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Gordillo-Urbano RM, Crespo-Facorro B, Pérez-Solá V, Cardoner N, García-Ligero E, Moreno C, Ramos-Quiroga JA, Ruiz-Veguilla M, Vázquez-Vallejo M, Prados-Ojeda JL. Spanish experts consensus on emergency psychiatric care in hospital emergency departments. BMC Psychiatry 2024; 24:489. [PMID: 38965477 PMCID: PMC11225242 DOI: 10.1186/s12888-024-05939-1] [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] [Received: 03/26/2024] [Accepted: 06/28/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND The demand for urgent psychiatric care is increasing, but in Spain there are no clear recommendations for emergency departments (ED) on how to optimize care for patients with psychiatric emergencies. We aimed to provide expert consensus recommendations on the requirements for general hospitals´ emergency departments to treat patients with urgent psychiatric symptoms. METHODS We used a modified Delphi technique. A scientific committee compiled 36 statements based on literature search and clinical experience. The statements covered the organizational model, facilities, staffing, safety, patient interventions, and staff training. A panel of 38 psychiatry specialists with expertise in psychiatric emergencies evaluated the questionnaire in two rounds. RESULTS After two rounds of voting, 30 out of 36 proposed items (83%) were agreed upon. The panel agreed that psychiatric emergencies should be managed in a general hospital, with dedicated facilities for patient assessment, direct supervision of patients at risk, and an observation unit run by the psychiatric service. In addition to the psychiatrist, the ED should have specialist nurses and security staff available 24/7. Social workers should also be readily available. ED and consulting rooms should be designed to ensure patient and staff safety. A triage system should be established for patients with psychiatric symptoms, with medical evaluation preceding psychiatric evaluation. Guidance on supplies, equipment, and staff training is also provided. CONCLUSION All ED in general hospitals should have adequate resources to handle any psychiatric emergency. This paper provides recommendations on the minimum requirements to achieve this goal.
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Affiliation(s)
- Rafael Manuel Gordillo-Urbano
- Mental Health Clinical Management Unit of the South Health Management Area of Cordoba (Unidad de Gestión Clínica de Salud Mental del Área de Gestión Sanitaria Sur de Córdoba). Hospital Infanta Margarita, Córdoba, Spain
| | - Benedicto Crespo-Facorro
- Department of Mental Health, Hospital Universitario Virgen del Rocío, Seville, Spain
- Department of Psychiatry, School of Medicine, University of Sevilla, Seville, Spain
- Institute of Biomedicine of Seville (Instituto de Biomedicina de Sevilla; IBiS), Seville, Spain
- Spanish Network for Research in Mental Health (Centro de Investigación Biomédica en Red Salud Mental; CIBERSAM), Health Institute Carlos III (Instituto de Salud Carlos III; ISCIII), Madrid, Spain
| | - Víctor Pérez-Solá
- Spanish Network for Research in Mental Health (Centro de Investigación Biomédica en Red Salud Mental; CIBERSAM), Health Institute Carlos III (Instituto de Salud Carlos III; ISCIII), Madrid, Spain
- Mental Health Institute. Hospital del Mar, Barcelona, Spain
- Hospital del Mar Medical Research Institute, Barcelona, Spain
- University Pompeu Fabra, Barcelona, Spain
| | - Narcís Cardoner
- Spanish Network for Research in Mental Health (Centro de Investigación Biomédica en Red Salud Mental; CIBERSAM), Health Institute Carlos III (Instituto de Salud Carlos III; ISCIII), Madrid, Spain
- Sant Pau Biomedical Research Institute, Hospital de La Santa Creu I Sant Pau, Psychiatry and Legal Medicine, UAB, CIBERSAM, Barcelona, Spain
- Department of Psychiatry and Forensic Medicine, School of Medicine Bellaterra, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Elena García-Ligero
- Department of Mental Health, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Carmen Moreno
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, IiSGM, CIBERSAM, ISCIII, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Josep Antoni Ramos-Quiroga
- Spanish Network for Research in Mental Health (Centro de Investigación Biomédica en Red Salud Mental; CIBERSAM), Health Institute Carlos III (Instituto de Salud Carlos III; ISCIII), Madrid, Spain
- Department of Mental Health, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Group of Psychiatry, Mental Health and Addictions, Vall d'Hebron Research Institute (Vall d'Hebron Institut de Recerca; VHIR), Barcelona, Spain
- Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Miguel Ruiz-Veguilla
- Department of Mental Health, Hospital Universitario Virgen del Rocío, Seville, Spain
- Department of Psychiatry, School of Medicine, University of Sevilla, Seville, Spain
- Institute of Biomedicine of Seville (Instituto de Biomedicina de Sevilla; IBiS), Seville, Spain
- Spanish Network for Research in Mental Health (Centro de Investigación Biomédica en Red Salud Mental; CIBERSAM), Health Institute Carlos III (Instituto de Salud Carlos III; ISCIII), Madrid, Spain
| | | | - Juan Luis Prados-Ojeda
- Department of Mental Health, Hospital Universitario Reina Sofía, Córdoba, Spain.
