Creating a safe space for psychiatric emergencies

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Teamwork is paramount in Toronto Western Hospital's Psychiatric Emergency Services Unit (PESU).

During the day shift, five staff members (two nurses, two psychiatric assistants and one clinician) are in close quarters in the enclosed nursing station while they watch over patients who are experiencing a mental health crisis.

Despite this, they move about effortlessly, handing off tasks to each other to ensure patients can be discharged from the unit safely with the supports they need to continue their recovery in the community.​

​Patients are cared for in PESU for a variety of reasons. In some cases people are experiencing a situational crisis and are not coping well, or they may have a mental illness that they are not able to self-manage. Patients with addictions can also find themselves in an emergency situation that requires medical care and support.

"Mental health affects people from all walks of life," says Nanette Lang, Manager of PESU. "With one in five people experiencing mental illness at some point in the lives, it is essential that we reduce stigma so there is no judgement against those seeking help."

Ten years ago, UHN changed the care model for mental health emergencies and has since been a leader providing evidence-based and holistic services to patients in crisis.

A new approach

Prior to the opening of PESU, it was not uncommon for mental health patients to be stuck in the emergency department (ED), waiting for a psychiatrist to see them or for a bed to become available in an inpatient unit. In the noisy and often hectic pace of an ED, mental health patients can become further distressed and often don't have access to the trained support team they require.

Dr. Jodi Lofchy, Director of PESU, was instrumental in implementing the new approach, which fast-tracks patients out of the ED into PESU -- a safe and secure environment, where they can stay for up to 72 hours.

Once inside the unit, patients are surrounded by a team comprised of psychiatric nurses, psychiatric assistants, and clinicians. There, they have access to staff psychiatrists, psychiatric residents and ED physicians. Together, they work collaboratively to conduct assessments and interventions for each patient, manage patient transitions throughout the services, provide linkages to community agencies, and facilitate ongoing treatment.

"With the support of UHN, and the participation of our Emergency Medicine colleagues, we have created a unit that allows our patients to receive timely specialized care in a safe and secure setting," said Dr. Lofchy. "We have become the 'gold standard' that other hospitals aspire to and many emergency departments across the country are now building their own units based on the PESU model." 

PESU has four holding beds and four waiting spaces, with an average length of stay of less than 48 hours. Aside from the care available in-hospital, patients discharged from the ED can access a variety of urgent-care services, which can provide follow-ups within days.

'A humbling experience'

Recovery is the primary goal for patients in PESU, which emphasizes that while individuals may not be able to have full control over their symptoms, they can have full control over their lives.

The team assesses and treats patient needs through a number of avenues including crisis intervention, medication, de-escalation, cognitive behaviour therapy, empowerment, fostering hope, finding personal meaning, increasing awareness of individual strengths and self-efficacy.

"The journey to recovery is a personal one, and therefore looks different for each individual we see," says Pamela Rose, RN. "PESU may represent the beginning of an individual's recovery or a single step somewhere along the journey, but wherever patients are, it is an honour and humbling experience to support an individual who presents in crisis and acute distress, along their journey towards recovery."