Providing safe haven for mental health emergencies

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To hear staff tell it, the emergency department of the Centre for Addiction and Mental Health was a dark and dingy place before renovation work began in April, 2013.

Located on the ground floor of 250 College St., it was crowded, outdated and ill-designed to meet the needs of a growing number of patients seeking urgent mental health care. Family members were often prevented from staying in the wait area with loved ones struggling with addictions or suicidal thoughts because there was no space to accommodate them. And staff had to step over chairs just to move around the cramped care stations.

However, after a $7-million renovation, CAMH officially opened its refurbished and expanded 24-hour emergency department last month, with the aim of increasing efficiency and safety, and giving patients a more dignified experience. The facility – dubbed the Gerald Sheff and Shanitha Kachan Emergency Department, after donors who made a $2.5-million contribution – is now brighter, calmer and double in size. The overhaul is part of the hospital's aim to break down barriers to mental health care, making it less intimidating for people to receive help.

Other hospitals experiencing an increased demand for urgent psychiatric care, such as St. Michael's Hospital, are also creating self-contained mental health emergency units within their general emergency departments. Toronto Western Hospital opened one in 2005.

A separate unit offers more streamlined care, and provides a more tranquil environment for psychiatric patients who may find the general emergency setting overly stimulating, says Dr. Vicky Stergiopoulos, psychiatrist-in-chief at St. Michael's, where a designated psychiatric emergency unit is slated for 2018-2019. It also prevents agitated psychiatric patients from disturbing others in general care.

At CAMH, the emergency department is often where individuals access psychiatric care for the first time.

"It's a gateway, that's for sure," says Dr. Brittany Poynter, clinical head of the emergency department. "I think people see it as one of the most accessible entry points [to mental health care] given that it's open 24 hours a day, seven days a week."

As such, offering a comfortable space designed around patients' needs was critical. Those with severe psychiatric issues are now directed to a designated acute-care waiting area with room to pace, separate from patients with less acute concerns. A spacious, centralized care station surrounded by large glass windows offers staff a line of sight to all areas of the department, ensuring they can respond immediately to patients at risk of injuring themselves or others. A doubling of private interview rooms to a total of nine means patients are assessed more quickly; the department's goal is to get people out the door within four hours. From there, patients are either admitted to in-patient care, they're referred to other resources, or discharged with treatment recommendations.

Hastening the duration of emergency visits is important, as patients would spend less time waiting around, and resources would be put to better use. "Before, we used to have the staff to see people, but not enough room to see people. So people actually had to wait longer just because we were waiting for a room," says CAMH emergency department manager Kristen Cleary.

The renovation, which lasted 18 months, was a major undertaking, especially considering CAMH intends eventually to relocate the emergency department to its Queen Street West location. There, the hospital has been transforming the neighbourhood with an ambitious, multiphase redevelopment that integrates shops, residences and businesses with its facilities. The third phase, expected to be completed by late 2019 or early 2020, will bring all of the hospital's clinical programs from its College Street location to Queen Street. But faced with surging demand, hospital officials say, improvements to the existing emergency department could not wait.

The number of visits to the department have doubled since 2003. In 2013, it recorded 7,400 visits. St. Michael's Hospital is seeing a similar trend, with demand for psychiatric emergency services up year after year. CAMH officials believe the increase is a result, in part, to efforts to lift the stigma around mental health issues, as well as heightened awareness among the public that the emergency department exists.

Linda Mohri, executive director of access and transitions, likens CAMH's emergency department to that of the Hospital for Sick Children.

"Parents may choose to drive by multiple general hospital emergency departments that can offer pediatric services but they decide to go to SickKids because … they're concerned and they want to see a specialist," Ms. Mohri says. "We believe the same is true at CAMH; people want to go to where the specialist is."

The 75-member emergency team comprises psychiatrists, residents, medical students, nurses, social workers, program assistants, a pharmacist and a hospitalist. They handle a wide range of cases, from intoxicated individuals seeking detox to people experiencing their first episodes of psychosis. "We see anybody and everybody with any sort of mental health or addiction concern," Dr. Poynter says.

Aside from the care available in-hospital, patients discharged from the emergency department can access a variety of urgent-care services, which can provide follow-ups within days. The new department also includes eight beds for patients waiting for openings in other units, those requiring short stays of less than 24 hours, and for those needing further assessment.

Because of its planned relocation to Queen Street, the expanded department, carved out of space previously used as CAMH's auditorium, has been designed in a way that was as generic as possible, so it can be used for other purposes once the unit has moved, Ms. Mohri says. One of the advantages of renovating the existing space is the emergency department can test design ideas for its future location.

To form its own plans, St. Michael's Hospital looked at psychiatric emergency facilities at Toronto Western Hospital, as well as those in Boston, New York and Houston, says Dr. Stergiopoulos. She adds, however, that improving and increasing emergency psychiatric services will not be enough. More community-based support services are necessary to ensure patients get continuous care, she says. "Emergency departments are not set up that way."