- Morphological and Socio-Sanitary Sciences Department, School of Medicine, University of Córdoba, Córdoba, Spain.
- Maimonides Biomedical Research Institute of Cordoba (Instituto Maimónides de Investigación Biomédica de Córdoba; IMIBIC), Córdoba, Spain.
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Gillard S, Anderson K, Clarke G, Crowe C, Goldsmith L, Jarman H, Johnson S, Lomani J, McDaid D, Pariza P, Park AL, Smith J, Turner K, Yoeli H. Evaluating mental health decision units in acute care pathways (DECISION): a quasi-experimental, qualitative and health economic evaluation. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-221. [PMID: 38149657 DOI: 10.3310/pbsm2274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
Background People experiencing mental health crises in the community often present to emergency departments and are admitted to a psychiatric hospital. Because of the demands on emergency department and inpatient care, psychiatric decision units have emerged to provide a more suitable environment for assessment and signposting to appropriate care. Objectives The study aimed to ascertain the structure and activities of psychiatric decision units in England and to provide an evidence base for their effectiveness, costs and benefits, and optimal configuration. Design This was a mixed-methods study comprising survey, systematic review, interrupted time series, synthetic control study, cohort study, qualitative interview study and health economic evaluation, using a critical interpretive synthesis approach. Setting The study took place in four mental health National Health Service trusts with psychiatric decision units, and six acute hospital National Health Service trusts where emergency departments referred to psychiatric decision units in each mental health trust. Participants Participants in the cohort study (n = 2110) were first-time referrals to psychiatric decision units for two 5-month periods from 1 October 2018 and 1 October 2019, respectively. Participants in the qualitative study were first-time referrals to psychiatric decision units recruited within 1 month of discharge (n = 39), members of psychiatric decision unit clinical teams (n = 15) and clinicians referring to psychiatric decision units (n = 19). Outcomes Primary mental health outcome in the interrupted time series and cohort study was informal psychiatric hospital admission, and in the synthetic control any psychiatric hospital admission; primary emergency department outcome in the interrupted time series and synthetic control was mental health attendance at emergency department. Data for the interrupted time series and cohort study were extracted from electronic patient record in mental health and acute trusts; data for the synthetic control study were obtained through NHS Digital from Hospital Episode Statistics admitted patient care for psychiatric admissions and Hospital Episode Statistics Accident and Emergency for emergency department attendances. The health economic evaluation used data from all studies. Relevant databases were searched for controlled or comparison group studies of hospital-based mental health assessments permitting overnight stays of a maximum of 1 week that measured adult acute psychiatric admissions and/or mental health presentations at emergency department. Selection, data extraction and quality rating of studies were double assessed. Narrative synthesis of included studies was undertaken and meta-analyses were performed where sufficient studies reported outcomes. Results Psychiatric decision units have the potential to reduce informal psychiatric admissions, mental health presentations and wait times at emergency department. Cost savings are largely marginal and do not offset the cost of units. First-time referrals to psychiatric decision units use more inpatient and community care and less emergency department-based liaison psychiatry in the months following the first visit. Psychiatric decision units work best when configured to reduce either informal psychiatric admissions (longer length of stay, higher staff-to-patient ratio, use of psychosocial interventions), resulting in improved quality of crisis care or demand on the emergency department (higher capacity, shorter length of stay). To function well, psychiatric decision units should be integrated into the crisis care pathway alongside a range of community-based support. Limitations The availability and quality of data imposed limitations on the reliability of some analyses. Future work Psychiatric decision units should not be commissioned with an expectation of short-term financial return on investment but, if appropriately configured, they can provide better quality of care for people in crisis who would not benefit from acute admission or reduce pressure on emergency department. Study registration The systematic review was registered on the International Prospective Register of Systematic Reviews as CRD42019151043. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/49/70) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 25. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Steve Gillard
- School of Health and Psychological Sciences, City, University of London, London, UK
| | - Katie Anderson
- School of Health and Psychological Sciences, City, University of London, London, UK
| | | | - Chloe Crowe
- Adult Acute Mental Health Services, North East London NHS Foundation Trust, London, UK
| | - Lucy Goldsmith
- Population Health Research Institute, St George's, University of London, London, UK
| | - Heather Jarman
- Emergency Department Clinical Research Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Sonia Johnson
- Division of Psychiatry, University College London, London, UK
| | - Jo Lomani
- School of Health and Psychological Sciences, City, University of London, London, UK
