THE EMERGENCY DEPARTMENT AND VICTIMS OF SEXUAL VIOLENCE AN .docx

THE EMERGENCY DEPARTMENT AND
VICTIMS OF SEXUAL VIOLENCE: AN
ASSESSMENT OF PREPAREDNESS TO HELP
STACEY BETH PLICHTA, SC.D.
TANCY VANDECAR-BURDIN, M.A.
Old Dominion University, Norfolk, VA
REBECCA K ODOR, M.S.W.
Virginia Department of Health, Richmond, VA
SHANI REAMS, A.A.S.
Virginia Sexual and Domestic Violence Action Alliance,
Richmond, VA
YAN ZHANG, M.S.
Old Dominion University, Norfolk, VA
ABSTRACT
The Emergency Department (ED) is a key source of care for
victims of sexual violence but there is little information
available about
the extent to which EDs are prepared to provide this care. This
study
examines the structural and process factors that the ED has in
place to
assist victims. A survey of all 82 publicly accessible EDs in the
Commonwealth of Virginia was conducted (RR 76%). In
general, the
EDs provide the recommended medical care to victims.

However, at
least half do not have the needed resources in place to
effectively assist
victims and most (80%) do not provide regular training to their
medical
staff about sexual violence. Further, almost one-quarter do not
have a
relationship with a local rape crisis center. It is recommended
that each
ED partner with local rape crisis centers to provide training to
their
staff and to ensure continuity of support for victims. It is also
suggested that the state government explore ways in which a
forensic
(SANE) nurse be made available to every victim of sexual
violence that
presents to the ED for medical assistance. Ideally, each ED
would
become part of a community-wide Sexual Assault Response
Team
286 JHHSA WINTER 2006
(SART) in order to provide comprehensive care to victims and
thorough evidence collection and information to law
enforcement.
INTRODUCTION
This study seeks to examine the extent to which
Emergency Departments (EDs) in the Commonwealth of
Virginia are prepared to provide care for victims of sexual
violence through an examination of both structural and

process factors that are currently in place. Many studies
indicate that sexual violence victimization has both long-
term and short-term health consequences (Plichta and Falik,
2001; see also Rentoul and Applebloom 1997; Cloutier,
Martin and Poole, 2002; Bohn and Holz, 1996). The ED is
a key source of care for victims of sexual assault. It is one
of the first points of entry to care. Competent care by
professionals trained in treating sexual assault victims is
critical to the timely recovery of physical and mental
health. The ED also plays a critical role in the collection of
evidence that may lead to the conviction of the perpetrator
and a recent study found that specially trained (forensic)
nurses perform this function significantly better than do
other staff (Sievers, Murphy and Miller, 2003). Forensic
nurses are registered nurses (R.N.’s) who have advanced
training in the examination of sexual assault victims; this
includes training on legal aspects of evidence gathering.
Few studies have examined the preparedness of the
ED to assist victims of sexual violence and to collect
evidence, and none have been completed in Virginia.
Those few studies, which have examined different aspects
of care offered to victims in the ED, generally find that the
care is incomplete (Rovi and Shimoni, 2002) and that
comprehensive training of the staff is necessary (Lewis et
al., 2003). There is however some evidence that those EDs
with sexual assault nurse examiners (forensic nurses)
generally provide better and timelier care to victims (Selig,
JHHSA WINTER 2006 287
2000; see also Stermac and Stirpe, 2002; Ledray and
Simmelink ,1997).

Prevalence of Sexual Violence and Care-Seeking in
Virginia
There are a substantial number of victims of sexual
violence in Virginia, many of whom may not be obtaining
the care that they need. The lifetime prevalence of sexual
violence victimization in Virginia is estimated to be
approximately 27.6% for women and 12.9% for men, with
a one-year rate of 1% for women and .1% for men (Masho
and Odor, 2003); these rates are consistent with those found
in national studies of sexual violence (Resnick et al., 2000).
Using U.S. Census data for the adult population of Virginia
(U.S. Census, 2000) and these incidence rates, it is
estimated that about 26,000 female and 2,580 male adults
will be victims of sexual violence each year in Virginia.
Numerous studies have documented that sexual violence
victimization is underreported (Bachar and Koss, 2001; see
also Bureau of Justice Statistics, 1996). This appears to be
true in Virginia, as the majority of the estimated victims are
not found in the legal, social service, rape crisis service or
health care system (Virginia Uniform Crime Reporting
Program, 2004; see also VAASA, 2002; Masho and Odor,
2003). Masho and Odor (2003) report that only 10.8% of
women and 2.2% of males sought medical care after being
raped or sexually assaulted. This is significantly lower than
a national estimate of 26.2% of women seeking care after
an incident (Resnick et al., 2000). Some of this variation
may be due to the difference in definitions of rape and
sexual assault between the two studies. However, the care-
seeking rate for Virginia is still low, and the reasons why so
few victims seek medical care are worth exploring. One
possibility is that the services may not be well prepared to
assist victims.

