Management of Agitation During the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic caused by the coronavirus SARS-CoV-2 has radically altered delivery of care in emergency settings. Unprecedented hardship due to ongoing fears of exposure and threats to personal safety, along with societal measures enacted to curb disease transmission, have had broad psychosocial impact on patients and healthcare workers alike. These changes can significantly affect diagnosing and managing behavioral emergencies such as agitation in the emergency department. On behalf of the American Association for Emergency Psychiatry, we highlight unique considerations for patients with severe behavioral symptoms and staff members managing symptoms of agitation during COVID-19. Early detection and treatment of agitation, precautions to minimize staff hazards, coordination with security personnel and psychiatric services, and avoidance of coercive strategies that cause respiratory depression will help mitigate heightened risks to safety caused by this outbreak.

A dynamic baseline for dissolved methane in English groundwater

Elevated dissolved methane (CH₄) concentrations in groundwater are an environmental concern associated with hydraulic fracturing for shale gas. Therefore, determining dissolved CH₄ baselines is important for detecting and understanding any potential environmental impacts. Such baselines should change in time and space to reflect ongoing environmental change and should be able to predict the probability that a change in dissolved CH₄ concentration has occurred. We considered four dissolved CH₄ concentration datasets of English groundwater using a Bayesian approach: two national datasets and two local datasets from shale gas exploration sites. The most sensitive national dataset (the previously published British Geological Survey CH₄ baseline) was used as a strong prior for a larger (2153 measurements compared to 439) but less sensitive (detection limit 1000 times higher) Environment Agency dataset. The use of the strong prior over a weak prior improved the precision of the Environment Agency dataset by 75%. The expected mean dissolved CH₄ concentration in English groundwater based on the Bayesian approach is 0.24 mg/l, with a 95% credible interval of 0.11 to 0.45 mg/l, and a Weibull distribution of W(0.35 ± 0.01, 0.34 ± 0.16). This result indicates the amount of CH₄ degassing from English groundwater to the atmosphere equates to between 0.7 and 3.1 kt CH₄/year, with an expected value of 1.65 kt CH₄/year and a greenhouse gas warming potential of 40.3 kt CO₂eq/year. The two local monitoring datasets from shale gas exploration sites, in combination with the national datasets, show that dissolved CH₄ concentrations in English groundwater are generally low, but locations with concentrations greater than or equal to the widely used risk action level of 10.0 mg/l do exist. Statistical analyses of groundwater redox conditions at these locations suggest that it may be possible to identify other locations with dissolved CH₄ concentrations ≥10.0 mg/l using redox parameters such as Fe concentration.

Managing Delirium and Agitation in the Older Emergency Department Patient: The ADEPT Tool

Agitation and delirium are common reasons for older adults to seek care in the emergency department (ED). Providing care for this population in the ED setting can be challenging for emergency physicians. There are several knowledge translation gaps in how to best screen older adults for these conditions and how to manage them. A working group of subject-matter experts convened to develop an easy-to-use, point-of-care tool to assist emergency physicians in the care of these patients. The tool is designed to serve as a resource to address the knowledge translation and implementation gaps that exist in the field. The purpose of this article is present and explain the Assess, Diagnose, Evaluate, Prevent, and Treat tool. Participants were identified with expertise in emergency medicine, geriatric emergency medicine, geriatrics, and psychiatry. Background literature reviews were performed before the in-person meeting in key areas: delirium, dementia, and agitation in older adults. Participants worked electronically before and after an in-person meeting to finalize development of the tool in 2017. Subsequent work was performed electronically in the following months and additional expert review sought. EDs are an important point of care for older adults. Behavioral changes in older adults can be a manifestation of underlying medical problems, mental health concerns, medication adverse effects, substance abuse, or dementia. Five core principles were identified by the group that can help ensure adequate and thorough care for older adults with agitation or delirium: assess, diagnose, evaluate, prevent, and treat. This article provides background for and explains the importance of these principles related to the care of older adults with agitation. It is important for emergency physicians to recognize the spectrum of underlying causes of behavioral changes and have the tools to screen older adults for those causes, and methods to treat the underlying causes and ameliorate their symptoms.