| | - David McDaid
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Paris Pariza
- Improvement Analytics Unit, Health Foundation, London, UK
| | - A-La Park
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Jared Smith
- Population Health Research Institute, St George's, University of London, London, UK
| | - Kati Turner
- Population Health Research Institute, St George's, University of London, London, UK
| | - Heather Yoeli
- School of Health and Psychological Sciences, City, University of London, London, UK
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Emergency Psychiatry: Updates, Future Directions, and Core Concepts. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2023; 21:70-71. [PMID: 37205034 PMCID: PMC10172547 DOI: 10.1176/appi.focus.23022003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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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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Wilson MP, Hamrick E, Stiebel V, Nordstrom K. Contemporary Practices for Medical Evaluation of the Psychiatric Patient in the Emergency Department. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2023; 21:28-34. [PMID: 37205042 PMCID: PMC10172537 DOI: 10.1176/appi.focus.20220063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Although emergency department (ED) visits for patients with mental illness are frequent, medical evaluation (i.e., "medical screening") of patients presenting with psychiatric complaints is inconsistent. This may largely be related to differing goals for medical screening, which often vary according to specialty. Although emergency physicians typically focus on stabilization of life-threatening diseases, psychiatrists tend to believe that care in the ED is more comprehensive, which often places the two fields at odds. The authors discuss the concept of medical screening, review the literature on this topic, and offer a clinically oriented update to the 2017 American Association for Emergency Psychiatry consensus guidelines on medical evaluation of the adult psychiatric patient in the ED.
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Affiliation(s)
- Michael P Wilson
- Department of Emergency Medicine and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Wilson); Department of Psychiatry (Hamrick, Stiebel) and Department of Emergency Medicine (Stiebel), West Virginia University, Morgantown; Department of Psychiatry, University of Colorado Denver, Denver (Nordstrom)
| | - Edward Hamrick
- Department of Emergency Medicine and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Wilson); Department of Psychiatry (Hamrick, Stiebel) and Department of Emergency Medicine (Stiebel), West Virginia University, Morgantown; Department of Psychiatry, University of Colorado Denver, Denver (Nordstrom)
| | - Victor Stiebel
- Department of Emergency Medicine and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Wilson); Department of Psychiatry (Hamrick, Stiebel) and Department of Emergency Medicine (Stiebel), West Virginia University, Morgantown; Department of Psychiatry, University of Colorado Denver, Denver (Nordstrom)
| | - Kimberly Nordstrom
- Department of Emergency Medicine and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Wilson); Department of Psychiatry (Hamrick, Stiebel) and Department of Emergency Medicine (Stiebel), West Virginia University, Morgantown; Department of Psychiatry, University of Colorado Denver, Denver (Nordstrom)
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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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Srivastava A, Nair R. Utility of Investigations, History, and Physical Examination in "Medical Clearance" of Psychiatric Patients: A Meta-Analysis. Psychiatr Serv 2022; 73:1140-1152. [PMID: 35734861 DOI: 10.1176/appi.ps.202000858] [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] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Few reviews and no meta-analyses have explored the utility of investigations, such as laboratory tests, among patients presenting with psychiatric symptoms, and none has explored the yield of history and physical examination. A meta-analysis of studies exploring the utility of "medical clearance" among adult psychiatric patients was conducted. METHODS PubMed, PsycInfo, and Web of Science were systematically searched from inception until February 15, 2021. Primary outcome was detection by investigations (e.g., bloodwork and imaging), history, or physical examination of an illness that caused or aggravated psychiatric symptoms or was comorbid and that resulted in change in the patient's diagnosis or management ("yield"). A mixed-effects meta-analysis with inverse-variance weighting was used to pool results. RESULTS Twenty-five cross-sectional studies were included. Pooled yield of investigations was 1.1% (95% confidence interval [CI]=0.5%-2.2%), although yield was relatively higher among disoriented, agitated, or older patients. Yield was higher in the inpatient setting, compared with the emergency room, with similar results by approach (protocolized versus nonprotocolized). Compared with investigations, yield of history and physical examination was higher (15.6%, 95% CI=9.1%-25.6%, and 14.9%, 95% CI=8.1%-25.9%, respectively), with nonsignificant differences by evaluator (psychiatrist versus nonpsychiatrist) for physical examination. CONCLUSIONS Investigations were of relatively low yield, especially when weighed against cost and potential harm, and they should not be routinely conducted for patients presenting with primarily psychiatric complaints, although certain subgroups may benefit. History and physical examination, by contrast, should be undertaken for all patients, ideally with participation of the consulting psychiatrist.