Existing Clinical Guidelines for the Care of Victims
The evaluation of services for victims of sexual
violence is somewhat challenging as there is currently no
definitive standard of medical (physician) care for the
treatment of victims of sexual violence. An extensive
search of the Association for Health Research and Quality
(AHRQ) website, which houses the majority of clinical
guidelines developed and used in the U.S., only uncovered
some limited guidelines from Great Britain
(www.ahrq.gov). The closest approximation to medical
guidelines for the treatment of sexual violence victims in
the U.S. comes from the American Medical Association
(AMA,1995) which has published some recommendations
for the care of victims based on available evidence;
however, the document is careful to point out that these
recommendations should not be regarded as absolute
clinical guidelines. The American College of Obstetrics and
Gynecology (www.acog.org; ACOG,1997) and the CDC
(2002) have also published recommendations for specific
aspects of care, but the AMA report was the most
comprehensive of the three.
Nursing has been much more pro-active in the
development of standards of nursing care for victims of
sexual violence. The nursing specialty devoted to this area
is the Sexual Assault Nurse Examiner or SANE nurse (also
referred to as a forensic nurse) and there are currently over
100 SANE programs in the United States (www.sane-
sart.com; Ahrens et al., 2000). This specialty has
developed extensive nursing guidelines for both the care of
victims and for evidence collection, as well as training
standards for forensic nurses (Ledray, 1999). These
guidelines are generally in agreement with the AMA

strategies, although they are more extensive and detailed
regarding evidence collection and the psychosocial care of
victims.
These authoritative sources that provide guidelines
regarding the care of victims of sexual violence are
generally in agreement with one another, although some
sources are more comprehensive than others (AMA, 1995;
see also ACOG, 2004; CDC, 2002; Ledray, 1999). Table 1
presents a list of recommended components of care based
upon these sources.
Recommended Linkages to Other Agencies
The care of a victim of sexual violence has medical,
psycho-social and legal (evidentiary) aspects. While the
ED is generally well-placed to perform medical services, it
is not as well prepared to provide the array of other
services, such as counseling and evidence storage that a
victim may need. In order to do so, it is recommended that
ED’s partner with rape crisis advocates (who can provide
on-going emotional support to the victim) (Preston, 2003).
A more comprehensive model of care expands this
partnership to other agencies and involves the ED
participating on a multidisciplinary team, such as a Sexual
Assault Response Team (SART) (Heger,1999; see also
Botello et al., 2003; Derhammer et al., 2000). The SART,
a fairly new model of care, shows promise in providing
comprehensive services to victims. The SART is a multi-
disciplinary team developed to coordinate services to
victims. It is comprised of advocates from the local rape
crisis center, law enforcement officers, the ED and other

SANE programs. SART’s have the ability to provide a full
range of comprehensive services to victims, including:
immediate crisis intervention, team interviews, forensic
examination, and follow-up care. This partnership enables
law enforcement to receive a fuller view of the facts
regarding the case, and provides for better forensic
evidence collect and storage for prosecution of the sexual
offender (Ledray, 2001).
Table 1
Recommended Components of ED Care for Sexual Violence
Victims
General Recommendations
Screen all patients, or at least those with injuries of unknown
origin
Screen all patients when sexual assault is suspected
Medically stabilize the victim
Obtain a medical history
Obtain a relevant sexual history
Have the patient in a quiet and safe area
Do not leave the patient alone
Contact (with the patient’s permission) a friend or family
member
Offer the services of a rape crisis advocate
Where medically indicated:
Offer emergency contraception
Offer HIV testing and prophylaxis
Offer STD testing and prophylaxis
Offer follow-up for re-testing for HIV and/or STD’s

