with an in- patient population, this research is transferable to the ED setting.

Nurses in a busy ED triage area are not tuned in to cues of escalat- ing agitation and often lack skill in anger management, frequently resulting in difficult-to-control violence. Binder and McNiel (1999) conducted a survey that focused on how clinicians in the ED actually manage acutely agitated clients. They found that skilled clinicians place a high pri- ority on preventing patient and staff injuries by quickly halting violent behavior, often through the use of chemical and physical restraints. Psychiatric nurses, who have refined skills in early detec- tion, begin their interventions with less restrictive measures, such as verbal de-escalation.

Nurses’ perceptions of vio- lence in the ED have been the focus of several research articles (Catlette & Belzoni, 2005; Er- ickson & Williams-Evans, 2000), which suggests that acts of vio- lence often go unreported and that many nurses believe being assaulted “goes with the job.” Such findings indicate a need for further education and increased awareness around this topic.

Elopement Risk. Summers and Happell (2003) explored why patients elope or leave prior to treatment and what can be done to improve satisfaction with the services they receive. The re- searchers found major areas of dissatisfaction among clients, such as lengthy waiting times, lack of privacy in the triage area, and negative attitudes of general staff. Suggestions for addressing these issues included creating a triage system that gives clients with psychiatric complaints equal priority to those with medical problems, increasing education for emergency nurses to over- come stereotyping, and raising levels of professionalism.

High-risk patients who are a danger to themselves and others are often left in the triage area without adequate supervision. Sentinel events have occurred due to elopement of patients in mental health crises. This has cre- ated an additional impetus to find a timely resolution to this crisis.

Patient dignity Stigmatization. Although safety

is a top priority, the treatment and possible stigmatization that clients with psychiatric complaints ex- perience also provoke great con- cern. Camilli and Martin (2005) raised the question of whether intoxicated or psychiatric clients receive inadequate care as a result of negative or apathetic attitudes among nursing staff. Although a low tolerance and high frustration level with such patients has been noted, the researcher found that nurses provide adequate medi- cal care to stabilize them, but of- ten lack compassion (Camilli & Martin, 2005). This attitude is evident in the early application of restraints, which often extends beyond need, for patients who demonstrate agitation.

Appropriate Level of Care. Lack of psychiatric resources and a need for timely disposition of patients with mental illnesses has resulted in increased involuntary hospital- izations, another form of criminal- ization, which has taken the place of psychiatric institutionalization for many of these patients.

tHE cAPEs unit: A solution Planning stage

Mental Health Crisis in Dela- ware. The mental health crisis in this nation’s first state is not un- like that depicted throughout the country. Delaware’s scenario is manifested by an increasing num- ber of clients with psychiatric is- sues becoming homeless or incar- cerated as a result of diminishing

JourNal of Psychosocial NursiNg • Vol. 46, No. 6, 2008 27

resources for a growing population. In Delaware, budget appropria- tions for mental health had been significantly cut. For example, in the state’s efforts to curb hospital- ization costs in the few years prior to opening the CAPES unit, the population at Delaware’s state-run hospital shrunk by more than 100 clients (Goldblatt, 2005). Consis- tent with the climate across the country, three private community hospitals in Delaware closed their inpatient psychiatric units.

Representatives from the State of Delaware’s Division of Sub- stance Abuse and Mental Health shared common beliefs and goals

with the Departments of Psychiatry and

Emergency Medi- cine of CCHS and formed a coalition. They

recognized

that inadequate resources trans- lated into inadequate services and inappropriate levels of care. Progressively worsening condi- tions for individuals, as well as the community, were anticipated if a solution was not found.

Innovative Models of Care. The development of the CAPES unit began with an investigation of in-

novative practices developed in other states designed to counter- act the many barriers to providing optimal care to clients with psy- chiatric complaints in the ED.

Tyrell, Winters, and Gold- sworth (2003) discussed a collab- orative model developed to im- prove client outcomes in which the ED staff and psychiatric screeners work together to coordi- nate care. Long wait times for psy- chiatric patients in the ED prior to medical clearance and a high rate of recidivism among clients dis- charged from the ED were among the problems that prompted this study. The ongoing presence of psychiatric screeners in the ED, as well as additional education for all staff, was recommended.

