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Williams K, French A, Jackson N, McMickens CL, White D, Vinson SY. Mental Health Crisis Responses and (In)Justice: Intrasystem and Intersystem Implications. Psychiatr Clin North Am 2024; 47:445-456. [PMID: 39122339 DOI: 10.1016/j.psc.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2024]
Abstract
Mental health crises among people who are marginalized merit special consideration. These groups are both overserved and underserved by mental health crisis systems: over-represented in acute treatment settings by number while facing inequities in outcomes. The predisposing, precipitating, and perpetuating factors that contribute to crises, however, neither begin nor end with the mental health system. Rather, these factors are multisystemic. As an illustration of this concept, this article highlights select marginalized groups, those that have faced inequities in mental health diagnosis and treatment due to race, medical complexity, age, and criminal justice system involvement.
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Affiliation(s)
- Kamille Williams
- Department of Psychiatry and Behavioral Sciences, Morehouse School of Medicine, 720 Westview Drive Southwest, Atlanta, GA 30310, USA.
| | - Alexis French
- Department of Psychiatry and Behavioral Sciences, Duke University, 2608 Erwin Road, Durham, NC 27705, USA
| | - Nicole Jackson
- Lorio Forensics, 675 Seminole Avenue Northeast, Atlanta, GA 30307, USA
| | - Courtney L McMickens
- Department of Psychiatry and Behavioral Sciences, Duke University, 2608 Erwin Road, Durham, NC 27705, USA; Lorio Forensics, 675 Seminole Avenue Northeast, Atlanta, GA 30307, USA
| | - DeJuan White
- Department of Psychiatry and Behavioral Sciences, Emory University, 12 Executive Park Drive Northeast, Atlanta, GA 30329, USA
| | - Sarah Y Vinson
- Department of Psychiatry and Behavioral Sciences, Morehouse School of Medicine, 720 Westview Drive Southwest, Atlanta, GA 30310, USA; Lorio Forensics, 675 Seminole Avenue Northeast, Atlanta, GA 30307, USA; Department of Psychiatry and Behavioral Sciences, Emory University, 12 Executive Park Drive Northeast, Atlanta, GA 30329, USA
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Wang Y, Wang X, Bi M, Mou P, Zhang R, Zhang C, Li S, Jiang M, Mi L, Li Z. Patterns and characteristics of visits to psychiatric emergency departments: a three-year data study in China. Eur Arch Psychiatry Clin Neurosci 2024:10.1007/s00406-024-01881-1. [PMID: 39217591 DOI: 10.1007/s00406-024-01881-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 08/13/2024] [Indexed: 09/04/2024]
Abstract
The composition and characteristics of emergency patients in the Affiliated Brain Hospital, Guangzhou Medical University during 2020-2022 were retrospectively analyzed to provide data support for the optimization of the process of psychiatric emergency and the elastic allocation of emergency medical staff. This study collected data from patients who sought medical attention at the emergency department of the Affiliated Brain Hospital, Guangzhou Medical University between January 1, 2020, and December 31, 2022. The fundamental information of these patients was statistically analyzed using descriptive analytic methods. In addition, a comprehensive statistical analysis was performed on the data of patient visits, which included precise triage time points, months, and seasons, in order to evaluate the temporal distribution of patient visits. The patient population had an average age of 36.4 years and was slightly more female (54.08%). The mean age of the male and female patients was 36.4 ± 18.91 and 36.4 ± 16.80 years, respectively. There was no statistically significant age difference between the male and female patients (p > 0.05). The top five diseases were mental disorder (6,483 cases), bipolar disorder (3,017 cases), depressive episode (2522 cases), schizophrenia (1778 cases) and anxiety state (1097 cases), accounting for 35.63%, 16.58%, 13.86%, 9.77% and 6.03% of the total, respectively. Additionally, a notable record of psychiatric drug intoxication was noted. Significant comorbidity with physical disorders, such as hypertension (9.36%), hypokalemia (3.41%), diabetes (2.83%), and cerebral infarction (2.79%), was also seen. The results of seasonal and monthly analysis indicated that emergency attendance patterns fluctuated, peaking in the spring and fall. The patterns of daily visits also revealed two peak times. The first peak occurs from 8:00 to 10:00, and the second peak occurs from 14:00 to 16:00. This study emphasizes the increasing occurrence of mental problems in psychiatric crises, particularly among younger populations, underscoring the necessity for comprehensive care methods. Specialized treatment methods and collaborative networks are required to address the substantial prevalence of psychiatric medication poisoning. Efficient allocation of resources and heightened security protocols are vital in emergency departments, particularly during periods of high demand and in handling instances of patient hostility.
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Affiliation(s)
- Youping Wang
- Department of Emergency Medicine, National Clinical Key Specialty, The Affiliated Brain Hospital, Guangzhou Medical University, Guangzhou, 510370, China
- Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou Medical University, Guangzhou, 510370, China
| | - Xida Wang
- Department of Emergency Medicine, National Clinical Key Specialty, The Affiliated Brain Hospital, Guangzhou Medical University, Guangzhou, 510370, China
- Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou Medical University, Guangzhou, 510370, China
| | - Mingfeng Bi
- Department of Emergency Medicine, National Clinical Key Specialty, The Affiliated Brain Hospital, Guangzhou Medical University, Guangzhou, 510370, China
| | - Penglin Mou
- Department of Emergency Medicine, National Clinical Key Specialty, The Affiliated Brain Hospital, Guangzhou Medical University, Guangzhou, 510370, China
| | - Ruizhi Zhang
- Department of Emergency Medicine, National Clinical Key Specialty, The Affiliated Brain Hospital, Guangzhou Medical University, Guangzhou, 510370, China
| | - Cuiling Zhang
- Department of Emergency Medicine, National Clinical Key Specialty, The Affiliated Brain Hospital, Guangzhou Medical University, Guangzhou, 510370, China
| | - Shuyun Li
- Department of Emergency Medicine, National Clinical Key Specialty, The Affiliated Brain Hospital, Guangzhou Medical University, Guangzhou, 510370, China
| | - Miaoling Jiang
- Department of Emergency Medicine, National Clinical Key Specialty, The Affiliated Brain Hospital, Guangzhou Medical University, Guangzhou, 510370, China
| | - Lin Mi
- Department of Nutritional and Metabolic Psychiatry, The Affiliated Brain Hospital, Guangzhou Medical University, Mingxin Road #36, Liwan District,, Guangzhou, 510370, China
| | - Zezhi Li
- Department of Nutritional and Metabolic Psychiatry, The Affiliated Brain Hospital, Guangzhou Medical University, Mingxin Road #36, Liwan District,, Guangzhou, 510370, China.
- Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou Medical University, Guangzhou, 510370, China.
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Ali AA. Pearls for Caring for the Boarding Psychiatric Patient in the Emergency Department. J Emerg Med 2024; 67:e42-e49. [PMID: 38816261 DOI: 10.1016/j.jemermed.2024.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 03/07/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Emergency department (ED) boarding of psychiatric patients is a national issue that continues to worsen at a disturbing rate. Implementing strategies in the ED to provide continuous care for patients can help secure patient safety. OBJECTIVE The objective of this review is to discuss the boarding of psychiatric patients and its implications. It will focus on executing best clinical practices in managing boarding psychiatric patients in the ED. It will not focus on the treatment of substance use disorders. DISCUSSION This article will address the pearls for management plans that can be implemented in the ED, alongside discussing pregnant and elderly patients. Risk factors, complications, and treatments for boarding psychiatric patients are discussed. CONCLUSIONS Patients with psychiatric disorders boarding in the ED need careful consideration of management plans to mitigate patient safety events.
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Affiliation(s)
- Afrah A Ali
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD.
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Singh P. Macroeconomic antecedents of racial disparities in psychiatric-related emergency department visits. Front Psychiatry 2024; 15:1287791. [PMID: 38932936 PMCID: PMC11200170 DOI: 10.3389/fpsyt.2024.1287791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 05/07/2024] [Indexed: 06/28/2024] Open
Abstract
Objective To test whether monthly declines in aggregate employment precede a rise in African American psychiatric-related ED visits (PREDVs) relative to white visits among low-income, working-age populations. Design This study used repeated cross-sectional time series data for 6.7 million PREDVs among African Americans and white individuals from the State Emergency Department Database in 48 Metropolitan Statistical Areas (MSAs) across four states (Arizona, California, New York, New Jersey) from 2006 to 2011. MSA-level monthly employment data were obtained from the US Bureau of Labor Statistics. The outcome was specified as the race of a PREDV (African American = 1, white = 0). The exposure was operationalized as monthly percent change in MSA-level aggregate employment lagged by 0 to 3 months. Analysis included logistic regressions with county, month and year fixed effects, and clustered standard errors to examine the relation between odds of an African American PREDV (relative to white) following 0 to 3 months lag of MSA-level aggregate employment change. Findings Logistic regression results indicate that the odds of PREDVs for publicly insured, working-age African Americans (relative to white individuals) increase 3 months after ambient employment decline (OR: 0.994, 95% CI: [0.990 0.998]). Conclusion Economic downturns may marginally increase psychiatric help-seeking in EDs among publicly insured (low-income), working-age African Americans relative to white individuals. Findings from this study may contribute to the theoretical understanding of dynamic drivers of racial disparities in psychiatric ED visits.
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Huber JP, Milton A, Brewer MC, Norrie LM, Hartog SM, Glozier N. The effectiveness of brief non-pharmacological interventions in emergency departments and psychiatric inpatient units for people in crisis: A systematic review and narrative synthesis. Aust N Z J Psychiatry 2024; 58:207-226. [PMID: 38140961 DOI: 10.1177/00048674231216348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
OBJECTIVE Heterogeneous brief non-pharmacological interventions and guidelines exist to treat the burgeoning presentations to both emergency department and inpatient settings, for those in a crisis of mental ill-health. We systematically reviewed the literature to create a taxonomy of these brief non-pharmacological interventions, and review their evaluation methods and effectiveness. METHOD We conducted a systematic review across Cochrane, CINAHL, DARE, Embase, MEDLINE, PsycINFO databases. Studies meeting quality criteria, using Joanna Briggs Institute tools, were eligible. Interventions were categorised, and outcomes synthesised. RESULTS Thirty-nine studies were included: 8 randomised controlled trials, 17 quasi-experimental, 11 qualitative studies, and 3 file audits. Taxonomy produced six coherent intervention types: Skills-focussed, Environment-focussed, Special Observation, Psychoeducation, Multicomponent Group and Multicomponent Individual. Despite this, a broad and inconsistent range of outcome measures reflected different outcome priorities and prevented systematic comparison of different types of intervention or meta-analysis. Few brief non-pharmacological interventions had consistent evidential support: sensory modulation rooms consistently improved distress in inpatient settings. Short admissions may reduce suicide attempts and readmission, if accompanied by psychotherapy. Suicide-specific interventions in emergency departments may improve depressive symptoms, but not suicide attempt rates. There was evidence that brief non-pharmacological interventions did not reduce incidence of self-harm on inpatient wards. We found no evidence for frequently used interventions such as no-suicide contracting, special observation or inpatient self-harm interventions. CONCLUSION Categorising brief non-pharmacological interventions is feasible, but an evidence base for many is severely limited if not missing. Even when there is evidence, the inconsistency in outcomes often precludes clinicians from making inferences, although some interventions show promise.