EXCITATION study: Unexplained in-custody deaths: Evaluating biomarkers of stress and agitation

BACKGROUND

Law enforcement personnel often confront violent and dangerous individuals suffering from Excited Delirium Syndrome (ExDS) who need emergent medical evaluation and treatment to optimize the best outcomes for this potentially lethal medical emergency. These subjects typically require physical restraint and use of force measures to control them. We sought to determine if stress-related biomarkers can differentiate ExDS subjects when compared with agitation and stress under other circumstances, including agitation and extreme physical exhaustion and restraint coupled with emotional stressors.

METHODS

This was a prospective multi-center study enrolling a convenience sample of patients who presented with agitation or ExDS. Patients were enrolled from three academic emergency departments (ED), two in the United States and one in Canada. Three study groups (SG) included: SG1) patients brought to the ED with ExDS based on the use of standardized clinical criteria; SG2) ED patients with acute agitation who were not in a clinical state of ExDS but required sedation; SG3) a laboratory control group of subjects exercised to physical exhaustion, restrained, and psychologically stressed with threat of Conducted Energy Device (CED) activation. We examined a panel of stress-related biomarkers, including norepinephrine (NE), cortisol, copeptin, orexin A, and dynorphin (Dyn) from the blood of enrolled subjects.

RESULTS

A total of 82 subjects were enrolled: 31 in the agitation group, 21 in the ExDS group, and 30 in the laboratory control group. Data were analyzed, comparing the findings between ExDS and the two other groups to determine if specific stress-related biomarkers are associated with ExDS. Biomarker comparisons between subjects identified with ExDS, agitation, and control groups demonstrated that cortisol levels were more elevated in the ExDS group compared with the other groups. Orexin was only significant in ExDs (with Agitated tendency but lot of variability in the group). NE and Dyn increased as response to stress in Agitated and ExDS.

CONCLUSIONS

Cortisol levels were more elevated in subjects in the ExDS group compared with the other comparison groups and orexin was elevated in ExDS compared to controls, a trend that did not reach statistical significance in the agitated group. The clinical or diagnostic significance of these difference have yet to be defined and warrants further study.

The utility of a statewide prescription drug-monitoring database vs the Current Opioid Misuse Measure for identifying drug-aberrant behaviors in emergency department patients already on opioids

BACKGROUND

The most recent guidelines on prescribing opioids from the United States Centers for Disease Control recommend that clinicians not prescribe opioids as first-line therapy for chronic non-cancer pain. If an opioid prescription is considered for a patient already on opioids, prescribers are encouraged to check the statewide prescription drug monitoring database (PDMP). Some additional guidelines recommend screening tools such as the Current Opioid Misuse Measure (COMM) which may also help identify drug-aberrant behaviors.

OBJECTIVE

To compare the PDMP and the Current Opioid Misuse Measure (COMM), a commonly-recommended screening tool for patients on opioids, in detecting drug-aberrant behaviors in patients already taking opioids at the time of ED presentation.

METHODS

Patients on opioids were enrolled prospectively in a mixed urban-suburban ED seeing approximately 65,000 patients per year. The sensitivity, specificity, likelihood ratios, and diagnostic odds ratios of the PDMP and COMM were compared against objective criteria of drug-aberrant behaviors as documented in the electronic medical record (EMR) and medical examiner databases.

RESULTS

Compared to the COMM, the PDMP had similar sensitivity (36% vs 45%) and similar specificity (79% vs 55%), but better positive predictive value, better negative predictive value, and better diagnostic odds ratio. The combination of the PDMP and the COMM did not improve the detection of drug-aberrant behaviors.