Lewis et al. (2005) detailed the development of the EBH at LVHHN, specifically focusing on patient and staff safety. Outcomes of this EBH unit include greater staff satisfaction, decreased elope- ments, reduction in wait times, and decreased patient frustra- tion levels. Many protocols of Lehigh Valley’s EBH were incor- porated into the development of the CAPES unit, whereas others demonstrated a need for modifi- cation. For example, the restric- tive protocols for eligibility to the CAPES unit from the triage area were found to cause derision be- tween ED and CAPES staff. Loos- ening those criteria improved staff satisfaction, as evidenced by a consensus of opinions expressed by nurses at staff meetings. How- ever, issues surrounding this topic continue to be a challenge.

Findings reported by Lewis et al. (2005) aided in identifying and proactively addressing potential problems in Delaware’s unique program. For example, prior to opening the CAPES unit, staff- ing was augmented to offset the anticipated dramatic increase in the volume of behavioral health clients admitted to the ED. This

was based on the 40% increase of patients in mental health crisis documented at Lehigh Valley’s EBH unit (Lewis et al., 2005). In fact, the CAPES unit has seen a more than 15% increase in vol- ume from 2005 through 2007.

development of the cAPEs unit

Medical-Psychiatric Treatment. The CAPES unit serves adult patients who are experiencing a psychiatric crisis. Given the high prevalence of comorbidity in the psychiatric population, the ED is an ideal location for establishing an EBH unit. Emergent medical care supersedes psychiatric assess- ments and precludes immediate admission to the CAPES unit. This requires a vigilant effort to maintain safety while in the medi- cal area of the ED and flexibility of psychiatric nurses to accept pa- tients with persistent medical con- ditions at the earliest opportunity.

Modification of admission standards now allows for more medical management within the CAPES unit, such as monitoring blood sugars, performing labora- tory tests and electrocardiograms, and occasionally assisting with bedside medical procedures, in- cluding suturing. Questions re- garding where a patient’s needs would be best served arise in situ- ations where close observation and safety are weighed against the need for urgent medical attention. An example is patients at risk for delirium tremors.

Unit Design. The CAPES unit is a specialized, secured area lo- cated within the ED of an inner- city hospital. The CAPES unit is composed of four designated interview rooms containing only reclining lounge chairs designed for safety. There is a medical eval- uation room with a stretcher for

Continued on page 29.

This unique multidisciplinary approach has greatly improved the manner in which individuals in crisis receive psychiatric services in the ED.

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any medical problems that may arise that do not require transport to the main ED. Medications, located in a locked room onsite, are readily accessible. A restraint room, free of objects other than a bed that is secured to the floor, is also located within the unit.

Measures to ensure patient and staff safety are incorporated into the unit design. Prior to be- ing taken to the unit, patients are escorted to a private area where they are electronically screened by a constable for the presence of metal objects. Trained ED or psy- chiatric staff conduct a thorough safety search and place the patient in hospital attire. Additional safe- ty measures include cameras in each of the rooms in the CAPES unit. The camera images can be viewed on monitors located at a remote security station, as well as at a work station in the CAPES unit. Panic buttons are located under desks at the work stations on the CAPES unit and are worn by staff to alert security of any un- safe situations that suddenly arise.

Staffing. Prior to the devel- opment of the CAPES unit, comprehensive psychiatric eval- uations were completed by a psy- chiatric nurse with an in-depth knowledge of the management of patients in mental health crisis. Since opening the CAPES unit, there are routinely two psychiat- ric RNs on each shift. CCHS has also provided additional staffing for the CAPES unit consisting of a mental health associate and an attending psychiatrist. All men- tal health associates are required to have a bachelor’s degree in a related field and psychiatric expe- rience, and they receive 6 weeks of orientation to the psychiat- ric crisis team. All hospital staff must attend an annual inservice session on psychiatric emergency assistance training, which stresses

competence in verbal de-escala- tion skills and hands-on compe- tencies in the management of pa- tients who are physically violent.