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Affiliation(s)
- Jacqueline P Huber
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
- Centre of Excellence for Children and Families over the Life Course, Australian Research Council, Canberra, ACT, Australia
- Mental Health, St Vincent's Hospital Sydney, Sydney, NSW, Australia
| | - Alyssa Milton
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
- Centre of Excellence for Children and Families over the Life Course, Australian Research Council, Canberra, ACT, Australia
| | - Matthew C Brewer
- Mental Health, St Vincent's Hospital Sydney, Sydney, NSW, Australia
| | - Louisa M Norrie
- Mental Health, St Vincent's Hospital Sydney, Sydney, NSW, Australia
| | - Saskia M Hartog
- Centre of Excellence for Children and Families over the Life Course, Australian Research Council, Canberra, ACT, Australia
| | - Nick Glozier
- Centre of Excellence for Children and Families over the Life Course, Australian Research Council, Canberra, ACT, Australia
- Mental Health, St Vincent's Hospital Sydney, Sydney, NSW, Australia
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Fu T, Liu H, Chen C, Zhang B, Chen G, Bai Y, Li J, Hou F. Preventing post-discharge suicides in psychiatric patients: insights from patients, lay healthcare supporters, and mental health professionals-a qualitative analysis. BMC Public Health 2024; 24:64. [PMID: 38166746 PMCID: PMC10762919 DOI: 10.1186/s12889-023-17475-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 12/13/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Discharged psychiatric patients are at higher risk of suicide due to various risk factors in their lives compared to the general population. However, specific problems and needs of these patients after discharge remain unclear. This research constitutes a segment of a broader implementation study designed to formulate an interventional strategy targeting post-discharge suicide among Chinese psychiatric patients. The present study seeks to qualitatively investigate the problems and needs from the perspectives of patients, their lay healthcare supporters (LHSs), and mental health professionals (MPs), aiming to enhance the efficacy of the interventional strategy. METHODS This study is part of a larger implementation study based on Shenzhen Kangning Hospital (SKH) in Shenzhen, Guangdong, China. Under the community-based participatory research framework, we recruited discharged psychiatric patients, their LHSs, and MPs as a collaborative community team, and we conducted individual in-depth interviews for patients and LSHs and focus group interviews with MPs. We utilized a thematic analysis approach to identify sub-themes and themes from interviews through systematically coding and analyzing the data. RESULTS A total of 45 participants were recruited for interviews, comprising 17 patients, 8 LHSs, and 20 MPs. We conducted 25 individual in-depth interviews and 3 focus group interviews. Through the interviews, we identified three themes of post-discharge problems: problems related to self, family-related problems, societal and community-related problems. We also identified four themes related to reducing post-discharge suicide: proactive self-management, multifunctional relatives, multifunctional MP group, and a warm society. The tangible support from LHSs and emotional support from MPs are strongly emphasized. Follow-up interventions were identified as the most significant way to addressing these unmet needs. Instrumental support from the community and a caring and non-discriminatory environment for individuals with mental disorders are essential for reducing suicide risk. CONCLUSIONS Establishing an integrated mental health care service network that connects psychiatric patients, LHSs, and MPs cross community and societal sectors, with patient-centered follow-up care at its core, is a practical approach to better address patients' needs and reduce post-discharge suicide. TRIAL REGISTRATION Registration number: NCT04907669. Date of registration: May 26th,2021.
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Affiliation(s)
- Tiantian Fu
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, No. 74 Zhongshan 2Nd Road, Guangzhou, 510080, Guangdong, China
- Sun Yat-Sen University Global Health Institute, Sun Yat-Sen University, Guangzhou, China
| | - Huiming Liu
- Department of Public Health, Shenzhen Mental Health Center/Shenzhen Kangning Hospital, No.1080, Cuizhu Road, Shenzhen, 518020, Guangdong, China
| | - Chang Chen
- Department of Public Health, Shenzhen Mental Health Center/Shenzhen Kangning Hospital, No.1080, Cuizhu Road, Shenzhen, 518020, Guangdong, China
| | - Bin Zhang
- Department of Public Health, Shenzhen Mental Health Center/Shenzhen Kangning Hospital, No.1080, Cuizhu Road, Shenzhen, 518020, Guangdong, China
| | - Guanjie Chen
- Department of Public Health, Shenzhen Mental Health Center/Shenzhen Kangning Hospital, No.1080, Cuizhu Road, Shenzhen, 518020, Guangdong, China
| | - Yuanhan Bai
- Department of Bipolar Disorders, Shenzhen Mental Health Center, Shenzhen Kangning Hospital (Pingshan Campus), Shenzhen, Guangdong Province, China
| | - Jinghua Li
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, No. 74 Zhongshan 2Nd Road, Guangzhou, 510080, Guangdong, China.
- Sun Yat-Sen University Global Health Institute, Sun Yat-Sen University, Guangzhou, China.
| | - Fengsu Hou
- Department of Public Health, Shenzhen Mental Health Center/Shenzhen Kangning Hospital, No.1080, Cuizhu Road, Shenzhen, 518020, Guangdong, China.
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McCarthy M, McIntyre J, Nathan R, Saini P. Factors Influencing Emergency Department Staff Decision-Making for People Attending in Suicidal Crisis: A Systematic Review. Arch Suicide Res 2024; 28:35-49. [PMID: 36724348 DOI: 10.1080/13811118.2023.2173113] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Emergency department (ED) staff are often the first point of contact for individuals in suicidal crisis. Despite this, there is no published research systematically examining the factors influencing decision-making for this patient group. METHODS MedLine, CINAHL, PsycINFO, Web of Science and Cochrane Library databases were searched for three key concepts: (1) suicide, (2) accident and emergency department and (3) decision-making. Three reviewers screened titles, abstracts and full papers independently against the eligibility criteria. Data synthesis was achieved by extracting and analyzing study characteristics and findings. The Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of included studies. RESULTS Seventeen studies met the eligibility criteria and were included in this systematic review. Studies were published from 2004 to 2020 and were of good methodological quality. A number of patient (method of self-harm, age, gender), contextual (availability of services and staff) and staff-related factors (attitudes, training, knowledge) were reported to influence decision-making for patients in suicidal crisis presenting to EDs. CONCLUSION Decision-making in the ED is complex and is influenced by patient, contextual and staff-related factors. These decisions can have an impact on the future care and clinical pathways of patients in suicidal crisis. Additional training is needed for ED staff specifically related to suicide prevention.
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McCarthy M, McIntyre J, Nathan R, Ashworth E, Saini P. Staff perspectives of emergency department pathways for people attending in suicidal crisis: A qualitative study. J Psychiatr Ment Health Nurs 2023. [PMID: 37860987 DOI: 10.1111/jpm.12991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 09/13/2023] [Accepted: 10/11/2023] [Indexed: 10/21/2023]
Abstract
WHAT IS KNOWN ON THE SUBJECT?: Emergency departments (ED) are key settings to support and manage suicidal crisis; thus, ED staff are often the first point of contact for people in suicidal crisis. Despite this, some ED staff receive little training and/or education on how to best support such patients. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE Previous research focuses on one staffing role (e.g. triage nurses) whereas this paper includes staff working across the ED pathway. Administrative staff have often been excluded from research, despite representing a key part of the clinical pathway and being a person's initial contact with the ED. Overall findings demonstrate that staff experience a lack of confidence, training and burnout due to regularly supporting people in suicidal crisis. Staff also perceive there to be a negative ED culture, which often leads to poor attitudes towards suicidal crisis. The main challenges reported are an increase in working pressures, unavailability of resources and staff retention. Findings build upon previous research to highlight key challenges different staff face along the clinical pathway and the implications this can have on a patient's journey and follow-up care provided. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Findings are of particular importance and relevance to ED managers, and more broadly NHS England. Negative ED culture, poor staff attitudes and confidence can have a detrimental impact on both staff health and wellbeing, as well as a patient's journey throughout the ED, resulting in repeat presentations and absconding as appropriate support is not received. Policymakers need to consider staff burnout and lack of resources in mental health care strategies, and training programmes should be developed to improve culture and confidence among ED staff and managers to improve care for people attending EDs in suicidal crisis. ABSTRACT INTRODUCTION: Emergency departments (EDs) are often the first point of contact for people in suicidal crisis. Yet, previous work has tended to focus on only one type of staffing role, failing to account for different staff perspectives along the clinical pathway. AIMS To explore and synthesise the perspectives of ED administrative (i.e. receptionists), medical (triage nurses) and mental health staff (liaison psychiatrists) working with people presenting in suicidal crisis. METHOD Qualitative study guided by thematic analysis of semi-structured interviews with 23 ED staff across six EDs in Cheshire and Merseyside, England. RESULTS Findings demonstrate that staff experience a lack of confidence, training and burnout due to regularly supporting people in suicidal crisis. The main challenges reported are an increase in working pressures, unavailability of resources and staff retention. DISCUSSION Staff felt unequipped to deal with suicide-related presentations. Organisational support is perceived to be lacking, with increased staffing pressures and poor service availability. This lack of support was linked to job dissatisfaction. IMPLICATIONS FOR PRACTICE Findings are of particular relevance to individual EDs and NHS England. Addressing the challenges staff are reporting can have positive implications for staff wellbeing, as well as a patient's experience and journey throughout the ED.
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Affiliation(s)
| | | | - Rajan Nathan
- Cheshire & Wirral Partnership NHS Foundation Trust, Chester, UK
| | | | - Pooja Saini
- Liverpool John Moores University, Liverpool, UK
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Keller S, Tilbor E, Shwiki A, Florentin S, Laufer S, Bonne O, Canetti L, Reuveni I. Psychiatric referrals to the general hospital emergency department: are we being effective? Front Psychiatry 2023; 14:1166191. [PMID: 37599892 PMCID: PMC10433187 DOI: 10.3389/fpsyt.2023.1166191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 07/10/2023] [Indexed: 08/22/2023] Open
Abstract
Introduction General hospital emergency departments (GHEDs) are notoriously overcrowded. This is caused, in part, by ineffective referrals, that is to say referrals that do not require medical examination or other interventions in the context of a general hospital. This study aims to investigate the contribution of psychiatric referrals to this issue, to identify potential determinants of these referrals and offer means to reduce them. Materials and methods Retrospective data were collected from psychiatric admission files within a GHED of a tertiary-care city hospital over a 1 year period. Two experienced clinicians separately reviewed each file to determine rationale of referrals according to predetermined criteria. Results A total of 2,136 visits included a psychiatric examination, 900 (42.1%) were determined "effective," and 1,227 (57.4%) were deemed "potentially ineffective." The leading causes for potentially ineffective referrals to a GHED were psychiatric illness exacerbation (43.4%), and suicidal ideations (22%). Most referrals (66.9%) were initiated by the patient or their family, and not by a primary care physician or psychiatrist. Conclusion More than half of the psychiatric referrals did not necessarily require the services of a general hospital, and may be more suitable for referral to a dedicated psychiatric facility. Ineffective referrals to the GHED pose a burden on general hospital resources, and may be less effective for the psychiatric patients. This calls for clear guidelines for the provision of optimal emergency treatment for mental-health patients.
