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Crisis and emergency services 

Crisis and emergency services
Chapter:
Crisis and emergency services
Author(s):

Sonia Johnson

, Jonathan Totman

, and Lorna Hobbs

DOI:
10.1093/med/9780199565498.003.0068
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date: 22 July 2019

Our primary focus in this chapter is people with significant mental illnesses who are experiencing an exacerbation of their mental health or social problems of such severity that they reach the threshold for inpatient admission, or else seem likely very soon to reach this threshold unless pre-emptive action is taken. This is a relatively restrictive definition, excluding, for example, many crisis intervention services that have aimed to optimize the psychological adjustment of people experiencing difficult transitions in their lives. However, a focus on acute care at the threshold of admission is readily justified in economic, pragmatic, and policy terms. From the perspective of service users and carers, easy and prompt access to helpful and acceptable crisis services to help them at the times when they are most distressed is consistently rated as very important, with avoiding inpatient admission whenever possible also often identified as an important priority (Rose, 2001). From an economic and policy point of view, acute care, especially in hospital, consumes a large share of the mental health budget in most countries (Holloway and Sederer, Chapter 19, this volume), making it very desirable that optimal outcomes are achieved as efficiently as possible.

Given these major reasons for regarding acute care as a priority, the evidence base is surprisingly weak. For example, none of the 2009 recommendations of the Schizophrenia Patient Outcomes

Research Team (PORT) (Dixon et al., 2010) related to models of acute care delivery, and the National Institute of Health and Clinical Excellence (NICE) guidelines on schizophrenia and bipolar disorder make in relation to acute care only the general recommendations that crisis resolution and home treatment teams should be available. Despite this lack of robust evidence, mental health crises and, in particular, models aimed at diverting people from hospital admission, have been the focus of considerable innovative service development in the past few decades. In this chapter we complement Holloway and Sederer’s discussion of inpatient care by reviewing four other main types of care: two aimed mostly at initial triage of people experiencing crises (stand-alone emergency services and emergency department services in the general hospital), one combining assessment and provision of a community alternative to acute admission (crisis resolution and home treatment teams), and one mainly aimed at providing an alternative (community residential crisis services).

Acute day care is also excluded from our discussion as it is covered elsewhere, but, as the final section suggests, it should also be seen as a potentially important element in integrated care pathways.

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