As part of a contractual agree- ment with CCHS, the State of Delaware makes a substantial financial contribution that in- cludes provision of one master’s- prepared crisis intervention worker per shift and an occasion- al resident from the residency program of the state psychiatric center. In addition to perform- ing psychiatric evaluations, these state employees provide valuable information, such as identifica- tion of clients who are active with a continuous treatment team or other community mental health agencies. Because of their extensive knowledge of available state-funded agencies, they are also proficient in expediting pro- vision of services to individuals who are currently uninsured.

individuAl ExAmPlE Mr. J. is a 42-year-old divorced,

White man, seeking services at the ED with a chief complaint of “feeling depressed.” Suicidality is implied in his statement when he tells the triage nurse that “I am constantly fighting with my roommate, and I can’t live like this anymore.” He is registered in the ED, his vital signs are record- ed, and a brief medical history is obtained to identify any current medical problems. Mr. J. has no medical condition requiring treat- ment in the main ED. His mod- erately high blood pressure can be managed while in the CAPES unit. The triage nurse alerts the CAPES unit charge nurse of the client’s admission with expressed suicide ideation and alerts her of Mr. J.’s abnormal blood pressure.

The psychiatric crisis nurse, accompanied by a mental health associate, arrives at the triage area to greet Mr. J., explains the CAPES unit process, assesses his

level of cooperation, and performs a brief interview, which helps de- termine his mental status and po- tential risk for violence. The need for any p.r.n. (as needed) medica- tions is also assessed by the RN at this time to obtain orders and ad- minister medication prior to the patient entering the CAPES unit. A constable, whose office is adja- cent to the triage and search area, joins the mental health associate to search Mr. J. for contraband. To build trust, Mr. J. is first asked if he has any sharp objects or weap- ons with him, and if he does, he is asked to place them on a table near the constable. The con- stable then electronically screens him and stands outside a curtain while the mental health associate searches and bags Mr. J.’s clothing, and then helps him into a hospi- tal gown. Mr. J. is then escorted to the CAPES unit, where his per- sonal belongings are secured.

Once in the CAPES unit, Mr. J. is placed in an evaluation room. Prior to receiving a comprehen- sive psychiatric assessment by ei- ther the nurse, the crisis worker, or the psychiatric resident, a urine sample is obtained for toxicol- ogy, and his color-coded chart is placed in the ED “to-be-seen” rack for the medical doctor. (Col- or coding the charts alerts the ED doctors of a CAPES unit admis- sion and expedites assessment and medical clearance of psychiatric patients for a timely disposition.) Mr. J. is reassessed for current suicidality and any plan he may have to harm himself. He admits to having had a plan prior to ad- mission to end his life by taking an overdose of pills and driving his car off of a bridge. However, he is currently ambivalent about carrying out his plan if he were to be discharged today and states he will not harm himself while in the CAPES unit.

The nurse confers with the at- tending psychiatrist, Dr. G., and

Continued from page 28.

JourNal of Psychosocial NursiNg • Vol. 46, No. 6, 2008 29

the State of Delaware coworker, Mr. W., and they collaboratively discuss disposition options. Mr. W. discovers Mr. J. has been ac- tive with the state’s outpatient counseling center, which cares for many of the state’s chronically ill psychiatric patients. Mr. W. con- tacts the on-call caseworker and learns Mr. J. had expressed having some worsening symptoms of de- pression last week but missed his appointment with the psychiatrist this week.

A plan was developed and posed to Mr. J. to arrange an ap- pointment with the psychiatrist for the next day. In addition, Mr. J.’s counselor would arrange for emergency housing due to the conflicts with his roommate and agreed to have further discussion about housing options if Mr. J.’s conflicts with his roommate could not be resolved.

The counselor planned to call Mr. J. later that evening and in the morning to assess for safety.

In addition, the counselor would provide transportation home to- day and to the appointment in the morning, assuring Mr. J.’s compliance with follow up. Mr. J. was comfortable with this plan and after requesting help with his anxiety symptoms, received an anxiolytic agent to take home with him. Recommendations for follow up for hypertension were included in the discharge instruc- tions by the ED doctor.

If a patient were not able to contract for safety and was agree- able to admission, authorization would be obtained from his in- surance company for inpatient level of care. The report would be called to the receiving RN, and the patient would then be escort- ed by the mental health associate to the locked inpatient psychiat- ric unit. Alternatively, resistance to hospitalization would warrant an involuntary commitment for a patient deemed to be a danger to himself or herself or to others.

clinicAl imPlicAtions safety

Beginning when the CAPES unit opened, data were and still are being collected that target areas for improvement in the delivery of care to clients expe- riencing a mental health crisis. Comparison analyses on topics related to disposition and re- straints before and after opening the CAPES unit are considered a relevant information base to reflect program effectiveness.