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Affiliation(s)
- Shikma Keller
- Department of Psychiatry, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Einat Tilbor
- Department of Psychiatry, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Afnan Shwiki
- Department of Psychiatry, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sharon Florentin
- Department of Psychiatry, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sofia Laufer
- Department of Psychiatry, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Omer Bonne
- Department of Psychiatry, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Laura Canetti
- Department of Psychiatry, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Psychology, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Inbal Reuveni
- Department of Psychiatry, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Isbell LM, Chimowitz H, Huff NR, Liu G, Kimball E, Boudreaux E. A Qualitative Study of Emergency Physicians' and Nurses' Experiences Caring for Patients With Psychiatric Conditions and/or Substance Use Disorders. Ann Emerg Med 2023; 81:715-727. [PMID: 36669922 DOI: 10.1016/j.annemergmed.2022.10.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 10/06/2022] [Accepted: 10/11/2022] [Indexed: 01/20/2023]
Abstract
STUDY OBJECTIVE Patients with psychiatric conditions and/or substance use disorders (SUDs) frequently seek care in emergency departments (EDs), where providing care for these populations can involve considerable challenges. This study aimed to develop a comprehensive data-driven model of the complex challenges and unique dynamics associated with caring for these populations in the ED, as well as the effect on patient care quality. METHODS We conducted a preplanned topical analysis of grounded theory data obtained from semistructured interviews with 86 ED physicians and nurses from 8 hospitals in the Northeastern USA. Participants provided detailed descriptions of their experiences and challenges in caring for patients with psychiatric conditions and/or SUDs. We identified themes inductively using constant comparative analysis and developed a grounded model of physicians' and nurses' perceptions of challenges, biases, and effects on patient care. RESULTS Emergency physicians and nurses described emotional, diagnostic, and logistical challenges that patients with psychiatric conditions and/or SUDs present. These challenges are magnified by existing health care system issues and social structures, which fuel and reinforce negative attitudes, expectations, and biases. In combination, these processes create negative health care experiences for patients, physicians, and nurses and can adversely affect patient care quality and ED staff well-being. CONCLUSION Our findings uncover a cyclical process whereby challenges and biases associated with patients with psychiatric conditions and/or SUDs can reciprocally threaten patient care quality. Systemic changes and localized interventions are urgently needed to mitigate challenges, reduce bias, improve patient care, and improve physicians' and nurses' experiences in the ED.
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Affiliation(s)
- Linda M Isbell
- Department of Psychological and Brain Sciences, University of Massachusetts Amherst, Amherst, MA.
| | - Hannah Chimowitz
- Department of Psychological and Brain Sciences, University of Massachusetts Amherst, Amherst, MA
| | - Nathan R Huff
- Department of Psychological and Brain Sciences, University of Massachusetts Amherst, Amherst, MA
| | - Guanyu Liu
- Department of Psychological and Brain Sciences, University of Massachusetts Amherst, Amherst, MA
| | - Ezekiel Kimball
- College of Education, University of Massachusetts Amherst, Amherst, MA
| | - Edwin Boudreaux
- Department of Emergency Medicine, Psychiatry, and Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
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Colalillo JM, Govindasamy LS, Ley Greaves R. Moving beyond the dose makes the poison. Emerg Med Australas 2023; 35:333-335. [PMID: 36843217 DOI: 10.1111/1742-6723.14192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 02/13/2023] [Indexed: 02/28/2023]
Affiliation(s)
- James M Colalillo
- Emergency Department, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | | | - Robbie Ley Greaves
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- LifeFlight Retrieval Medicine, Brisbane, Queensland, Australia
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Nordstrom K, Berlin JS, Nash SS, Shah SB, Schmelzer NA, Worley LLM. Boarding of Mentally Ill Patients in Emergency Departments: American Psychiatric Association Resource Document. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2023; 21:74-79. [PMID: 37205035 PMCID: PMC10172531 DOI: 10.1176/appi.focus.23022001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The treatment of severe mental illness has undergone a paradigm shift over the last fifty years, away from a primary emphasis on hospital-based care and toward community-based care. Some of the forces driving this deinstitutionalization have been scientific and patient-centered, such as better differentiation between acute and subacute risk, innovations in outpatient and crisis care (assertive community treatment programs, dialectical behavioral therapy, treatment-oriented psychiatric emergency services), gradually improving psychopharmacology, and an increased appreciation of the negative effect of coercive hospitalization, except when risk is very high. On the other hand, some of the forces have been less focused on patient needs: budget-driven cuts in public hospital beds divorced from population-based need; managed care's profit-driven impact on private psychiatric hospitals and outpatient services; and purported patient-centered approaches promoting non-hospital care that may under-recognize that some extremely ill patients need years of painstaking effort to make a community transition. The result has been a reconfiguration of the country's mental health system that, at times, leaves large numbers of people without adequate mental health and substance abuse services. Often their only option is to seek care in medical emergency department's (ED's) that are not designed for their needs. Increasingly, many of those individuals end up waiting in ED's for appropriate care and disposition for hours or days. This overflow phenomenon has become so prevalent in ED's that it has been given a name: "boarding". This practice is almost certainly detrimental to patients and staff, and it has spawned efforts on multiple fronts to understand and resolve it. When considering solutions, both ED-focused and system-wide considerations must be explored. This resource document provides an overview and recommendations regarding this complex topic. Reprinted with permission from American Psychiatric Association. Copyright © 2019.
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13
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Long B, Keim SM, Betz M, Gottlieb M. Do All Adult Psychiatric Patients Need Routine Laboratory Evaluation and an Electrocardiogram? J Emerg Med 2022; 63:711-721. [PMID: 36274002 DOI: 10.1016/j.jemermed.2022.09.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 09/05/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Acute psychiatric presentations account for a significant number of emergency department (ED) visits. These patients require assessment by the emergency physician and often need further evaluation by a psychiatrist, who may request routine laboratory evaluation and an electrocardiogram (ECG). CLINICAL QUESTION Do all adult psychiatric patients need routine laboratory evaluation and an ECG? EVIDENCE REVIEW Studies retrieved included 2 prospective, observational studies and 7 retrospective studies. These studies evaluate the utility of laboratory analysis in all patients presenting a psychiatric complaint and its impact on patient management and disposition. CONCLUSION Based upon the available literature, routine laboratory analysis and ECG for all patients presenting with a psychiatric complaint are not recommended. Clinicians should consider the individual patient, clinical situation, and comorbidities when deciding to obtain further studies such as laboratory analysis. © 2022 Elsevier Inc.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Samuel M Keim
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, Arizona
| | - Marian Betz
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
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14
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Stacy M, Dwyer E, Kremer M, Schulkin J. Obstetrician/Gynecologists' Knowledge, Attitudes, and Practice Regarding Suicide Screening Among Women. J Womens Health (Larchmt) 2022; 31:1481-1489. [PMID: 35984865 DOI: 10.1089/jwh.2021.0646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Suicide is a public health issue, and there are differences between men and women in terms of suicide ideation, behavior, and completion. Obstetrician/gynecologists (OB/GYNs) are uniquely positioned to assess women's suicide risk. Methods: A 53-question survey was distributed to the Pregnancy-Related Care Research Network, assessing practice, attitudes, and knowledge regarding suicide risk assessment and management, and personal experience with suicide. Wilcoxon signed-rank tests with paired samples were used to compare the frequency of screening and interventions for different groups of women, and practices of those with and without suicide experience. Significance was set at p < 0.05. Results: Response rate was 31.9%. Respondents were largely White females. OB/GYNs reported more frequently screening for suicide ideation/intent/behavior among pregnant and postpartum patients than nonpregnant/nonpostpartum patients of childbearing age. The most common assessment tool was the Edinburgh Postnatal Depression Scale; half ask about past suicide ideation/behavior or current thoughts/plans. The most common intervention for at-risk patients was a mental health referral; all interventions were reported more frequently for pregnant patients. Common barriers to screening were inadequate mental health services, time constraints, and inadequate training. Most agreed suicide screening is within their purview, and were knowledgeable about the topic, although gaps were identified. Few reported adequate training in suicide risk assessment, and believed continuing education would be beneficial. A majority endorsed experience with suicide and some practice differences emerged. Conclusions: OB/GYNs view suicide risk assessment in their scope. Some knowledge gaps were identified, and respondents believe additional training would be beneficial.
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Affiliation(s)
- Meaghan Stacy
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Erin Dwyer
- Department of Obstetrics and Gynecology, University of Washington Medicine, Seattle, Washington, USA
| | - Mallory Kremer
- Department of Obstetrics and Gynecology, University of Washington Medicine, Seattle, Washington, USA
| | - Jay Schulkin
- Department of Obstetrics and Gynecology, University of Washington Medicine, Seattle, Washington, USA
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15
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Gaither R, Ranney M, Peachey A, Burock J, Rogers J, Bucci L, Beaudoin FL. A feasibility study of low-dose ketamine for acute management of suicidal ideation. J Am Coll Emerg Physicians Open 2022; 3:e12790. [PMID: 35990286 PMCID: PMC9377682 DOI: 10.1002/emp2.12790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/01/2022] [Accepted: 07/07/2022] [Indexed: 11/23/2022] Open
Abstract
Objective Mood disorders complicated by suicidal ideation (SI) frequently present to the emergency department (ED) for care. Currently, patients with SI in the ED do not typically receive targeted interventions. Ketamine may have a role in treating SI within the ED because subanesthetic doses have rapid-acting antidepressant and antisuicidal properties. Methods This single-arm, open-label feasibility study enrolled 14 participants from the ED with acute SI who were awaiting voluntary admission to inpatient psychiatry to receive ketamine at 0.5 mg/kg, administered intravenously. Participants were assessed post administration to evaluate feasibility of administration in the ED and short-term effectiveness. Feasibility was determined by acceptability by patients and physicians as well as tolerability and ability to recruit participants into the study. Efficacy was assessed based on changes in (1) self-reported mood and (2) suicidal ideation pre- and postinfusion of ketamine. Results All patients reported severe depression and active SI at baseline. No serious adverse events were reported, and acceptability was rated highly by both participants and physicians (>70%). Two hours after receiving ketamine 0.5 mg/kg, the mean SI and somatic symptom burden were decreased compared to baseline (P < 0.001 and P = 0.005, respectively), and the mean self-reported mood was increased (P = 0.006). Improvements in mood and decreases in suicidality persisted at 6 hours. Conclusions Overall, ketamine was well tolerated, considered feasible by both participants and physicians, and demonstrated short-term efficacy. There is a growing body of evidence demonstrating the feasibility of ketamine administration in the ED, and larger randomized trials should be conducted to establish treatment recommendations for patients with SI in the ED.