CONCLUSIONS

The PDMP alone is a more useful as a screening instrument than either the COMM or the combination of the PDMP plus COMM in patients already taking opioids at time of ED presentation. However, the PDMP misses a majority of patients with documented drug-aberrant behaviors in the EMR, and should not be used in isolation to justify whether a particular opioid prescription is appropriate.

Discontinuing involuntary mental health holds for children: Does psychiatrist specialty matter? A pilot study

BACKGROUND

Involuntary mental health detainments should only be utilized when less restrictive alternatives are unavailable and should be discontinued as soon as safety can be ensured. The study objective was to determine if child and adolescent psychiatrists discontinue a greater proportion of involuntary holds than general psychiatrists for similar pediatric patients.

METHODS

Retrospective analysis of consecutive patients under 18 years placed on an involuntary hold in the prehospital setting presenting over a 1-year period to one high-volume emergency department (ED) where youth on involuntary holds are seen by child and adolescent psychiatrists when available and general psychiatrists otherwise. The primary outcome of interest was hold discontinuation after initial psychiatric consultation. The key predictor of interest was psychiatrist specialty (child and adolescent vs. general). We conducted multivariate logistic regression modeling adjusting for patient characteristics and time of arrival.

RESULTS

Child and adolescent psychiatrists discontinued 27.4% (51/186) of prehospital holds while general psychiatrists discontinued only 10.6% (22/207). After adjusting for observable confounders, holds were over 3 times as likely to be discontinued in patients evaluated by child and adolescent psychiatrists rather than general emergency psychiatrists (adjusted OR 3.2, 95% CI 1.7-5.9, p < 0.001).

CONCLUSIONS

Child and adolescent psychiatrists are much more likely to discontinue prehospital involuntary mental health holds compared with general emergency psychiatrists. While inappropriate hold discontinuation places patients at risk of harm, prolonged hold continuation limits patients' rights and potentially increases psychiatric boarding in EDs. Earlier access to child and adolescent psychiatry may facilitate early hold discontinuation and standardize patient care.

Screening Tools Validated in the Outpatient Pain Management Setting Poorly Predict Opioid Misuse in the Emergency Department: A Pilot Study

BACKGROUND

Currently, no universally accepted methods exist to assess drug-related aberrant behaviors in emergency department (ED) patients. There are several screening tools to identify opioid misuse in patients with chronic pain, however, the validity of these screening tools to assess for misuse within the ED remains unclear.

OBJECTIVES

This study investigated the effectiveness of three commonly used screening tools, previously validated in outpatient pain management settings, to assess risk of opioid misuse in ED patients.

METHODS

This was a prospective observational study of 154 participants (median age 50 years; 49.6% female) presenting to an academic ED for a chief complaint of pain ≥ 6 months or an opioid refill request. Participants completed the Opioid Risk Tool, the Screener and Opioid Assessment for Patients with Pain-Revised, and the Current Opioid Misuse Measure. Scores for each were compared with electronic medical record (EMR) data alone or a reference standard comprising EMR + statewide prescription drug monitoring program (PDMP) + medical examiner database.

RESULTS

Using the combined reference standard, 55.8% of participants displayed at least one aberrant behavior. Regardless of the reference standard, the test characteristics of these screening tools were modest at best, with likelihood ratios close to 1.

CONCLUSION

Three screening tools previously validated in outpatient pain management settings poorly categorized risk among ED patients with chronic noncancer pain or requests for opioid refills, and should not be used to assess drug-aberrant behaviors in the ED. Review of the EMR alone or together with the PDMP may be more useful methods to assess drug-aberrant behaviors in the ED setting.