Forensic Exam Recommendations
Know the state guidelines
Obtain an informed consent
Obtain a history of the sexual assault
Obtain information about current pregnancy status
Collect the victim’s blood for typing and DNA
Collect a urine sample to screen for pregnancy, alcohol and
drugs
(including date rape drugs)
Collect samples of the victim’s hair
Examine the orifices involved for trauma and to collect
sperm/seminal fluid
Collect fingernail scrapings
Comb the victim’s pubic hair for foreign hair and matter
Collect torn and stained clothing
Document all injuries on a body map
Photograph injuries
Examine the victim’s body for sperm/seminal fluid that might
have
dried and been missed on initial examination
Structural and Process Components Related to the Care of
Victims
It is clear, that to allow these processes to occur, the
ED has to have a number of structural and process
components of care in place, as well as linkages to other
agencies. First and foremost, the ED needs a clearly
written protocol on the care of victims. Second, it is
necessary for the ED to have trained nursing personnel

(SANE/forensic nurses) available to all victims in a timely
manner. Nurses provide the majority of patient care to
victims. However, other medical staff, particularly the
physicians, also need some level of training in how to care
for victims. Third, the ED needs the physical resources (a
dedicated room, evidence collecting kits, medical
equipment) in order to be able to conduct the exam. If
clothing is to be collected, the ED will also need to have
other clothing available for the victims so that they have
something to wear when they leave the ED. Finally, the ED
will obviously need linkages to rape crisis centers and other
agencies that can provide extended assistance and follow-
up support to victims. Ideally, the ED would participate on
a community-wide sexual assault response team (SART),
as the SART formalizes these linkages. This study seeks to
explore the extent to which EDs in Virginia have these
resources and processes in place. This study also seeks to
to provide a base of information upon which a plan for
improved services can be built.
METHODS
The survey questions were based primarily upon the
list of victim resources discussed in the previous section.
The survey was reviewed and revised by experts from the
Virginia Sexual and Domestic Violence Action Alliance,
the Virginia Department of Health and by several
practicing forensic nurses across the Commonwealth of

Virginia. Survey items included questions about the ED’s
characteristics (location, number of visits), screening
practices, hospital resources available (SANE/forensic
nurse, linkage to a rape crisis center, participation on a
SART), services offered to victims of sexual assault,
components of the sexual assault examination, training
policies for medical staff and a self-rating of how the ED
was performing in the area of providing services to victims.
The survey focused on adolescent and adult victims, and
did not ask questions about child sexual abuse. The survey
was six pages long, and designed to be either self-
administered or completed in a phone interview by the ED
nurse manager or the lead forensic nurse in the ED. It took
approximately 15 minutes for respondents to complete.
Sampling Frame and Survey Distribution
The surveys were distributed by mail with a
telephone follow-up to each of the 82 publicly available
EDs in the commonwealth of Virginia. The initial contact
was with the chief executive officer (CEO) of each ED.
Each CEO was sent a survey with a cover letter requesting
that they pass the survey on to either the lead forensic nurse
or the ED nurse manager. If no response was received
within two weeks, a second survey was sent out directly to
the nurse manager of the ED. If a survey was not received
back within two weeks of that mailing, the ED nurse
manager was called and invited to participate in the survey
via a phone interview.
Respondent Characteristics
Overall, 76% (62) of the ED’s responded to the
survey (See Table 2). The respondent ED’s are similar to
the entire population of EDs across the state in terms of
geographic location and size. In general, the proportion of
the sample from each of the five health planning regions

across the state is similar to the proportion of EDs in those
planning regions. Also, all four of the teaching hospitals
in the commonwealth completed the survey.
A number (n=56) of the EDs provided estimates of
the number of victims they treat each year. These estimates
were approximate and not necessarily precise figures
derived from any data collection process at the ED. The
average hospital reported seeing about 44 victims each
year, although this varied greatly (0-310). The EDs
reported that the majority of the victims were adult women
(50%), but they also treated adolescent girls (38%),
adolescent boys (9%) and adult males (4%). Since this
study focused on services available to adolescent and adult
victims, there is no data on the number of younger children
(age 11 and under) served or any data about the services
available to children.
RESULTS
Policies and Available Resources
Emergency Departments varied greatly in policies
and available resources (See Table 3). The majority of the
EDs (86%) have a written protocol in place regarding the
care of victims of sexual violence and almost all (87%)
treat victims on-site. The remaining hospitals transfer
victims to a sister hospital in the same system. The
majority (75%) of hospitals which refer patients elsewhere
do have a written protocol in place.
Approximately two-thirds of the EDs have an
employee on staff that is trained to assist victims, but only