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Affiliation(s)
- Rachel Gaither
- Department of EpidemiologyBrown University School of Public HealthProvidenceRhode IslandUSA
| | - Megan Ranney
- Department of Emergency MedicineThe Alpert Medical School of Brown UniversityProvidenceRhode IslandUSA
- Department of Behavioral and Social Science and Health Services, Policy, and PracticeBrown University School of Public HealthProvidenceRhode IslandUSA
| | - Alyssa Peachey
- Department of EpidemiologyBrown University School of Public HealthProvidenceRhode IslandUSA
| | - Jeffrey Burock
- Department of PsychiatryThe Miriam HospitalProvidenceRhode IslandUSA
| | - Jyllian Rogers
- Department of PsychiatryThe Miriam HospitalProvidenceRhode IslandUSA
| | - Lindsey Bucci
- Department of PsychiatryThe Miriam HospitalProvidenceRhode IslandUSA
| | - Francesca L. Beaudoin
- Department of EpidemiologyBrown University School of Public HealthProvidenceRhode IslandUSA
- Department of Emergency MedicineThe Alpert Medical School of Brown UniversityProvidenceRhode IslandUSA
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16
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Patient and Provider Perspectives on Emergency Department Care Experiences among People with Mental Health Concerns. Healthcare (Basel) 2022; 10:healthcare10071297. [PMID: 35885824 PMCID: PMC9315815 DOI: 10.3390/healthcare10071297] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/01/2022] [Accepted: 07/12/2022] [Indexed: 11/17/2022] Open
Abstract
Emergency departments (EDs) are an important source of care for people with mental health (MH) concerns. It can be challenging to treat MH in EDs, and there is little research capturing both patient and provider perspectives of these experiences. We sought to summarize the evidence on ED care experiences for people with MH concerns in North America, from both patient and provider perspectives. Medline and EMBASE were searched using PRISMA guidelines to identify primary studies. Two reviewers conducted a qualitative assessment of included papers and inductive thematic analysis to identify common emerging themes from patient and provider perspectives. Seventeen papers were included. Thematic analysis revealed barriers and facilitators to optimal ED care, which were organized into three themes each with sub-themes: (1) interpersonal factors, including communication, patient–staff interactions, and attitudes and behaviours; (2) environmental factors, including accommodations, wait times, and restraint use; and (3) system-level factors, including discharge planning, resources and policies, and knowledge and expertise. People with MH concerns and ED healthcare providers (HCPs) share converging perspectives on improving ED connections with community resources and diverging perspectives on the interplay between system-level and interpersonal factors. Examining both perspectives simultaneously can inform improvements in ED care for people with MH concerns.
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17
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Wong AH, Ray JM, Cramer LD, Brashear T, Eixenberger C, McVaney C, Haggan J, Sevilla M, Costa DS, Parwani V, Ulrich A, Dziura JD, Bernstein SL, Venkatesh AK. Design and Implementation of an Agitation Code Response Team in the Emergency Department. Ann Emerg Med 2022; 79:453-464. [PMID: 34863528 PMCID: PMC9038629 DOI: 10.1016/j.annemergmed.2021.10.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/12/2021] [Accepted: 10/19/2021] [Indexed: 11/01/2022]
Abstract
STUDY OBJECTIVE Agitation, defined as excessive psychomotor activity leading to violent and aggressive behavior, is becoming more prevalent in the emergency department (ED) amidst a strained behavioral health system. Team-based interventions have demonstrated promise in promoting de-escalation, with the hope of minimizing the need for invasive techniques, like physical restraints. This study aimed to evaluate an interprofessional code response team intervention to manage agitation in the ED with the goal of decreasing physical restraint use. METHODS This quality improvement study occurred over 3 phases, representing stepwise rollout of the intervention: (1) preimplementation (phase I) to establish baseline outcome rates; (2) design and administrative support (phase II) to conduct training and protocol design; and (3) implementation (phase III) of the code response team. An interrupted time-series analysis was used to compare trends between phases to evaluate the primary outcome of physical restraint orders occurring during the study period. RESULTS Within the 634,578 ED visits over a 5-year period, restraint use significantly declined sequentially over the 3 phases (1.1%, 0.9%, and 0.8%, absolute change -0.3% between phases I and III, 95% confidence interval [CI] -0.4% to 0.3%), which corresponded to a 27.3% proportionate decrease in restraint rates between phases I and III. For the interrupted time-series analysis, there was a significantly decreasing slope in biweekly restraints in phase II compared to phase I (slope, -0.05 restraints per 1,000 ED visits per 2-week period, 95% CI -0.07 to -0.03), which was sustained in an incremental fashion in phase III (slope, -0.05, 95% CI -0.07 to -0.02). CONCLUSION With the implementation of a structured agitation code response team intervention combined with design and administrative support, a decreased rate of physical restraint use occurred over a 5-year period. Results suggest that investment in organizational change, along with interprofessional collaboration during the management of agitated patients in the ED, can lead to sustained reductions in the use of an invasive and potentially harmful measure on patients.
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Affiliation(s)
- Ambrose H. Wong
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jessica M. Ray
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | - Taylor Brashear
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | - Caitlin McVaney
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jeanie Haggan
- Adult Emergency Services, Yale-New Haven Hospital, New Haven, CT, USA
| | - Mark Sevilla
- Adult Emergency Services, Yale-New Haven Hospital, New Haven, CT, USA
| | - Donald S. Costa
- Department of Protective Services, Yale-New Haven Hospital, New Haven, CT, USA
| | - Vivek Parwani
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Andrew Ulrich
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - James D. Dziura
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Steven L. Bernstein
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Arjun K. Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
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18
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Di Lorenzo R, Fiore G, Bruno A, Pinelli M, Bertani D, Falcone P, Marrama D, Starace F, Ferri P. Urgent Psychiatric Consultations at Mental Health Center during COVID-19 Pandemic: Retrospective Observational Study. Psychiatr Q 2021; 92:1341-1359. [PMID: 33772425 PMCID: PMC7997653 DOI: 10.1007/s11126-021-09907-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/28/2021] [Indexed: 12/21/2022]
Abstract
The coronavirus pandemic and related social distancing measures have brought about dramatic changes in people's lives. In particular, health workers have been forced to change their activities both for the different needs of patients and for preventive measures against the spread of the virus. This study is aimed at comparing the urgent psychiatric consultations (UPC) performed at the outpatient Mental Health Center (MHC) of Modena during the coronavirus outbreak period, from 1 March to 31 August 2020, with the same period in 2019. We retrospectively collected in a database the demographic and clinical characteristics of patients who required UPC in the MHC during the 6-month observation periods in both 2019 and 2020. Data were statistically analyzed. We analyzed 656 urgent psychiatric consultations in 2019 and 811 in 2020, requested by 425 patients in 2019 and 488 in 2020, respectively. In the pandemic period, we observed an increase in the total and daily number of UPC which were more frequently required by patients in care at local outpatient services in comparison with the previous period. During 2020, an increased number of UPC was carried out remotely and the outcome was more frequently represented by discharge at home, avoiding hospitalization as much as possible. In the course of the coronavirus pandemic, MHC had to face an increased demand for clinical activity especially from the most clinically and socially vulnerable patients, who more frequently required UPC in outpatient psychiatric services.
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Affiliation(s)
- Rosaria Di Lorenzo
- Psychiatric Intensive Treatment Facility, Mental Health and Drug Abuse Department of AUSL-Modena, Via Paul Harris, 175, 41122 Modena, Italy
| | - Gianluca Fiore
- University of Modena and Reggio Emilia, Via del Pozzo, 71, 41124 Modena, Italy
| | - Alessandra Bruno
- School of Nursing, University of Modena and Reggio Emilia, Via del Pozzo, 71, 41124 Modena, Italy
| | - Margherita Pinelli
- University of Modena and Reggio Emilia, Via del Pozzo, 71, 41124 Modena, Italy
| | - Davide Bertani
- University of Modena and Reggio Emilia, Via del Pozzo, 71, 41124 Modena, Italy
| | - Patrizia Falcone
- Psychiatric Intensive Treatment Facility, Mental Health and Drug Abuse Department of AUSL-Modena, Via Paul Harris, 175, 41122 Modena, Italy
| | - Donatella Marrama
- Mental Health and Drug Abuse Department of AUSL-Modena, Via Paul Harris, 175, 41122 Modena, Italy
| | - Fabrizio Starace
- Mental Health and Drug Abuse Department of AUSL-Modena, Italian Society of Epidemiological Psychiatry (SIEP), Viale L.A. Muratori 201, 41124 Modena, Italy
| | - Paola Ferri
- Department of Biomedical, Metabolic and Neural Sciences, Via G. Campi, 287, 41125 Modena, Italy
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19
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Nam E, Lee E, Kim H. 10-Year Trends of Emergency Department Visits, Wait Time, and Length of Stay among Adults with Mental Health and Substance use Disorders in the United States. Psychiatr Q 2021; 92:1159-1174. [PMID: 33608848 DOI: 10.1007/s11126-021-09894-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/31/2021] [Indexed: 11/28/2022]
Abstract
This study examined if there was a change in the number of Emergency Department (ED) visits, wait time, and length of stay among adults with mental health and substance use disorders (MHSUD) in the United States from 2006 to 2015. From the National Hospital Ambulatory Medical Care Survey, a total of 17,488 ED visits by adults with MHSUD were identified. Linear regression and negative binomial regression analyses were conducted to assess statistically significant changes in trends of ED visits, wait time, and length of stay. Results indicated that ED visits by adults with MHSUD increased by 30.6% from 2006 to 2015. Wait time of ED visits by adults with MHSUD decreased for the same time period; however, length of stay did not change. Also, there were some differences in trends of wait time and length of stay by diagnosis. Specifically, wait time of ED visits by adults with psychotic disorders did not decrease. Length of stay of ED visits by adults with anxiety disorders statistically significantly increased from 2006 to 2015. More effort is needed to improve the quality of ED care for adults with MHSUD. In such an effort, diagnoses should be taken into consideration.
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Affiliation(s)
- Eunji Nam
- Department of Social Welfare, Incheon National University, 119 Academy-Ro, Yeonsu-Gu, Incheon, 22012, South Korea.
| | - Eunkyung Lee
- Department of Health Sciences, University of Central Florida, 4364 Scorpius Street, Orlando, FL, 32816, USA
| | - Hyemee Kim
- Department of Social Welfare, Incheon National University, 119 Academy-Ro, Yeonsu-Gu, Incheon, 22012, South Korea
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20
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Thomas B, McGillion A, Edvardsson K, O'Meara P, Van Vuuren J, Spelten E. Barriers, enablers, and opportunities for organisational follow-up of workplace violence from the perspective of emergency department nurses: a qualitative study. BMC Emerg Med 2021; 21:19. [PMID: 33579206 PMCID: PMC7880205 DOI: 10.1186/s12873-021-00413-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 01/31/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND A lack of follow-up of violence incidents and assaulted staff has been associated with high levels of workplace violence. There is a paucity of literature on the barriers, enablers and opportunities for organisational follow-up of workplace violence. The aim of this study was to explore the barriers, enablers and opportunities for organisational follow-up of workplace violence from the perspective of Emergency Department nurses. METHODS This qualitative study comprised two focus groups with Emergency Department nurses. Data were analysed thematically. COREQ guidelines were followed for the design and reporting of the study. RESULTS The barriers to follow-up in this study relate to the type of perpetrator, the initial incident response, the incident reporting process and organisational action. The enablers included hospital initiatives to manage violence and support staff wellbeing. The opportunities included strategies to improve follow-up and ideas for new follow-up strategies. CONCLUSIONS Organisational follow-up is important for the emotional and professional wellbeing of staff who experience workplace violence. Opportunities for follow-up include exploring different approaches to patients with mental health issues and focussing on reoffenders by providing appropriate support and consequences. Managers should advocate for efficient and standardised reporting processes and ensure assaulted staff have a clear perception of follow-up and are included in the follow-up process. Including the perpetrators in the follow-up process may reduce workplace violence.