Study Enrollment When "Preconsent" Is Utilized for a Randomized Clinical Trial of Two Treatments for Acute Agitation in the Emergency Department

BACKGROUND

Acute agitation in the emergency department (ED) represents a danger to both patients and their caregivers. Medication is often needed, and few high-quality randomized trials have evaluated the optimal drugs for this vulnerable population. In the United States, as of 2017, randomized trials of drugs typically cannot be conducted under Waiver of Consent (46 CFR 45.116), and Exception From Informed Consent trials (21 CFR 50.24) are limited to life-threatening conditions, are onerous, and require filing an investigational new drug application with the FDA. We sought to conduct a randomized double-dummy trial of inhaled loxapine versus intramuscular haloperidol + lorazepam for acute agitation in the ED by obtaining consent in advance ("preconsent") in patients at risk of future agitation, allowing study drug administration up to 3 years later if the patient presented with acute agitation.

OBJECTIVE

We sought to report the successful enrollment rate of patients preconsented at an earlier ED visit for this trial.

METHODS

This was an analysis of patients age 18 to 64 with bipolar I disorder or schizophrenia preconsented for enrollment in the trial (clinicaltrials.gov, NCT02877108) conducted at a single urban academic center seeing approximately 60,000 patients per year. Eligible patients were assessed for capacity to consent by trained research associates, and informed consent was obtained at an ED visit for the possibility of administering drugs for agitation within the next 3 years. In the event the patient later presented to the ED and the attending physician deemed the patient required treatment for acute agitation, preconsent was confirmed and study drug would be administered.

RESULTS

Over 67 days, 1,461 patients were screened in the ED, 269 had bipolar I or schizophrenia, 194 of whom had a contraindication to inhaled loxapine leaving 75 eligible patients; preconsent was obtained in 43 patients. Four additional patients who had not preconsented were consented for the trial in real time (three by surrogate, one patient had capacity while agitated) resulting in a total of 47 consented patients. Of these 47, a total of 12 were later removed from the study: 10 patients had unrecognized exclusion criteria for inhaled loxapine, one preconsented patient contacted the investigators at a later date and asked to be removed, and one surrogate revoked consent immediately after providing it. Only two patients were successfully enrolled, neither by preconsent: one was enrolled via a surrogate the day of enrollment, and the other was mildly agitated and had capacity to consent. The remaining patient with a valid surrogate consent did not receive study medication.

CONCLUSIONS

Utilization of preconsent to enroll patients in a randomized trial of treatments for acute agitation in the ED requires substantial resources and may not be feasible.

Cryptococcal Meningoencephalitis Presenting as a Psychiatric Emergency

BACKGROUND

Organic conditions can often mimic neuropsychiatric disorders, leading to delays in diagnosis and treatment for the most vulnerable populations presenting to the emergency department (ED).

CASE REPORT

Here we discuss a case of cryptococcal meningoencephalitis seemingly consistent with psychosis on initial evaluation, and present strategies to recognize and treat this condition. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Due to the indolent time course of this disease, initial symptoms of altered mental status and personality changes may be attributed to drug use or psychiatric illness before more overt evidence for increased intracranial pressure and neurologic infection develops. It is important for emergency clinicians to maintain a high level of suspicion for this condition in at-risk patients and reassess them frequently during their ED visit.

Opportunities for Research in Mental Health Emergencies: Executive Summary and Methodology

Introduction

Despite the ever-increasing numbers of mental health patients presenting to United States emergency departments, there are large gaps in knowledge about acute care of the behavioral health patient. To address this important problem, the Coalition on Psychiatric Emergencies convened a research consensus conference in December 2016 consisting of clinical researchers, clinicians from emergency medicine, psychiatry and psychology, and representatives from governmental agencies and patient advocacy groups.

Methods

Participants used a standardized methodology to select and rank research questions in the order of importance to both researchers and patients.

Results

Three working groups (geriatrics, substance use disorders, and psychosis) reached consensus on 26 questions within their respective domains. These questions are summarized in this document.

Conclusion

The research consensus conference is the first of its kind to include non-clinicians in helping identify knowledge gaps in behavioral emergencies. It is hoped that these questions will prove useful to prioritize future research within the specialty.