half have a forensic nurse examiner (SANE) who works at
the hospital. Note that not all of these actively provide
forensic nursing care 24 hours a day. Overall, only 35% of
the EDs have a forensic nurse who is a paid employee and
who is available to all victims of sexual violence.
Linkages to other services also vary by ED. Almost
one-quarter (23%) do not have a relationship with a rape
crisis center and over half (60%) do not participate on a
sexual assault response team (SART). Even among the
ED’s that do have a linkage to a rape crisis center, 12%
almost never use their services and 37% use their services
for less than half of the sexual violence victims that they
treat (the remaining 51% do work with the center for three-
quarters or more of the victims that they treat).
Providing training to ED staff about the care of
victims of sexual violence does not appear to be a priority
for most of the EDs. Almost half (47%) of the EDs did not
have a formal training plan in place and over half (56%)
had not provided training to new staff in the past year.
Further, the great majority (87%) did not provide any
training to existing medical staff in the past year. When
asked, however, almost all of the EDs rated various aspects
of training as ‘very important.’ In particular, over 80% said
that it was very important for them to have training in the
following: collecting evidence, working with the police,
testifying in court, talking with victims and their families,
and working with rape crisis centers .

Table 2
Characteristics of the Emergency Departments that Participated
(n=61)
Characteristic % of Sample
Health Planning Region
1 (Northwest Virginia) 13
2 (Northern Virginia) 11
3 (Southwest Virginia) 40
4 (Central Virginia) 18
5 (Eastern Virginia) 18
Teaching Hospital
Yes 7
No 93
ED Visits in the Past Year (all reasons) N=56
Mean (standard deviation) 34,536 (21,861)
Median (inter-quartile range) 32,000 (16,000-48,000)
Range
% 2,900 – 15,000 23
% 15,001 – 31,500 27
% 31,501 – 48,000 25
% 48,001 – 90,000 25
ED Visits in the past year (n=48)
(sexual violence)
Mean (sd) # of victims treated 44.17 (61.98)
Median (interquartile range) # treated 19.5 (6-46)
Range of victims treated
% Treating 0-6 victims/year 25

Age/Gender of Victims treated (n=45)
% of victims who are female age 12-
17
38
% of victims who are female age 18+ 50
% of victims who are male age 12-17 9
% of victims who are male age 18+ 4
Table 3
General Policies and Available Resources
Policies % Yes % No
The ED has a written protocol in place regarding
the
care of victims of sexual violence
86 14
The ED routinely refers victims to another
hospital
13 87
Resources and Linkages
The ED has an employee who is trained to assist
victims
of sexual violence
64 36

The ED has a forensic nurse examiner (SANE) on
staff
52 48
The ED has a relationship with a sexual assault or
rape
crisis center.
77 23
The ED participates on a Sexual Assault Response
Team
40 60
Training
The ED has a formal training plan about sexual
violence
53 47
The ED has provided training about sexual
violence to
new staff in the past year
44 56
The ED has provided training about sexual
violence to
current members of the medical staff in the past
year
13 87

Screening Protocols
Only 30% of the EDs use a standardized instrument
to screen for sexual violence (See Table 4). Among those
that do screen, almost 20% use screening instruments for
intimate partner violence (domestic violence) and not for
all types of sexual violence. Further, among those that
screen, 22% do not use a question from a written form on
the clinical record, but simply ask the patient verbally and
then included the answer in the patient notes. The EDs are
somewhat more likely to screen women for sexual violence
than men. For women, 7% of the EDs screen all women
for violence victimization, 38% screen all women with
injuries of unknown origin, 47% only screen women when
they suspect sexual violence and 8% only discuss sexual
violence if the women discloses it to the provider. For
men, 5% of the ED’s screen all men for violence
victimization, 26% screen all men with injuries of unknown
origin, 50% only screen men when they suspect sexual
violence, 13% only discuss sexual violence if the man
discloses it to the provider and 5% report that they do not
discuss sexual victimization with male patients.
Services Routinely Offered to Sexual Violence Victims
In general, the EDs provide the necessary medical
care, but are less likely to offer comfort care (See Table 5).
Almost all of the ED’s provide the recommended medical
care to victims of sexual assault, with the exception of a
follow-up phone call within 48 hours (54% do not). A
minority of the EDs do not provide some of the