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Affiliation(s)
- Brodie Thomas
- La Trobe Rural Health School, La Trobe University, 471 Benetook Ave, Mildura, VIC, 3500, Australia.
| | - Anthony McGillion
- School of Nursing and Midwifery, La Trobe University, Plenty Rd & Kingsbury Dr, Bundoora, VIC, 3086, Australia
| | - Kristina Edvardsson
- School of Nursing and Midwifery, La Trobe University, Plenty Rd & Kingsbury Dr, Bundoora, VIC, 3086, Australia
- Judith Lumley Centre, La Trobe University, Melbourne, Australia
| | - Peter O'Meara
- Department of Emergency Health and Paramedic Practice, Monash University, McMahons Road, Frankston, VIC, 3199, Australia
| | - Julia Van Vuuren
- La Trobe Rural Health School, La Trobe University, 471 Benetook Ave, Mildura, VIC, 3500, Australia
| | - Evelien Spelten
- La Trobe Rural Health School, La Trobe University, 471 Benetook Ave, Mildura, VIC, 3500, Australia
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21
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Daniel C, Mukaro V, Yap CYL, C Knott J, Kelly P, Innes A, Braitberg G, Gerdtz M. Characteristics and clinical outcomes for mental health patients admitted to a behavioural assessment unit: Implications for model of care and practice. Int J Ment Health Nurs 2021; 30:249-260. [PMID: 32929864 DOI: 10.1111/inm.12779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 07/15/2020] [Accepted: 08/04/2020] [Indexed: 11/30/2022]
Abstract
Behavioural assessment units (BAU) have been established in emergency departments (EDs) to provide short-term observation, treatment, and care to people experiencing acute behavioural disturbance. A prospective observational study was conducted in a cohort of adult patients admitted to one BAU located within an ED (July-December 2017) to compare clinical characteristics, treatment outcomes, and use of restrictive interventions for those who received a specialist mental health (MH) assessment with those who did not. Of the 457 patients, 61.5% received a specialist MH assessment. This group had a lower acuity (Australasian Triage Score 10.4%; CI 0.2-2.0% vs 13.6%; CI 9.3-19.5%); more arrived with police (28.8%; CI 23.8-34.3 vs 5.1%; CI 2.7-9.4%); and were subjected to restrictive interventions while in the BAU. Security responses for unarmed threat (code grey) were higher (10.9%; CI 7.8-15.0% vs 4.4%; CI 2.3-8.5%), as was the use of chemical restraint (4.2%; CI 2.4-7.2 vs 0.0% CI 0.0 - 2.1%). Those requiring specialist MH assessment had a longer length of stay (12.7 vs 5.2 hours). Further development of the BAU model of care must include targeted, evidence-based strategies to minimize the use of restrictive interventions and ensure timely access to acute mental health services.
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Affiliation(s)
- Catherine Daniel
- Department of Nursing, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Melbourne Health, Parkville, Victoria, Australia.,Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Violet Mukaro
- Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Celene Y L Yap
- Department of Nursing, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Emergency Department, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jonathan C Knott
- Emergency Department, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Melbourne Health, Parkville, Victoria, Australia.,Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Peter Kelly
- Melbourne Health, Parkville, Victoria, Australia
| | - Andrew Innes
- Emergency Department, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - George Braitberg
- Melbourne Health, Parkville, Victoria, Australia.,Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Marie Gerdtz
- Department of Nursing, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
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22
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Di Lorenzo R, Frattini N, Dragone D, Farina R, Luisi F, Ferrari S, Bandiera G, Rovesti S, Ferri P. Psychiatric Emergencies During the Covid-19 Pandemic: A 6-Month Observational Study. Neuropsychiatr Dis Treat 2021; 17:1763-1778. [PMID: 34113107 PMCID: PMC8184244 DOI: 10.2147/ndt.s307128] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/22/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The new SARS-CoV-2 has caused an ongoing pandemic. Health prevention measures to contain the outbreak are profoundly affecting the physical and mental health as well as personal freedom of the population. AIM To evaluate psychiatric emergencies in a 6-month period during the COVID-19 pandemic in 2020 compared to those of the corresponding period of the previous year. METHODS This monocentric observational study preliminarily collected variables of the urgent psychiatric consultations (UPCs) carried out in emergency room (ER) from 1-3-2020 to 31-8-2020 and the socio-demographic and clinical characteristics of patients who required UPCs in the 6-month period, comparing these data with those collected from 1-3-2019 to 31-8-2019. The data, collected in alpha-numeric code, were statistically analyzed through STATA 12-2011. RESULTS This research reported a reduction of both UPCs and hospital psychiatric admissions. Concomitantly, we observed an increase of UPCs required by people already being treated by psychiatric and other health services, residents in psychiatric facilities and non-Italians. In 2020, differently from 2019, the most frequent reasons for urgent psychiatric consultations were aggressive behavior and adjustment disorders with anxiety and depressive mood. CONCLUSION This preliminary study suggests that, during the COVID-19 epidemic, urgent psychiatric consultations in ER were reduced, except for the most vulnerable people due to their clinical and/or social conditions.
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Affiliation(s)
- Rosaria Di Lorenzo
- Psychiatric Intensive Treatment Facility, Mental Health and Drug Abuse Department of AUSL-Modena, Modena, Italy
| | - Nicoletta Frattini
- Department of Biomedical, Metabolic and Neural Sciences, School of Nursing, University of Modena and Reggio Emilia, Modena, Italy
| | - Diego Dragone
- Department of Biomedical, Metabolic and Neural Sciences, School of Psychiatry, University of Modena and Reggio Emilia, Modena, Italy
| | - Riccardo Farina
- Department of Biomedical, Metabolic and Neural Sciences, School of Psychiatry, University of Modena and Reggio Emilia, Modena, Italy
| | - Filippa Luisi
- Department of Biomedical, Metabolic and Neural Sciences, School of Psychiatry, University of Modena and Reggio Emilia, Modena, Italy
| | - Silvia Ferrari
- Department of Biomedical, Metabolic and Neural Sciences, School of Psychiatry, University of Modena and Reggio Emilia, Modena, Italy
| | - Geminiano Bandiera
- Emergency Room and Emergency Medicine Unit, General Hospital of Baggiovara, AOU of Modena, Modena, Italy
| | - Sergio Rovesti
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Paola Ferri
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
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23
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Odejimi O, Bagchi D, Tadros G. Typology of psychiatric emergency services in the United Kingdom: a narrative literature review. BMC Psychiatry 2020; 20:587. [PMID: 33302905 PMCID: PMC7727184 DOI: 10.1186/s12888-020-02983-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 11/23/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Mental health crisis requiring emergency access to psychiatric service can occur at any time. Psychiatric Emergency Service (PES) is described as one that provides an immediate response to an individual in crisis within the first 24 h. Presently, several types of PESs are available in the United Kingdom (UK) with the aim of providing prompt and effective assessment and management of patients. Therefore, this study aims to provide a detailed narrative literature review of the various types of Psychiatric Emergency Service (PES) currently available in the UK. METHOD Electronic search of five key databases (MEDLINE, PsychINFO, EMBASE, AMED and PUBMED) was conducted. Studies were included if it described a mental health service in the UK that provides immediate response in mental health crisis within the first 24 h. Excluded studies did not describe a PES, non-English, and were not conducted in UK. RESULTS Nine types of PESs were found. Amongst the 9 services, more papers described crisis resolution home treatment. Majority of the papers reported services within England than other countries within the UK. CONCLUSION All types of PESs were described as beneficial, particularly to mental health service users, but not without some shortcomings. There is a need to continue carrying out methodological research that evaluate impact, cost-effectiveness as well as identify methods of optimising the beneficial outcomes of the various types of PESs. This may help inform researchers, policy makers and commissioners, service users and carers, service providers and many more on how to ensure current and future PESs meet the needs as well as aid recovery during crisis.
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Affiliation(s)
- Opeyemi Odejimi
- Urgent Care Pathway, Birmingham and Solihull Mental Health Foundation Trust, Birmingham, UK
| | - Dhruba Bagchi
- Urgent Care Pathway, Birmingham and Solihull Mental Health Foundation Trust, Birmingham, UK
| | - George Tadros
- Aston Medical School, Aston University, Birmingham, UK
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Rezaie L, Phillips D. Post-discharge needs of Iranian women diagnosed with severe mental illness: A qualitative study. J Psychiatr Ment Health Nurs 2020; 27:752-762. [PMID: 32277722 DOI: 10.1111/jpm.12634] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 03/11/2020] [Accepted: 03/18/2020] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN ON THE SUBJECT?: A search of common databases indicates the absence of any research focused on the needs of Iranian women diagnosed with severe mental illness post-discharge from an inpatient setting. Moreover, there is a lacuna of information about the unique experiences and needs of persons diagnosed with severe mental illness living in non-Western communities (esp. Middle Eastern communities). WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE: This study examined interviews of women diagnosed with severe mental illness receiving treatment at an Iranian inpatient hospital. Three categories of post-discharge needs emerged: support, skill acquisition and information. Support consisted of family, social and health system subcategories. Skill acquisition was comprised of social skills, work skills and self-management skills. Lastly, information distinguished between illness-related information and women's health information. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Findings highlight the need for systemic changes to current care models. Broadly, families should be incorporated into care to improve outcomes and decrease stigma. Regarding mental health nursing, results highlighted the need for additional nursing and occupational therapy interventions to empower families and patients. Nursing practitioners can aid in preparing these patients for employment and public health initiatives to decrease stigma and improve access to care. ABSTRACT: Introduction Understanding the post-discharge needs of patients diagnosed with severe mental illness is critical for improving treatment outcomes. Aim The aim of the present study was to determine the unique post-discharge needs of Iranian women diagnosed with severe mental illness. Method Conventional content analysis was utilized to analyse data gathered via focus group interviews conducted within the psychiatric inpatient unit at Farabi hospital located in Kermanshah, Iran. Participants (N = 42; M age = 40; SD = 6.3 years) had been diagnosed with a severe mental illness, had a history of at least two psychiatric hospitalizations and were awaiting discharge following significant symptom improvement. Results Content analysis extracted three categories of post-discharge needs: support, skill acquisition and information. Support consisted of family, social and health system subcategories. Skill acquisition was comprised of social skills, work skills and self-management skills. Lastly, information distinguished between illness-related information and women's health information. Discussion/Implications for practice Analysis of interview data highlighted the general need for adopting a family-system approach to reduce stigma, increase knowledge and foster skill acquisition. Regarding mental health nursing, results highlighted the unique role of nurses and their capacity to pre-emptively address needs such as aiding in employment. Lastly, findings are contrasted against Western care models.
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Affiliation(s)
- Leeba Rezaie
- Sleep Disorders Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - David Phillips
- Department of Psychology, Eastern Michigan University, Ypsilanti, MI, USA
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Knorr AC, Ammerman BA, LaFleur SA, Misra D, Dhruv MA, Karunakaran B, Strony RJ. An investigation of clinical decisionmaking: identifying important factors in treatment planning for suicidal patients in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:383-391. [PMID: 33000061 PMCID: PMC7493507 DOI: 10.1002/emp2.12087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 04/09/2020] [Accepted: 04/13/2020] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE We sought to evaluate the influence of several well-documented, readily available risk factors that may influence a psychiatric consultant's decision to admit an emergency department (ED) patient reporting suicidal ideation for psychiatric hospitalization. METHODS We conducted a retrospective study of adult patients presenting to six affiliated EDs within Pennsylvania from January 2015 to June 2017. We identified 533 patients reporting current active suicidal ideation and receiving a complete psychiatric consultation. Socio-demographic characteristics, psychiatric presentation and history, and disposition were collected. Decision tree analysis was conducted with disposition as the outcome. RESULTS Four of 27 variables emerged as most influential to decisionmaking, including psychiatric consultant determination of current suicide risk, patient age, current depressive disorder diagnosis, and patient history of physical violence. Likelihood of admission versus discharge ranged from 97% to 58%, depending on the variables considered. Post hoc analysis indicated that current suicide plan, access to means, lack of social support, and suicide attempt history were significantly associated with psychiatric consultant determination of moderate-to-high suicide risk, with small-to-medium effect sizes emerging. CONCLUSIONS Only a handful of variables drive disposition decisions for ED patients reporting current active suicidal ideation, with both high and low fidelity decisions made. Patient suicide risk, determined by considering empirically supported risk factors for suicide attempt and death, contributes the greatest influence on a psychiatric consultant's decision to admit. In line with American College of Emergency Physicians (ACEP) recommendations, this study accentuates the importance of using clinical judgment and adjunct measures to determine patient disposition within this population.