Outcomes to date confirm projected advancements in safety and care delivery since opening the CAPES unit. Consistency in adhering to a more detailed safety protocol has significantly helped accomplish the identified goals. These safeguards include prompt assessment by the psychiatric crisis team and a search for contraband performed prior to admission. The addition of trained psychi- atric staff to provide one-to-one observation helps ensure the ob- servance of safety procedures for those clients who must remain in the ED setting because they do not meet criteria for immediate admission to the CAPES unit.

Elopement. Statistics related to elopement or leaving against medical advice from the ED do not differentiate between psy- chiatric and medical clients at CCHS. However, strong anecdot- al evidence indicates that follow- ing recommended safety proce- dures, including securing clients in a locked unit and/or placing them under close observation by the psychiatric crisis team, has, not surprisingly, accounted for the significant drop in the number of elopements from the ED. This has obvious implications in lowering risks for injury.

Restraint Use. Diminishing the use of restraints and patient time in restraints also enhances safety for patients, as well as staff. A study was conducted, comparing

Figure. Charts indicating the effects of collaboration on delivering the appropriate level of care. Referrals to state outpatient facilities increased and committals decreased since the Crisis Assessment and Psychiatric Emergency Services unit opened.

Voluntary inpatient 32%

Involuntary inpatient 28%

Outpatient (private) 13%

Outpatient (state) 10%

Drugs and alcohol 9%

Medical admission 4%

Other 4%

Voluntary inpatient 31%

Drugs and alcohol 15%

Medical admission 6%

Other 3%

Involuntary inpatient 16%

Outpatient (private) 14%

Outpatient (state) 15%

January to may 2004 January to may 2005

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the use of restraints from August to December 2004 with use during the same time frame in 2005 (re- flecting dates before and after the opening of the CAPES unit). An average of 188 patients was seen per month for psychiatric evalua- tion in 2004, compared with 231 patients in 2005. It should be not- ed that the increase in number of patients evaluated accurately re- flects the aforementioned upsurge in the number of patients in men- tal health crisis being admitted to the ED for psychiatric evaluation.

From August to Decem- ber 2004, 938 patients were evaluated for psychiatric issues. Twenty-eight of these patients were placed in restraints—an av- erage of 5.6 patients per month or 3% of those patients evaluated— for an average of 3.9 hours. In comparison, 2005 data revealed that of 1,161 patients evalu- ated, 16 patients were placed in restraints—an average of 3.2 pa- tients per month or 1.4% of pa- tients evaluated—for an average of 2.3 hours. Despite the growing population served, fewer patients were placed in restraints. In ad- dition, a psychiatric team trained to more effectively intervene with agitated patients appears to underlie the decrease in time pa- tients remained in restraints.

The advantages of a trained staff were further demonstrated when comparisons were made be- tween patients being managed for agitation while in the ED versus those in the CAPES unit. From January to December 2005, 44 patients were placed in restraints while being detained in the ED, an average of 3.7 patients per month. In the CAPES unit, only 8 pa- tients were placed in restraints, an average of 0.7 patients per month. No patients were placed in re- straints in the CAPES unit for 5 of those 12 months, but for those who were placed in restraints, the average time was 0.84 hours, com-

pared with an average time of 2.6 hours in the ED. These results also reflect efforts made to promote pa- tient dignity and staff satisfaction.

Psychiatric Hospitalizations Improvement in patient care

was also evident from the ex- amination of data associated with the disposition of patients seen for psychiatric evaluations. Cost containment and reallocation of resources have improved emer- gent outpatient access, a desirable outcome for the individuals, the community, and the state. This has had a significant effect on in- voluntary commitment rates. A total of 777 patients were commit- ted in 2004, compared with 573 in 2005. In light of the increase in psychiatric evaluations from 2004 to 2005, this shows remarkable improvement as a result of imple- mented changes, demonstrating a 43% decline in involuntary com- mitments to psychiatric facilities.

referrals to Appropriate levels of care

Collaboration between the State of Delaware and CCHS has opened channels of communica- tion and provided more options for outpatient treatment. Crisis intervention workers facilitate communication with clients’ outpatient counselor, who is then

often able to provide the needed intervention to avoid hospital ad- mission. Consequently, there was a significant increase in referrals to state outpatient facilities in conjunction with a decrease in committals since the opening of the CAPES unit. The pie charts in the Figure demonstrate the ef- fectiveness of this collaboration in delivering the appropriate level of care.