recommended services, such as screening for date rape
drugs (17%), prophylactic HIV treatment (17%) and
emergency contraception (10%) do not. Comfort care (a
place to shower and fresh clothes) is still not offered by a
substantial minority of EDs. Most EDs do offer referrals to
support services for victims, such as rape crisis centers,
safe housing and counseling. It should be noted that a
substantial minority do not have specially trained personnel
to provide these services; almost half do not offer a forensic
nurse, about one-quarter do not have a rape crisis counselor
in the examination room with victims and one-fifth do not
give victims any access to a rape crisis counselor.
Table 4
Screening Protocols for Sexual Violence Victims
Uses a Standardized Instrument %
The ED uses a standardized instrument to screen patients for
sexual
Violence
30
Screening Protocol for Women
All female patients are screened 7
All female patients with injuries of unknown origin are
screened
38

All female patients with suspected victimization are screened
47
All female patients who disclose victimization are screened 8
Screening Protocol for Men
All male patients are screened 5
All male patients with injuries of unknown origin are
screened
26
All male patients with suspected victimization are screened 51
All male patients who disclose victimization are screened 13
Sexual violence victimization is not discussed with male
patients
5
Components of the Sexual Assault Forensic (Evidentiary)
Exam
The assessment of the contents of the forensic exam
was only conducted for the 53 EDs that treat the victims
on-site and do not refer to another ED; data was available
for 96% of these EDs (See Table 6). On average, the EDs
perform 8.69 (s.d. 2.59) of the ten components measured
here, with 66% of the EDs performing all of the
recommended components. The components of the exam
that are performed less frequently are: obtaining an
informed consent (78%), taking photographs of the injuries
(78%), making a body map of the injuries (83%), collecting
fingernail scrapings (86%) and collecting the victim’s

blood for type and DNA screening (89%). All of the other
components are performed by at least 90% of the EDs.
Table 5
Services Routinely Offered to Sexual Violence Victims
Offered By1:
Type of Service
Hospital Outside
Agency
Not
Offered
Medical Care
Follow-up phone call within 48 hours 16 30 54
Emergency contraception 87 3 10
HIV testing 82 12 6
Prophylactic HIV treatment 63 20 17
STD testing 97 0 3
Prophylactic STD treatment 97 0 3
Pregnancy test 97 0 3
Mental health assessment 70 26 4
Blood and urine screening for date rape
drugs
69 14 17
Screening for the presence of drugs or
alcohol
97 3
Personnel

Forensic Nurse Examiner available to all
victims
41 14 46
Rape crisis advocate/companion in the
room with the victim during the
examination
36 39 25
Rape crisis advocate/companion
available to meet with the victim
18 62 20
Comfort Care
A place for the victim to shower after
the exam
59 0 41
Fresh clothing for the victim 68 5 27
Referrals
Referral to a local rape/sexual assault
center
68 20 12
Referral for safe housing 59 34 7
Referral for follow-up counseling 73 23 3
1Services offered by an outside agency may or may not be
offered in
the ED setting.

Table 6
Components of the Sexual Assault Exam
N=51
Component
% performing
this component
Obtaining written consent from the victim 78
Taking photographs of the injuries 78
Making a body map of the injuries 83
Collecting fingernail scrapings 86
Collecting the victim’s blood for type and DNA screening 89
Examining the orifices involved for trauma and to collect
sperm/seminal fluid
90
Combing pubic hair for foreign hair and matter 90
Collecting torn or stained clothing 90
Getting an assault history of the current assault 95
Obtaining pertinent medical information about current
pregnancy status
97

Emergency Department’s Self-Rating of Performance in
Assisting Victims
The EDs were asked to rate themselves on how they
performed on various aspects of assisting victims (the
rating scale went from 1-5, where 1 was poor and 5 was
excellent). The majority of the EDs rate themselves as
somewhere between good and very good (average score
3.72/5.00) in treating victims of sexual violence (See Table
7). The ED’s generally rate themselves better in areas such
as preserving the victims confidentiality, making the victim
comfortable, and working with the police. They tend to
rate themselves less positively on training staff and
screening patients. They are also less sure of their
performance when it comes to assisting families of the
victims and working with the local rape crisis centers.
Table 7
Self-Rating of Performance in Treating Victims
% Rating themselves as:
Type of Assistance Excellent /
Very Good
Good Fair or
Poor
Training to staff on how to assist
victims
36 26 38