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Affiliation(s)
- Anne C Knorr
- Department of Emergency Medicine Geisinger Medical Center Danville Pennsylvania USA
| | - Brooke A Ammerman
- Department of Psychology University of Notre Dame Notre Dame Indiana USA
| | - Sean A LaFleur
- Department of Emergency Medicine Geisinger Medical Center Danville Pennsylvania USA
| | - Debdipto Misra
- Geisinger System Services UDA Data Management Danville Pennsylvania USA
| | | | - Bipin Karunakaran
- Geisinger System Services UDA Data Management Danville Pennsylvania USA
| | - Robert J Strony
- Department of Emergency Medicine Geisinger Medical Center Danville Pennsylvania USA
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Nordstrom K, Berlin JS, Nash SS, Shah SB, Schmelzer NA, Worley LL. Boarding of Mentally Ill Patients in Emergency Departments: American Psychiatric Association Resource Document. West J Emerg Med 2019; 20:690-695. [PMID: 31539324 PMCID: PMC6754202 DOI: 10.5811/westjem.2019.6.42422] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 06/03/2019] [Accepted: 06/03/2019] [Indexed: 11/11/2022] Open
Abstract
The treatment of severe mental illness has undergone a paradigm shift over the last 50 years, away from a primary emphasis on hospital-based care and toward community-based care. Some of the forces driving this deinstitutionalization have been scientific and patient-centered, such as better differentiation between acute and subacute risk, innovations in outpatient and crisis care (assertive community treatment programs, dialectical behavioral therapy, treatment-oriented psychiatric emergency services), gradually improving psychopharmacology, and an increased appreciation of the negative effect of coercive hospitalization, except when risk is very high. On the other hand, some of the forces have been less focused on patient needs: budget-driven cuts in public hospital beds divorced from population-based need; managed care's profit-driven impact on private psychiatric hospitals and outpatient services; and purported patient-centered approaches promoting non-hospital care that may under-recognize that some extremely ill patients need years of painstaking effort to make a community transition.The result has been a reconfiguration of the country's mental health system that, at times, leaves large numbers of people without adequate mental health and substance abuse services. Often their only option is to seek care in medical emergency departments (ED) that have not been designed for the needs of mentally ill patients. Increasingly, many of those individuals end up waiting in EDs for appropriate care and disposition for hours or days. This overflow phenomenon has become so prevalent that it has been given a name: "boarding." This practice is almost certainly detrimental to patients and staff, and it has spawned efforts on multiple fronts to understand and resolve it. When considering solutions, both ED-focused and systemwide considerations must be explored. This resource document provides an overview and recommendations regarding this complex topic.
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Affiliation(s)
- Kimberly Nordstrom
- University of Colorado School of Medicine, Department of Psychiatry, Aurora, Colorado
| | - Jon S. Berlin
- Medical College of Wisconsin, Department of Psychiatry and Behavioral Medicine, Milwaukee, Wisconsin
| | - Sara Siris Nash
- Columbia University Irving Medical Center, Department of Psychiatry, New York, New York
| | - Sejal B. Shah
- Harvard Medical School, Department of Psychiatry, Boston, Massachusetts
- Brigham and Women’s Hospital, Department of Psychiatry, Boston, Massachusetts
| | - Naomi A. Schmelzer
- Harvard Medical School, Department of Psychiatry, Boston, Massachusetts
- Brigham and Women’s Hospital, Department of Psychiatry, Boston, Massachusetts
| | - Linda L.M. Worley
- University of Arkansas for Medical Sciences-Northwest, Department of Psychiatry, Fayetteville, Arkansas
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Accueillir le patient en crise aux urgences psychiatriques : étude du vécu subjectif. ANNALES MEDICO-PSYCHOLOGIQUES 2019. [DOI: 10.1016/j.amp.2018.03.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Wilson MP, Shenvi C, Rives L, Nordstrom K, Schneider S, Gerardi M. Opportunities for Research in Mental Health Emergencies: Executive Summary and Methodology. West J Emerg Med 2019; 20:380-385. [PMID: 30881561 PMCID: PMC6404701 DOI: 10.5811/westjem.2019.1.39260] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 01/22/2019] [Accepted: 01/25/2019] [Indexed: 12/05/2022] Open
Abstract
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.
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Affiliation(s)
- Michael P Wilson
- University of Arkansas for Medical Sciences, Department of Emergency Medicine, Little Rock, Arkansas
| | - Christina Shenvi
- University of North Carolina, Department of Emergency Medicine, Chapel Hill, North Carolina
| | - Loren Rives
- American College of Emergency Physicians, Irving, Texas
| | - Kimberly Nordstrom
- University of Colorado School of Medicine, Department of Psychiatry, Denver, Colorado
| | - Sandra Schneider
- American College of Emergency Physicians, Irving, Texas.,John Peter Smith Hospital, Department of Emergency Medicine, Fort Worth, Texas.,Hofstra Northwell School of Medicine, Hempstead, New York
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Dombagolla MH, Kant JA, Lai FW, Hendarto A, Taylor DM. Barriers to providing optimal management of psychiatric patients in the emergency department (psychiatric patient management). Australas Emerg Care 2019; 22:8-12. [DOI: 10.1016/j.auec.2019.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 12/17/2018] [Accepted: 01/03/2019] [Indexed: 10/27/2022]
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Meyer JD, McKean AJS, Blegen RN, Demaerschalk BM. Emergency Department Telepsychiatry Service Model for a Rural Regional Health System: The First Steps. Telemed J E Health 2018; 25:18-24. [PMID: 29742036 DOI: 10.1089/tmj.2017.0293] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Emergency departments (EDs) have recognized an increasing number of patients presenting with mental health (MH) concerns. This trend imposes greater demands upon EDs already operating at capacity. Many ED providers do not feel they are optimally prepared to provide the necessary MH care. One consideration in response to this dilemma is to use advanced telemedicine technology for psychiatric consultation. INTRODUCTION We examined a rural- and community-based health system operating 21 EDs, none of which has direct access to psychiatric consultation. Dedicated beds to MH range from zero (in EDs with only 3 beds) to 6 (in an ED with 38 beds). MATERIALS AND METHODS We conducted a needs assessment of this health system. This included a survey of emergency room providers with a 67% response rate and site visits to directly observe patient flow and communication with ED staff. A visioning workshop provided input from ED staff. Data were also obtained, which reflected ED admissions for the year 2015. RESULTS The data provide a summary of provider concerns, a summary of MH presentations and diagnosis, and age groupings. The data also provide a time when most MH concerns present to the ED. DISCUSSION Based upon these results, a proposed model for delivering comprehensive regional emergency telepsychiatry and behavioral health services is proposed. CONCLUSIONS Emergency telepsychiatry services may be a tenable solution for addressing the shortage of psychiatric consultation to EDs in light of increasing demand for MH treatment in the ED.
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Affiliation(s)
- James D Meyer
- 1 Department of Psychiatry and Psychology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Alastair J S McKean
- 1 Department of Psychiatry and Psychology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Rebecca N Blegen
- 2 Center for Connected Care, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Bart M Demaerschalk
- 2 Center for Connected Care, Mayo Clinic College of Medicine and Science, Rochester, Minnesota.,3 Department of Neurology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
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Heyland M, Delaney KR, Shattell M. Steps to Achieve Universal Suicide Screening in Emergency Departments: A Call to Action. J Psychosoc Nurs Ment Health Serv 2018; 56:21-26. [PMID: 29741746 DOI: 10.3928/02793695-20180503-03] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 03/01/2018] [Indexed: 11/20/2022]
Abstract
American individuals attempt suicide at alarmingly high rates of approximately 1.1 million times per year. Yet the United States has failed to adopt a systematic approach to suicide prevention, particularly via universal screening. Given the increasing number of individuals with suicidal ideation presenting to emergency departments (EDs), all patients who present to the ED for treatment should be screened, as opposed to only individuals with mental health complaints. In the current article, barriers to suicide screening in the ED are discussed, as well as strategies to move ED providers toward the goal of universal screening. The current article entreats nurses to be leaders in achieving universal screening and provides practical actions to begin the process. Specific recommendations for action include improving training, increasing lethal means assessment, and achieving compliance with The Joint Commission suicide screening guidelines. [Journal of Psychosocial Nursing and Mental Health Services, 56(10), 21-26.].
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Deriving a Framework for a Systems Approach to Agitated Patient Care in the Emergency Department. Jt Comm J Qual Patient Saf 2018; 44:279-292. [PMID: 29759261 DOI: 10.1016/j.jcjq.2017.11.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 11/13/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND The rising agitated patient population presenting to the emergency department (ED) has caused increasing safety threats for health care workers and patients. Development of evidence-based strategies has been limited by the lack of a structured framework to examine agitated patient care in the ED. In this study, a systems approach from the patient safety literature was used to derive a comprehensive theoretical framework for addressing ED patient agitation. METHODS A mixed-methods approach was used with ED staff members at an academic site and a community site of a regional health care network. Participants consisted of resident and attending physicians, physician assistants/nurse practitioners, nurses, technicians, and security officers. After a simulated agitated patient encounter to prime participants, uniprofessional and interprofessional focus groups were conducted, followed by a structured thematic analysis using a grounded theory approach. Quantitative data consisted of surveys of violence exposure and attitudes toward patient aggression and management. RESULTS Data saturation was reached with 57 participants. Violence exposure was higher for technicians, nurses, and officers. Conflicting priorities and management challenges occurred due to four main interconnected elements: perceived complex patient motivations; a patient care paradox between professional duty and personal safety; discordant interprofessional dynamics mitigated by respect and trust; and logistical challenges impeding care delivery and long-term outcomes. CONCLUSION Using a systems approach, five interconnected levels of ED agitated patient care delivery were identified: patient, staff, team, ED microsystem, and health care macrosystem. These care dimensions were synthesized to form a novel patient safety-based framework that can help guide future research, practice, and policy.
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Abstract
OBJECTIVES Pediatric mental illness poses a significant burden with an overall prevalence of approximately 10%. Increasingly, children with mental disorders seek care in the emergency department (ED). However, the ED is not an ideal setting. Pediatric mental health patients receive limited treatment and experience significantly longer length of stay (LOS) than other patients seen in the ED. This study examines patient and hospital factors associated with LOS and prolonged LOS (PLOS). METHODS This is a retrospective chart review of patients between the ages of 3 and 17 presenting at 2 participating urban EDs with a psychiatric diagnosis from May 2010 to May 2012. RESULTS This study includes 939 patients with an average age of 14.1 years and a median LOS of 295 minutes. The diagnosis was the strongest predictor of LOS and PLOS. Patients with a psychotic disorder or suicide attempt or ideation experienced a longer LOS, 35% and 55% increases, respectively, and an increased odds of PLOS (odds ratio, 3.07 and 8.36, respectively). Patient sex, previous history of self-harm, and the daily census were associated with both a longer LOS and PLOS. Ethnicity, site of admission, and year of admission were only associated with LOS. CONCLUSIONS Diagnosis-specific management factors are the primary determinant of LOS. However, some patient characteristics and hospital operational factors are also associated with LOS. Organizational reforms and an evaluation of the required human and material resources are necessary to improve access to and availability of pediatric mental health care.