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Affiliation(s)
- Anil Srivastava
- Department of Psychiatry, Humber River Hospital, Toronto (Srivastava); Island Health and Department of Family Medicine, University of Victoria, Victoria, British Columbia, Canada (Nair)
| | - Rajesh Nair
- Department of Psychiatry, Humber River Hospital, Toronto (Srivastava); Island Health and Department of Family Medicine, University of Victoria, Victoria, British Columbia, Canada (Nair)
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Salles J, Birmes P, Schmitt L, Bastiani B, Soto M, Lafont-Rapnouil S, Mathur A, Bougon E, Arbus C, Yrondi A. Teaching emergency situations during a psychiatry residency programme using a blended learning approach: a pilot study. BMC MEDICAL EDUCATION 2021; 21:473. [PMID: 34488745 PMCID: PMC8419928 DOI: 10.1186/s12909-021-02887-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 08/19/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Emergency psychiatry is an essential component in the training of psychiatry residents who are required to make patient-centred orientation decisions. This training calls for specific knowledge as well as skills and attitudes requiring experience. Kolb introduced a theory on experiential learning which suggested that effective learners should have four types of abilities: concrete experience, reflective observation, abstract conceptualisation and active experimentation. We aimed to evaluate a resident training programme that we designed for use in an emergency psychiatry setting based on the experimental learning theory. METHODS We designed a four-step training programme for all first-year psychiatry residents: (i) theoretical teaching of psychiatric emergency knowledge, (ii) concrete experience of ability teaching involving an initial simulation session based on three scenarios corresponding to clinical situations frequently encountered in emergency psychiatry (suicidal crisis, hypomania and depressive episodes), (iii) reflective observation and abstract conceptualisation teaching based on videos and clinical interview commentary by a senior psychiatrist for the same three scenarios, (iv) active experimentation teaching during a second simulation session based on the same three frequently encountered clinical situations but with different scenarios. Training-related knowledge acquisition was assessed after the second simulation session based on a multiple-choice quiz (MCQ), short-answer questions and a script concordance test (SCT). The satisfaction questionnaire was assessed after the resident had completed his/her initial session in order to evaluate the relevance of teaching in clinical practice. The descriptive analyses were described using the mean (+/- standard deviation). The comparative analyses were conducted with the Wilcoxon or Student's t tests depending on data distribution. RESULTS The residents' mean MCQ and short-answer question scores and SCT were 7.25/10 (SD = 1.2) 8.33/10 (SD = 1.4), 77.5/100 (SD = 15.8), respectively. The satisfaction questionnaire revealed that 67 % of residents found the teaching consistent. CONCLUSION We designed a blended learning programme that associated, classical theoretical learning to acquire the basic concepts, a learning with simulation training to experiment the clinical situations and a video support to improve learning of interview skills and memory recall. The residents indicate that this training was adequate to prepare them to be on duty. However, despite this encouraging point, this program needs further studies to attest of its efficiency.