Screening patients for sexual assault and
rape
35 28 37
Assisting the families of victims 57 19 24
Working with the local rape crisis center 62 18 20
Collecting evidence from victims 72 11 17
Working with patients victimized by
intimate partners
54 27 18
Working with the police 79 14 7
Making victims feel as comfortable as
possible
67 22 9
Preserving the confidentiality of the
victim
91 5 4
DISCUSSION
Summary of Findings
This study provides a summary of services available
to victims of sexual violence at emergency departments
(EDs) in the Commonwealth of Virginia. In general, this
study finds that the EDs generally provide needed medical
services to victims. However, less than half are
consistently doing so with specially trained personnel (e.g.
forensic nurses) and the majority are not training their

medical staff about victims of sexual violence on a regular
basis. This study also finds that the EDs are not
consistently screening their patients for violence
victimization (particularly men) and may be missing an
opportunity to assist some victims. Further, this study finds
that the EDs are not all well situated to provide the full
level of services needed by victims (such as counseling
from a rape crisis center and evidence collection by a
trained nurse) and that many lack necessary linkages to
other services that care for victims.
Implications for Policy and Practice
In order to ensure consistent, high quality care for
victims of sexual violence in Virginia, standard protocols
for the treatment of victims and the training of medical staff
need to be established. While the great majority of EDs
have written protocols, little is known about their contents
or how consistent they are between EDs. The General
Assembly should consider supporting the Virginia
Department of Health (VDH), rape crisis centers and
representatives from the EDs to establish model written
protocols and training materials. These protocols and
training models should be based upon the strong models
that currently exist in a number of the EDs in Virginia.
These protocols need to include policies regarding
screening for sexual violence victimization in the ED.
Currently, the screening policies are varied across EDs, and
it is likely that many victims are not being identified and
thus not receiving all of the care that they need.

Once identified, victims of sexual violence need
access to forensic (SANE) nurses and trained staff, both to
optimize their own medical care and to ensure the proper
collection of evidence for the potential prosecution of the
perpetrator. About half of the EDs in Virginia currently
offer consistent access to forensic (SANE) nurses, and the
funding for forensic nursing programs in individual EDs is
currently declining. Within the Commonwealth, there are
several models of providing this access that need further
exploration. One model is to have forensic nurses
employed at each hospital and on-call 24 hours a day.
Another model is to share forensic nurses between several
hospitals (e.g. ‘floating’ nurses). A third model is to
designate a single hospital in each city/county as the
forensic hospital, and refer all patients to that hospital. It is
currently unknown how well each of these models works to
provide comprehensive care and good evidence collection
for victims and studies are needed.
Victims also are likely to need post-hospital care
(both medical and psycho-social). In order to provide the
full basket of services needed by victims, EDs need to be
linked to other agencies, such as rape crisis centers and law
enforcement. A significant minority of EDs (23%) do not
have any linkages with rape crisis centers, and less than
half (40%) participate on a community-wide SART. The
Virginia Department of Health and the community-based
rape crisis centers may need to approach the EDs to build
these linkages. It will likely take efforts at the General
Assembly level to establish SARTs in every community. It
is worth noting that many models for partnership with the
rape crisis centers, and for SARTs, currently exist within

Virginia that may be worth replicating.
Limitations
This study raised almost as many questions as it
answered. In particular, this study did not measure any
aspects of the quality of care from the victim’s perspective.
The study relied on hospital self-report, and no attempt was
made to externally validate any of the reported data. Also,
the reported figures of the number of victims served are
estimates made by the survey respondent (this data is not
collected in any systematic way across the ED’s in
Virginia). Further, this study is based in Virginia, and may
or may not generalize to other regions. Finally, this study
focused only on services available to adolescent and adult
victims and does not provide any information about
services available to victims age 12 and under.
Future Research
The limitations of this study highlight the critical
need for research in this area. Little is known about the
provision of services to victims of sexual violence through
the health care setting and studies that examine the quality
of care from the viewpoint of the victim are especially
lacking. These studies will be difficult to conduct, as they
obviously need to be planned with great care and concern
for the psychological and physical well-being of the victim.
Another critical need is to examine the effectiveness of
different models of providing emergent care to victims.