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Abstract
Depression is the leading cause of disability globally, and more than one-half of those suffering with depression are not receiving effective treatment. Untreated or undertreated depression poses a significant risk for suicide. Suicide is the 10th leading cause of death in the United States. The emergency room provides an essential opportunity to screen for depression as well as suicide and to provide important and evidence-based interventions. The Basic Suicide Assessment Five-step Evaluation (B-SAFE) model provides a structure for all physicians to assess suicide risk and intervene.
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Ng P, McGowan M, Goldstein M, Kassardjian CD, Steinhart BD. The impact of CT head scans on ED management and length of stay in bizarre behavior patients. Am J Emerg Med 2017; 36:213-217. [PMID: 28789887 DOI: 10.1016/j.ajem.2017.07.080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 07/26/2017] [Accepted: 07/26/2017] [Indexed: 12/21/2022] Open
Abstract
METHODS A 5-year retrospective chart review was conducted at 3 EDs. Inclusion criteria were patients ≥18years old triaged as "mental health - bizarre behavior" (deviation from normal cognitive behaviour with no obvious cause) with a CT head scan ordered in the ED. Exclusion criteria were focal neurologic deficits on exam, alternative medical etiology (i.e. delirium, trauma) and/or pre-existing CNS disease. Clinical, demographic and administrative data were extracted with 10% of charts independently reviewed by an Emergency Physician for inter-rater reliability. RESULTS 266 cases met study criteria. Population demographics: 49% percent female, average age 51years old, 28% homeless, 58% arrived by police or ambulance. CT head results: 1 (0.4%) case with possible acute findings, 105 (39%) with incidental findings (i.e. cerebral atrophy) that did not impact clinical management. Average time to physician assessment was 1:48 (hour:min) (sd 1:11), time to CT completion was 5:05 (sd 7:28) and an average delay of 3:17 awaiting results. Subgroup analysis revealed a net increase in ED length of stay (ED LOS) of 5:02 from obtaining neuroimaging. 85% of patients were referred to a consultant, 92% were to psychiatry. CONCLUSIONS CT head results prolonged ED LOS, delayed patient disposition and did not change the patient's clinical management. A prospective trial for ordering CT head scans in these patients is warranted.
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Affiliation(s)
- P Ng
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Canada.
| | - M McGowan
- Emergency Medicine, St. Michael's Hospital, Canada
| | - M Goldstein
- Department of Psychiatry, University of Toronto, Canada
| | - C D Kassardjian
- Division of Neurology, Department of Medicine, University of Toronto, Canada
| | - B D Steinhart
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Canada; Emergency Medicine, St. Michael's Hospital, Canada
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Abstract
Psychiatric emergencies are acute disturbances in thought, behavior, mood, or social relationship that require immediate intervention as defined by the patient, family, or social unit to save the patient and/or others from imminent danger. Ensuring the safety of the patient, surrounding persons, and the medical team is the first step of evaluation. Treatment focuses on stabilization of the patient, then on specific symptoms and ultimately the cause of symptoms. There are important legal considerations, particularly regarding involuntary admissions. It is important to debrief with the patient, surrounding family, and the health care team to ensure a continued therapeutic alliance and the emotional health of all involved.
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Affiliation(s)
- Santina Wheat
- Northwestern McGaw Family Medicine Residency Program, Erie Family Heath Center, 2750 West North Avenue, Chicago, IL 60647, USA.
| | - Dorothy Dschida
- Northwestern McGaw Family Medicine Residency Program, Erie Family Heath Center, 2750 West North Avenue, Chicago, IL 60647, USA
| | - Mary R Talen
- Northwestern McGaw Family Medicine Residency Program, Erie Family Heath Center, 2750 West North Avenue, Chicago, IL 60647, USA
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Wong AH, Combellick J, Wispelwey BA, Squires A, Gang M. The Patient Care Paradox: An Interprofessional Qualitative Study of Agitated Patient Care in the Emergency Department. Acad Emerg Med 2017; 24:226-235. [PMID: 27743423 DOI: 10.1111/acem.13117] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 09/30/2016] [Accepted: 10/06/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The emergency department (ED) has been recognized as a high-risk environment for workplace violence. Acutely agitated patients who perpetrate violence against healthcare workers represent a complex care challenge in the ED. Recommendations to improve safety are often based on expert opinion rather than empirical data. In this study we aim to describe the lived experience of staff members caring for this population to provide a broad perspective of ED patient violence. The findings of this study will contribute to the development of a comprehensive framework for ED agitated patient care that will guide safety interventions. METHODS We conducted uniprofessional focus groups and individual interviews using a phenomenologic approach with emergency medicine resident physicians, ED staff nurses, patient care technicians, and hospital police officers at an urban hospital in New York City. Audio recordings were transcribed and coded for thematic analysis using the constant comparison method. RESULTS We reached theoretical saturation with 31 interprofessional participants. Three broad themes emerged from our analysis: 1) ED healthcare workers provide high-quality care to a marginalized patient population that concurrently poses safety threats, creating a patient care paradox; 2) teamwork is critical to safely managing this population, but hierarchy and professional silos hinder coordinated care between healthcare professionals; and 3) environmental challenges and systems issues both in and outside the ED exacerbate threats to safety. CONCLUSION The experience of ED staff members while caring for agitated patients is complex and multidimensional. We identified issues that coalesced into four tiers of healthcare delivery at the individual, team, environment, and system levels. Future research is needed to determine applicability of our findings across institutions to build a comprehensive framework for ED agitated patient care.
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Affiliation(s)
| | | | | | | | - Maureen Gang
- Department of Emergency Medicine NYU School of Medicine New York NY
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Abstract
OBJECTIVES This article reviews recent trends in the provision of psychiatric services to the emergency departments of tertiary hospitals in Australia, involving the establishment of specialised in-reach or liaison services as well as various forms of short stay unit attached to emergency departments. The Emergency Psychiatry Service at Flinders Medical Centre, South Australia, is described as a case example. Its specialised models of assessment and clinical care are described, highlighting how these are differentiated from more traditional models in inpatient, community and general hospital consultation-liaison psychiatry. CONCLUSIONS Emergency psychiatry, and in particular the application of specialised psychiatric models of in-reach service and short stay units, is an increasingly important and growing field of psychiatry that warrants further exploration in research. The Emergency Psychiatry Service at Flinders Medical Centre has developed a distinct group of assessment and treatment approaches that exemplifies this growing field.
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Affiliation(s)
- Paul Cammell
- Senior Psychiatrist, Department of Psychiatry, Flinders Medical Centre, Adelaide, SA, Australia
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Anderson EL, Nordstrom K, Wilson MP, Peltzer-Jones JM, Zun L, Ng A, Allen MH. American Association for Emergency Psychiatry Task Force on Medical Clearance of Adults Part I: Introduction, Review and Evidence-Based Guidelines. West J Emerg Med 2017; 18:235-242. [PMID: 28210358 PMCID: PMC5305131 DOI: 10.5811/westjem.2016.10.32258] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Accepted: 10/13/2016] [Indexed: 11/22/2022] Open
Abstract
Introduction In the United States, the number of patients presenting to the emergency department (ED) for a mental health concern is significant and expected to grow. The breadth of the medical evaluation of these patients is controversial. Attempts have been made to establish a standard evaluation for these patients, but to date no nationally accepted standards exist. A task force of the American Association of Emergency Psychiatry, consisting of physicians from emergency medicine and psychiatry, and a psychologist was convened to form consensus recommendations on the medical evaluation of psychiatric patients presenting to EDs. Methods The task force reviewed existing literature on the topic of medical evaluation of psychiatric patients in the ED (Part I) and then combined this with expert consensus (Part II). Results In Part I, we discuss terminological issues and existing evidence on medical exams and laboratory studies of psychiatric patients in the ED. Conclusion Emergency physicians should work cooperatively with psychiatric receiving facilities to decrease unnecessary testing while increasing the quality of medical screening exams for psychiatric patients who present to EDs.
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Affiliation(s)
- Eric L Anderson
- University of Maryland, Department of Psychiatry, College Park, Maryland
| | - Kimberly Nordstrom
- University of Colorado School of Medicine, Department of Psychiatry, Aurora, Colorado; Denver Health Medical Center, Emergency Psychiatry, Denver, Colorado
| | - Michael P Wilson
- Department of Emergency Medicine Behavioral Emergencies Research lab, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jennifer M Peltzer-Jones
- Henry Ford Hospital, Senior Staff Psychologist, Department of Emergency Medicine, Detroit, Michigan
| | - Leslie Zun
- Chicago Medical School, Department of Emergency Medicine, North Chicago, Illinois
| | - Anthony Ng
- Uniformed Services School of Medicine, Department of Psychiatry, Bethesda, Maryland
| | - Michael H Allen
- University of Colorado School of Medicine, Department of Psychiatry, Aurora, Colorado
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Chesin MS, Stanley B, Haigh EAP, Chaudhury SR, Pontoski K, Knox KL, Brown GK. Staff Views of an Emergency Department Intervention Using Safety Planning and Structured Follow-Up with Suicidal Veterans. Arch Suicide Res 2017; 21:127-137. [PMID: 27096810 DOI: 10.1080/13811118.2016.1164642] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The objective of this study is to summarize staff perceptions of the acceptability and utility of the safety planning and structured post-discharge follow-up contact intervention (SPI-SFU), a suicide prevention intervention that was implemented and tested in five Veterans Affairs Medical Center emergency departments (EDs). A purposive sampling approach was used to identify 50 staff member key informants. Interviews were transcribed and coded using thematic analysis. Almost all staff perceived the intervention as helpful in connecting SPI-SFU participants to follow-up services. A slight majority of staff believed SPI-SFU increased Veteran safety. Staff members also benefited from the implementation of SPI-SFU. Their comfort discharging Veterans at some suicide risk increased. SPI-SFU provides an appealing option for improving suicide prevention services in acute care settings.
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Maruca-Sullivan PE, Goldenberg MN, Cone DC, Ciarleglio J. Missing the point: self-inflicted traumatic brain injury in psychosis. BMJ Case Rep 2016; 2016:bcr-2016-216767. [PMID: 28003228 DOI: 10.1136/bcr-2016-216767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 36-year-old man was brought to the emergency department by emergency medical services after being found acting unusually at a gas station with blood on his head and clothing. He presented acutely psychotic and reported that he had a pen in his head. Medical evaluation was notable for a superficial puncture wound to the right temple, and he was medically cleared for psychiatric evaluation. After he developed nausea and headache later that evening, the CT scan revealed a temporal bone fracture, pneumocephalus, intraparenchymal haemorrhage and the presence of a metal pen tip lodged in the brain parenchyma. The full nature of the injury went undiscovered in the emergency department for 16 hours due to the superficial appearance of the injury and his acute psychosis with prominent delusional thought content and disorganisation. He underwent craniotomy with removal of the pen and subsequent hospitalisation for intravenous antibiotics, followed by a prolonged psychiatric hospitalisation for psychosis.