Identifying groundwater compartmentalisation for hydraulic fracturing risk assessments

An environmental concern with hydraulic fracturing (fracking) is that injected fluids or formation fluids could migrate upwards along high-permeability faults and contaminate shallow groundwater resources. However, numerical modelling has suggested that compartmentalisation by low-permeability faults may be a greater risk factor to shallow aquifers than high-permeability faults because lateral groundwater flow is reduced and upward flow through strata may be encouraged. Therefore, it is important that compartmentalisation can be adequately identified prior to fracking. As a case study we used historical groundwater quality data and two-dimensional seismic reflection data from the Bowland Basin, northwest England, to investigate if compartmentalisation could be adequately identified in a prospective shale basin. Five groundwater properties were spatially autocorrelated and interpolation suggests a regional trend from recent (<10 000 years old) meteoric groundwater in the upland Forest of Bowland to more brackish groundwater across the Fylde plain. Principal components analysis suggests two end-member brackish groundwater types. These end-members along with seismic interpretation suggest that a fault may structurally compartmentalise the northwest Bowland Basin. Furthermore, the Woodsfold fault structurally compartmentalises the southern Fylde and the Blackpool area provides evidence for stratigraphic compartmentalisation in the superficial deposits. However, large areas of the Bowland Basin are not sampled and the influence of known faults on groundwater is therefore difficult to assess. Consequently, the adequate identification of compartmentalisation in prospective basins may require supplementing historic data with dedicated basin-wide groundwater monitoring programmes and the acquisition of new seismic reflection data in areas of poor coverage or quality.

Emergency Medicine Research Priorities for Early Intervention for Substance Use Disorders

Introduction

Patients with substance use disorders (SUDs) frequently seek emergency care, and the emergency department (ED) may be their only point of contact with the healthcare system. While the ED visit has been increasingly recognized as providing opportunity for interventions around substance use, many questions remain.

Methods

In December 2016 the Coalition on Psychiatric Emergencies (CPE) convened the first Research Consensus Conference on Acute Mental Illness, which consisted of clinical researchers, clinicians from emergency medicine, emergency psychiatry, emergency psychology, representatives from governmental agencies and patient advocacy groups. Background literature review was conducted prior to the meeting, and questions were iteratively focused, revised, voted on and ranked by perceived importance using nominal group method.

Results

The main goal of the SUD workgroup was to identify research priorities and develop a research agenda to improve the early identification of and management of emergency department (ED) patients with SUDs with the goal of improving outcomes. This article is the product of a breakout session on “Special Populations: Substance Use Disorder.” The workgroup identified with high consensus six research priorities for their importance related to the care of ED patients with SUDs in these overall domains: screening; ED interventions; the role of peer navigators; initiation of SUD management in the ED; specific patient populations that may impact the effectiveness of interventions including sociogenerational and cultural factors; and the management of the acutely intoxicated patient.

Conclusion

Emergency providers are increasingly recognizing the important role of the ED in reducing adverse outcomes associated with untreated SUDs. Additional research is required to close identified knowledge gaps and improve care of ED patients with SUD.

A Research Agenda for the Assessment and Management of Acute Behavioral Changes in Elderly Emergency Department Patients

Introduction

Agitation, mental illness, and delirium are common reasons for older adults to seek care in the emergency department (ED). There are significant knowledge gaps in understanding how to best screen older adults for these conditions and how to manage them. In addition, in areas where research has been performed, implementation has been slow. A working group convened to develop a set of high-priority research questions that would advance the understanding of optimal management of older adults with acute behavioral changes in the ED. This manuscript is the product of a breakout session on "Special Populations: Agitation in the Elderly" from the 2016 Coalition on Psychiatric Emergencies' first Research Consensus Conference on Acute Mental Illness.

Methods

Participants were identified with expertise in emergency medicine (EM), geriatric EM, and psychiatry. Background literature reviews were performed prior to the in-person meeting in four key areas: delirium; dementia; substance abuse or withdrawal; and mental illness in older adults. Input was solicited from all participants during the meeting, and questions were iteratively focused and revised, voted on, and ranked by importance.