Studies are just beginning to be published regarding the
potential benefits of a trained forensic (SANE) nurse and of
hospital based teams. Little work has been done that
explores other models of care, such as hospital participation
on a Sexual Assault Response Team. No studies could be
found that explored the effectiveness of a hospital systems
designating one hospital as the care center for all victims
within a region. Solid data about the number of victims that
present to the emergency department and other health care
sources is also needed. Since the majority of the EDs do
not screen most patients for sexual violence victimization,
it is likely that the estimates provided here are undercounts
of the true number of victims that present each year.
Finally, it is important to have studies on services available
to victims of sexual violence be conducted nation-wide to
obtain a true picture of what is available to those harmed by
sexual violence who are seeking help from the health care
system.
NOTES
We would like to thank the Virginia General Assembly for
its vision and leadership on behalf of victims of sexual
violence. In 2004, they passed Senate Joint Resolution
131, directing the Virginia Department of Health to provide
them with recommendations for how to improve services to
victims across legal, social service, sexual assault crisis and
medical services. Subsequently, this study was funded by
the Virginia Department of Health, and we would like to
express our appreciation to them for choosing us to engage
in this work. Finally, we would like to thank our phone
interviewer, Addie Magnant, for her persistent and cheerful

efforts to obtain responses from as many of the emergency
departments as possible.
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24 JPNoNliNe.com

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.
26 JPNoNliNe.com
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
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.
28 JPNoNliNe.com
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.
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
30 JPNoNliNe.com
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
[email protected]
We’re waiting to hear from you!
k E Y P o i n t s
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.
Solution
s 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.
rEfErEncEs
Aguilera, D.C. (1998). Crisis intervention the-
ory and methodology (8th ed.). St. Louis:
Mosby.
Bartels, S. (2004). Caring for the whole

person: Integrated health care for older
adults with severe mental illness and
medical comorbidity. Journal of the
American Geriatrics Society, 52, 249-257.
Binder, R.L., & McNiel, D.E. (1999). Emer-
gency psychiatry: Contemporary practic-
es in managing acutely violent patients
in 20 psychiatric emergency rooms. Psy-
chiatric Services, 50, 1553-1554.
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.
Crowley, J. (2000). A clash of cultures:

A & E and mental health. Accident and
Emergency Nursing, 8, 2-8.
Emergency Nurses Association. (2006).
Emergency Nurses Association po-
sition statement: Violence in the
emergency care setting. Retrieved
March 28, 2008, from http://www.
e n a . o r g / a b o u t / p o s i t i o n / P D F s /
45BFF88286AF4167B3C59D4A
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Erickson, L., & Williams-Evans, S.A. (2000).
Attitudes of emergency nurses regarding
patient assaults. Journal of Emergency
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Goldblatt, J. (2005, January 11). Mental
health patients find little help in Dela-
ware. The News Journal, pp. F1, F3.
Lewis, C., Sierzega, G., & Haines, D. (2005).
The creation of a behavioral health unit
as part of the emergency department:

One community hospital’s two-year ex-
perience. Journal of Emergency Nursing,
31, 548-554.
National Coalition for the Homeless. (2006).
Mental illness and homelessness (Fact sheet
#5). Washington, DC: Author.
National Mental Health Association. (2004,
April 27). Emergency departments see dra-
matic increase in people with mental illness
seeking care. Retrieved March 28, 2008,
from http://www1.nmha.org/newsroom/
system/news.vw.cfm?do=vw&rid=601
Quintal, S.A. (2002). Violence against
nurses: An untreated epidemic? Journal
of Psychosocial Nursing and Mental Health
Services, 40(1), 46-53.
Summers, M., & Happell, B. (2003). Patient
satisfaction with psychiatric services pro-
vided by a Melbourne tertiary hospital
emergency department. Journal of Psy-
chiatric and Mental Health Nursing, 10,

351-357.
Torrey, F. (1997). Out of the shadows: Con-
fronting America’s mental illness crisis.
New York: Wiley & Sons.
Tyrell, A.M., Winters, J., & Goldsworth, J.
(2003). Development and implementa-
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emergency psychiatric patient outcomes
[Abstract]. Journal of Emergency Nursing,
29, 421.
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: [email protected]
christianacare.org; or Rose Brownstein,
RN II, BC, 16 Riverview Avenue,
Chesapeake City, MD 21915; e-mail:
[email protected]
32 JPNoNliNe.com

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