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Affiliation(s)
| | | | - David C Cone
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
| | - Justine Ciarleglio
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
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Hall A, McKenna B, Dearie V, Maguire T, Charleston R, Furness T. Educating emergency department nurses about trauma informed care for people presenting with mental health crisis: a pilot study. BMC Nurs 2016; 15:21. [PMID: 27013926 PMCID: PMC4806472 DOI: 10.1186/s12912-016-0141-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 03/16/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Practicing with trauma informed care (TIC) can strengthen nurses' knowledge about the association of past trauma and the impact of trauma on the patient's current mental illness. An aim of TIC is to avoid potentially re-traumatising a patient during their episode of care. A TIC education package can provide nurses with content that describes the interplay of neurological, biological, psychological, and social effects of trauma that may reduce the likelihood of re-traumatisation. Although mental health nurses can be TIC leads in multidisciplinary environments, the translation of TIC into clinical practice by nurses working in emergency departments (EDs) is unknown. However, before ED nurses can begin to practice TIC, they must first be provided with meaningful and specific education about TIC. Therefore, the aims of this study were to; (1) evaluate the effectiveness of TIC education for ED nursing staff and (2) describe subsequent clinical practice that was trauma informed. METHODS This project was conducted as exploratory research with a mixed methods design. Quantitative data were collected with an 18-item pre-education and post-education questionnaire. Qualitative data were collected with two one-off focus groups conducted at least three-months after the TIC education. Two EDs were involved in the study. RESULTS A total of 34 ED nurses participated in the TIC education and 14 ED nurses participated in the focus groups. There was meaningful change (p < 0.01, r ≥ 0.35) in 9 of the 18-items after TIC education. Two themes, each with two sub-themes, were evident in the data. The themes were based on the perceived effectiveness of TIC education and the subsequent changes in clinical practice in the period after TIC education. CONCLUSION Emergency department nurses became more informed of the interplay of trauma on an individual's mental health. However, providing care with a TIC framework in an ED setting was a considerable challenge primarily due to time constraints relative to the day-to-day ED environment and rapid turnover of patients with potentially multiple and complex presentations. Despite this, nurses understood the effect of TIC to reduce the likelihood of re-traumatisation and expressed a desire to use a TIC framework.
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Affiliation(s)
- Andrea Hall
- Emergency Department, The Royal Melbourne Hospital, Melbourne Health, Parkville, Australia
| | - Brian McKenna
- School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Vikki Dearie
- Western Victorian Mental Health Learning & Development Cluster, Melbourne Health, Parkville, Australia
| | - Tessa Maguire
- Forensicare, Fairfield, Australia ; Centre for Forensic Behavioural Science, Swinburne University, Clifton Hill, Australia
| | - Rosemary Charleston
- Western Victorian Mental Health Learning & Development Cluster, Melbourne Health, Parkville, Australia
| | - Trentham Furness
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Fitzroy, Australia ; NorthWestern Mental Health, The Royal Melbourne Hospital, Parkville, Australia
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Halmer TC, Beall RC, Shah AA, Dark C. Health Policy Considerations in Treating Mental and Behavioral Health Emergencies in the United States. Emerg Med Clin North Am 2015; 33:875-91. [DOI: 10.1016/j.emc.2015.07.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Turner JE, Zun LS. An Evidence-Based Approach to Medical Clearance of Psychiatric Patients in the Emergency Department. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2015. [DOI: 10.1007/s40138-015-0088-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Tucci V, Siever K, Matorin A, Moukaddam N. Down the Rabbit Hole: Emergency Department Medical Clearance of Patients with Psychiatric or Behavioral Emergencies. Emerg Med Clin North Am 2015; 33:721-37. [PMID: 26493519 DOI: 10.1016/j.emc.2015.07.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Patients presenting with behavior or psychiatric complaints may have an underlying medical disorder causing or worsening their symptoms. Misdiagnosing a medical illness as psychiatric can lead to increased morbidity and mortality. A thorough history and physical examination, including mental status, are important to identify these causes and guide further testing. Laboratory and ancillary testing should be guided by what is indicated based on clinical assessment. Certain patient populations and signs and symptoms have a higher association with organic causes of behavioral complaints. Many medical problems can present with or exacerbate psychiatric symptoms, and a thorough medical assessment is imperative.
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Affiliation(s)
- Veronica Tucci
- Section of Emergency Medicine, Baylor College of Medicine, 1504 Taub Loop, Houston, TX 77030, USA.
| | - Kaylin Siever
- Section of Emergency Medicine, Baylor College of Medicine, 1504 Taub Loop, Houston, TX 77030, USA
| | - Anu Matorin
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1502 Taub Loop, NPC Building 2nd Floor, Houston, TX 77030, USA
| | - Nidal Moukaddam
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1502 Taub Loop, NPC Building 2nd Floor, Houston, TX 77030, USA
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Harris B, Beurmann R, Fagien S, Shattell MM. Patients' experiences of psychiatric care in emergency departments: A secondary analysis. Int Emerg Nurs 2015; 26:14-9. [PMID: 26459607 DOI: 10.1016/j.ienj.2015.09.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Revised: 09/05/2015] [Accepted: 09/10/2015] [Indexed: 11/29/2022]
Abstract
The number of psychiatric emergencies presenting to EDs in the United States continues to rise. Evidence suggests that psychiatric ED care encounters can have less than optimal outcomes, and result in stress for providers. The primary aim of this study is to describe the perceptions of ED visits by persons experiencing emotional distress, identifying themes among these that may guide nursing interventions that minimize stress and optimize outcomes in the treatment of psychiatric emergency. This secondary analysis used a qualitative, phenomenological method to analyze a de-identified data set originally collected in a study of experiences of psychiatric emergency in a community based crisis management setting. Findings consist of three major themes: "Emergency rooms are cold and clinical", "They talk to you like you're a crazy person", and "You get put away against your will". An overarching theme through all three is the influence of RN communication, both positive and negative, on patient perceptions of their ED encounters. While nurse-patient communication is basic to all areas of practice, it may be a low priority in the urgent and chaotic context of the ED. However, our findings suggest that increased attention to timely, empathic and validating communication and openness to the patient's reality may decrease severity of symptoms, optimize outcomes, and decrease provider stress.
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Affiliation(s)
- Barbara Harris
- School of Nursing, DePaul University, 990 W. Fullerton Ave., Chicago, IL 60614, USA.
| | - Ross Beurmann
- School of Nursing, DePaul University, 990 W. Fullerton Ave., Chicago, IL 60614, USA
| | - Samantha Fagien
- School of Nursing, DePaul University, 990 W. Fullerton Ave., Chicago, IL 60614, USA
| | - Mona M Shattell
- School of Nursing, DePaul University, 990 W. Fullerton Ave., Chicago, IL 60614, USA
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Afilalo M, Soucy N, Xue X, Colacone A, Jourdenais E, Boivin JF. Characteristics and Needs of Psychiatric Patients With Prolonged Hospital Stay. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2015; 60:181-8. [PMID: 26174218 PMCID: PMC4459245 DOI: 10.1177/070674371506000405] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 07/01/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe the characteristics and needs prior to, on admission, during the first month in hospital, at the thirtieth day of hospitalization and posthospital discharge of psychiatric patients occupying acute beds. METHODS This prospective observational study was conducted in 2 tertiary care hospitals. Adult patients hospitalized on a psychiatric unit for 30 days were identified. Data was collected from their medical charts and interviews with their health care team. The categorization of acute and nonacute status at day 30 was based on the health care professional's evaluation. Descriptive and univariate analyses were performed. RESULTS A total of 262 patients were identified (mean age 45 years), 66% lived at home and 11% were homeless. More than one-half were cognitively impaired and a few had special medical needs. Ninety-seven per cent had been admitted from the emergency department. At day 30, 81% of patients required acute care, while 19% (95% CI 15% to 24%) occupied an acute care bed, despite the resolution of their acute condition. The main reason preventing discharge of nonacute patients was the difficulty or inability to find appropriate resources that met patients' needs. As for patients who required acute care, the most common psychiatric issues were delusions or hallucinations (34%), inability to take medications independently (23.6%), and inadequate control of aggression or impulsivity (16.5%). CONCLUSIONS Prevention of the discharge of nonacute patients is largely due to the difficulty in finding appropriate resources that meet patients' needs. Improved access to community and subacute care resources could potentially facilitate the hospital discharge of psychiatric nonacute patients.
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Affiliation(s)
- Marc Afilalo
- Associate Professor, Department of Medicine, McGill University, Montreal, Quebec; Director, Emergency Department, Jewish General Hospital, Montreal, Quebec
| | - Nathalie Soucy
- Clinical Research Associate, Emergency Department—Research Division, Jewish General Hospital, Montreal, Quebec
| | - Xiaoqing Xue
- Statistician, Emergency Department—Research Division, Jewish General Hospital, Montreal, Quebec
| | - Antoinette Colacone
- Research Coordinator, Emergency Department—Research Division, Jewish General Hospital, Montreal, Quebec
| | - Emmanuelle Jourdenais
- Director, Emergency Department, Centre Hospitalier de L’Université de Montréal, Notre-Dame Hospital, Montreal, Quebec
| | - Jean-François Boivin
- Professor, Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec
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Psychometric Testing of the Agitation Severity Scale for Acute Presentation Behavioral Management Patients in the Emergency Department. Adv Emerg Nurs J 2014; 36:250-70. [DOI: 10.1097/tme.0000000000000014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Is Medical Clearance Necessary for Pediatric Psychiatric Patients? J Emerg Med 2014; 46:800-7. [DOI: 10.1016/j.jemermed.2013.12.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2013] [Revised: 08/22/2013] [Accepted: 12/03/2013] [Indexed: 11/19/2022]
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50
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Performance of a multi-disciplinary emergency department observation protocol for acetaminophen overdose. J Med Toxicol 2014; 9:235-41. [PMID: 23793935 DOI: 10.1007/s13181-013-0310-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
The availability of 20-h N-acetylcysteine (NAC) infusion for low-risk acetaminophen (APAP) overdose enabled our center to implement an Emergency Department observation unit (OU) protocol as an alternative to hospitalization. Our objective was to evaluate our early experience with this protocol. This retrospective cohort study included all patients treated for low-risk APAP overdose in our academic hospital between 2006 and 2011. Cases were identified using OU and pharmacy records. Successful OU discharge was defined as disposition with no inpatient admission. Differences in medians with 95 % confidence intervals were used for comparisons. One hundred ninety-six patients received NAC for APAP overdose with a mean age of 35 years (SD 14); 73 % were white, and 43 % were male. Twenty (10 %) received care in the OU; 3/20(15 %) met criteria for inclusion in the OU protocol and 13/20(65 %) were discharged successfully. Out of the 196 patients, 10 met criteria for inclusion in the OU protocol but instead received care in the inpatient setting. The median total length of stay from presentation to ED discharge was 41 h for all patients treated in the OU, compared to 68 h for ten patients who met criteria for inclusion in the OU protocol but who were admitted (difference 27 h, 95 % CI 18-72 h). ED observation for APAP overdose can be a viable alternative to inpatient admission. Most patients were successfully discharged from the OU. This evaluation identified both over- and under-utilization of the OU. OU treatment resulted in shorter median length of stay than inpatient admission.
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