Results

Fourteen questions were identified by the group with high consensus for their importance related to the care of older adults with agitation in the ED. The questions were grouped into three topic areas: screening and identification; management strategies; and the approach to delirium.

Conclusion

It is important for emergency physicians to recognize the spectrum of underlying causes of behavioral changes, have the tools to screen older adults for those causes, and employ methods to treat the underlying causes and ameliorate their symptoms. Answers to the identified research questions have great potential to improve the care of older adults presenting with behavioral changes.

Telephoned, Texted, or Typed Out: A Randomized Trial of Physician-Patient Communication After Emergency Department Discharge

BACKGROUND

Novel means of emergency department (ED) post-discharge communication-telephone callbacks and text messages-are increasingly being utilized to facilitate patient-oriented outcomes, such as ED revisits, patient adherence, and satisfaction.

OBJECTIVE

The primary measure of interest is the rate of ED revisits in the week after discharge. The secondary measures of interests are rate of primary medical doctor (PMD) or specialist physician contact in the week after discharge and patient satisfaction.

METHODS

Pilot randomized controlled trial with three groups: usual discharge; usual care + phone call 48 h after discharge asking if patients wanted to speak with a physician; or usual care + text message 48 h after discharge asking if patients wanted to speak with a physician. All participants received a 1-week assessment of patient satisfaction. ED revisit and contact with PMD or specialist physician within 7 days of discharge were obtained from electronic medical record and analyzed using χ² test.

RESULTS

Two hundred and fifty-one patients were enrolled and randomized (66 control, 103 phone, 82 text). Although the three groups did not show a statistically significant difference, the phone and text groups had similar and lower proportions of patients revisiting the ED (>50% reduction) and calling or visiting their PMD or specialist physician (approximately 30% reduction) than the control group (χ² = 4.57, degrees of freedom [df] = 2, p = 0.10; χ² = 1.36, df = 2, p = 0.51). There was no difference in patient satisfaction (χ² = 2.88, df = 2, p = 0.24).

CONCLUSIONS

Patients who are contacted for ED follow-up by phone and text, though perhaps not more satisfied, may tend to revisit the ED and contact their PMD or specialty physician less often than patients receiving standard written discharge instructions. However, this pilot study is underpowered, so larger randomized studies are needed to confirm.

Safety of Risperidone for Acute Agitation and Alcohol Intoxication in Emergency Department Patients

BACKGROUND

Acute agitation in the setting of alcohol intoxication is commonly encountered in the Emergency Department (ED). In this setting, expert consensus guidelines recommend haloperidol over second-generation antipsychotics due to their limited safety data in alcohol intoxication.

OBJECTIVE

The primary objective was to compare vital sign changes prior to and after risperidone administration between ED patients presenting with alcohol intoxication [ETOH (+)] and without alcohol intoxication [ETOH (-)]. The secondary objective was to assess the effect of benzodiazepine co-administration with risperidone on vital signs.

METHODS

This was a retrospective chart review of patients who received oral risperidone for acute agitation at two university EDs between January 1, 2012 and December 31, 2015. Vital signs (oxygen saturation, systolic and diastolic blood pressure, heart rate, and respiratory rate) were compared in patients who had ingested alcohol with those who had not.

RESULTS

There were 785 patients without evidence of alcohol intoxication who received risperidone in the ED, and 52 patients with alcohol intoxication who received risperidone. Overall, risperidone with and without alcohol intoxication and benzodiazepine administration had no statistically significant effect on vital signs (p = ns for all comparisons).

CONCLUSION

This study suggests that oral risperidone may be a safe option for acute agitation in patients presenting to the ED with alcohol intoxication.