rEcommEndAtions for futurE rEsEArcH

Enhanced communication among providers has had the ad- vantage of highlighting obstacles suspected of causing clients to de- compensate and subsequently re- turn to the ED in crisis. For exam- ple, examination of frequent ED admissions of a client enrolled in a continuous treatment team sug- gested that decompensation oc- curs in association with a frequent turnover among caseworkers or when individuals are unhappy with their living situation. After the continuous treatment team is notified of their client’s concerns, they search for a satisfactory so- lution. For example, a counselor might arrange for respite care, or a new counselor might increase contact with the client to estab- lish a bond. Identifying barriers for patients with mental illness to

1. Collaboration is key to providing comprehensive care to patients with mental health emergencies.

2. The Crisis Assessment and Psychiatric Emergency Services (CAPES) unit is a safe area in which to evaluate, observe, and stabilize patients.

3. Enhanced safety, decreased committal rates, and better linkage to appropriate levels of care have resulted from this innovative unit.

4. The CAPES unit helps provide relief to an overburdened emergency department.

Do you agree with this article? Disagree? Have a comment or questions? Send an e-mail to Karen Stanwood, Executive Editor, at kstanwood@slackinc.com.

We’re waiting to hear from you!

k E Y P o i n t s

JourNal of Psychosocial NursiNg • Vol. 46, No. 6, 2008 31

remain stable in the community requires research-based, rather than anecdotal, evidence and would be a giant step forward in replacing the revolving door.

Although collaborative efforts of staff have greatly enhanced care for individuals in crisis, staff conflict, as a result of changes in physical structure and redefin- ing roles, has also emerged. The sources of conflict identified be- tween ED and psychiatric staff have frequently involved differ- ing expectations and judgments regarding which clients are ap- propriate for immediate transfer to the CAPES unit and which require medical attention in the main ED prior to admission. The development of an “us versus them” mentality has been influ- enced by the creation of a physi- cal boundary that separates the psychiatric nurses from the ED nurses. This is aggravated when a refusal of admission occurs when the CAPES unit is empty and the ED triage is overburdened. Psy- chiatric nurses, once considered part of the ED team, have been less inclined to provide assistance when the CAPES unit is not busy because the CAPES unit has cre- ated a physical and psychological separation of staff. There appears to less “team spirit.”

Lack of collegiality has a far- reaching impact, including effects on patient and staff satisfaction. Solutions to this conflict remain challenging. Eliminating the con- troversial “criteria for admission to the CAPES unit” would require a more fluid working relationship of medical and psychiatric nursing staff. This particular psychologi- cal door between units, ironically, needs to be unlocked.

conclusion Creation of the CAPES unit

has been an extraordinary collab- oration between CCHS and the State of Delaware’s Department

of Substance Abuse and Mental Health. Many of the originally identified goals, such as providing stabilization in a safe environment, disposition to an appropriate level of care, improving communica- tion among providers, alleviat- ing an overburdened ED, and containing costs, have been met. This unique multidisciplinary ap- proach has greatly improved the manner in which individuals in crisis receive psychiatric services in the ED. Clients are now evalu- ated in a safe, quiet environment by qualified personnel while their dignity and privacy is preserved.

We trust this article provides ample evidence of the significant benefits resulting from a coalition among different providers striv- ing to find a solution to the cur- rent mental health crisis. We are proud of the successes achieved since the creation of the CAPES unit and acknowledge that prob- lems remain that merit a contin- ued search for solutions.

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Camilli, V., & Martin, J. (2005). Emergency department nurses’ attitudes toward suspected intoxicated and psychiatric patients. Topics in Emergency Medicine, 27, 313-316.

Catlette, M., & Belzoni, M. (2005). A de- scriptive study of the perceptions of workplace violence and safety strategies of nurses working in level I trauma cen- ters. Journal of Emergency Nursing, 31, 519-525.

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Ms. Lauer is Patient Care Coordina- tor, Psychiatry, and Ms. Brownstein is an RN II, BC, on the psychiatric crisis team, Christiana Care Health System, Wilming- ton, Delaware.

The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.

Address correspondence to Michelle Lauer, RN, BSN, BC, Patient Care Coordinator, Psychiatry, Christiana Care Health System, 710 Woodsdale Road, Wilmington, DE 19809; e-mail: mlauer@ christianacare.org; or Rose Brownstein, RN II, BC, 16 Riverview Avenue, Chesapeake City, MD 21915; e-mail: rosealma2@yahoo.com.

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