Suicide screening scales may not adequately predict disposition of suicidal patients from the emergency department

BACKGROUND

Suicide screening scales have been advocated for use in the ED setting. However, it is currently unknown whether patients classified as low-risk on these scales can be safely discharged from the emergency department. This study evaluated the utility of three commonly-used suicide screening tools in the emergency department to predict ED disposition, with special interest in discharge among low-risk patients.

METHODS

This prospective observational study enrolled a convenience sample of patients who answered "yes" to a triage suicidal ideation question in an urban academic emergency department. Patients were administered the weighted modified SADPERSONS Scale, Suicide Assessment Five-step Evaluation and Triage, and Columbia-Suicide Severity Rating Scale. Patients who subsequently received a psychiatric evaluation were included, and the utility of these screening tools to predict disposition was evaluated.

RESULTS

276 subjects completed all three suicide screening tools and were included in data analyses. Eighty-two patients (30%) were admitted or transferred. Three patients (1%) died by suicide within one year of enrollment; one was hospitalized at the end of his or her enrollment visit, dying by suicide seven months later and the other two were discharged, dying by suicide nine and ten months later, respectively. The screening tools exhibited modest negative predictive values (range: 0.66-0.73).

CONCLUSION

Three suicide screening tools displayed modest ability to predict the disposition of patients who presented to an emergency department with suicidal ideation. This study supports the current ACEP clinical policy on psychiatric patients which states that screening tools should not be used in isolation to guide disposition decisions of suicidal patients from the ED.

Health Care Usage and Suicide Risk Screening within 1 Year of Suicide Death

BACKGROUND

Research indicates patients often seek medical care within 1 year of suicide. Health care encounters are a crucial opportunity for health professionals to identify patients at highest risk and provide preventative services.

OBJECTIVE

Study aims were to determine the characteristics of persons seeking health care within 12 months of suicide death and evaluate suicide risk screening (SRS) frequency in the emergency department (ED) vs. clinic settings.

METHODS

Medical examiner and hospital data of patients who died by suicide from 2007 to 2013 were evaluated. Descriptive analyses included demographics and frequency of ED vs. clinic visits. We also compared SRS before and after implementation of The Joint Commission's recommendation to assess suicide risk.

RESULTS

The 224 deceased patients were primarily single white males (mean age 67 years). Mental health issues, substance abuse, and prior suicide attempts were present alone or in combination in 74%. Visits were primarily behavioral health or substance abuse problems in the ED, and medical issues in the clinic. After implementation of universal SRS in the ED, screening increased from 39% to 92%. Among patients screened in the ED, 73% (37 of 51) screened negative for suicide risk.

CONCLUSIONS

Universal SRS increased the number of people screened in the ED. However, negative SRS may not equate to reduced risk for future suicide within 1 year. Future studies might investigate targeted screening of individuals with known suicide risk factors, as well as alternatives to patient self-report of intent to self-harm for patients with mental health or substance abuse problems.

Risperidone in the Emergency Setting is Associated with More Hypotension in Elderly Patients

BACKGROUND

Expert consensus panels have recommended risperidone as first-line treatment for agitation of psychiatric origin. However, there are few if any studies on this medication in the emergency setting.

OBJECTIVES

To assess the hemodynamic effects of risperidone in an emergency department (ED) setting, stratified by age.

METHODS

This is a structured chart review of all patients who received oral risperidone over a 6-year period in an ED setting, excluding patients who received this medication as a prescription refill. Vital signs were analyzed for this subset prior to and after medication administration, and changes in vital signs were stratified by age.

RESULTS

The median dose of risperidone was less in patients aged > 65 years. However, the median drop in systolic blood pressure was larger in this age group compared with younger patients.

CONCLUSIONS

Clinicians tend to be more cautious with dosing of risperidone to geriatric patients in the ED. Despite this, decreases in systolic blood pressure are larger and more frequent in this age group. When possible, clinicians should consider or attempt nonpharmacologic methods of agitation treatment prior to administering medications such as risperidone to elderly patients.