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Affiliation(s)
- Juliette Salles
- Service de Psychiatrie et Psychologie, Department of Psychiatry and Psychology, CHU Toulouse (Toulouse University Hospital Centre), F-31000, Toulouse, France
- INSERM U1043, Infinity, Université Paul Sabatier (Paul Sabatier University), Toulouse, France
| | - Philippe Birmes
- Toulouse NeuroImaging Centre, Université de Toulouse (Toulouse University), Inserm, UPS, Toulouse, France
| | - Laurent Schmitt
- Service de Psychiatrie et de Psychologie Médicale, Department of Psychiatry and Medical Psychology, Centre Expert Dépression Résistante FondaMental (Expert Centre for Treatment-Resistant Fundamental Depression), CHU Toulouse, Hôpital Purpan, Toulouse, France
| | - Bruno Bastiani
- Institut Toulousain de Simulation en Santé (ITSIMS), Toulouse Institute for Health Stimulation, Toulouse, France
| | - Maria Soto
- Alzheimer's Disease Research and Clinical Centre, INSERM U 1027, Toulouse University Hospital, Gerontopôle, France
| | - Stéphanie Lafont-Rapnouil
- Pole de Psychiatrie (Psychiatric Emergency Department, Psychiatric Unit), Urgences Psychiatrique, CHU Toulouse, Hôpital Purpan, Toulouse, France
| | - Anjali Mathur
- Service de Psychiatrie et de Psychologie Médicale, Department of Psychiatry and Medical Psychology, Centre Thérapie Brève, Short Treatment Centre, CHU Toulouse, Hôpital Purpan, Toulouse, France
| | - Emmanuelle Bougon
- Pole de Psychiatrie (Psychiatric Emergency Department, Psychiatric Unit), Urgences Psychiatrique, CHU Toulouse, Hôpital Purpan, Toulouse, France
| | - Christophe Arbus
- Service de Psychiatrie et de Psychologie Médicale, Centre Expert Dépression Résistante FondaMental, CHU Toulouse, Hôpital Purpan, ToNIC, Toulouse NeuroImaging Centre, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Antoine Yrondi
- Service de Psychiatrie et de Psychologie Médicale, Centre Expert Dépression Résistante FondaMental, CHU Toulouse, Hôpital Purpan, ToNIC, Toulouse NeuroImaging Centre, Université de Toulouse, Inserm, UPS, Toulouse, France.
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Kverno K, Mangano E. Psychiatric Emergencies and the Potential Role of Psychiatric-Mental Health Nurse Practitioners. J Psychosoc Nurs Ment Health Serv 2021; 59:7-12. [PMID: 33647157 DOI: 10.3928/02793695-20210212-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Emergency departments (EDs) are experiencing a worsening crisis of overcrowding, especially during the coronavirus pandemic. Persons experiencing psychiatric emergencies must be evaluated medically and screened for risks of harm to self or others before they can be cleared for transfer to inpatient units or discharged. Severe shortages of inpatient psychiatric beds can lead to hours or even days of costly boarding in the ED. The purpose of this article is to examine the potential role of psychiatric-mental health nurse practitioners in psychiatric ED care, from initial intake and medical clearance, screening for suicide risk, de-escalation, stabilization, and discharge. [Journal of Psychosocial Nursing and Mental Health Services, 59(3), 7-12.].
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Zwank MD, Rupp PE, Salzman JG, Gudjonsson HP, LeFevere RC, Isenberger KM. Elimination of Routine Screening Laboratory Tests for Psychiatric Admission: A Quality Improvement Initiative. Psychiatr Serv 2020; 71:1252-1259. [PMID: 33106098 DOI: 10.1176/appi.ps.202000121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Research has shown that routine screening laboratory tests for patients with mental health symptoms admitted to psychiatry units find little unexpected clinical abnormalities. This study examined the effects on cost of care and patient safety measures of a hospital change in policy in which such routine tests were no longer required. METHODS This retrospective cohort study analyzed data from all patients admitted from the emergency department (ED) to inpatient psychiatry at a tertiary care hospital 4 months before and 4 months after the policy change. Primary outcome measures were number and costs of laboratory tests ordered in the ED and during the inpatient stay. Secondary measures included length of stay (LOS) and number of hospital consultations during admission, patient transfers to nonpsychiatry services, and inpatient deaths. Chi-square tests and Wilcoxon rank sum tests were used to examine group differences. RESULTS In total, data from 1,910 patients were included (886 preimplementation and 1,024 postimplementation). The median number of lab tests ordered during the hospital stay decreased from three (interquartile range [IQR]=3) to two (IQR=3). The median total lab charges decreased from $445 (IQR=$291) to $312 (IQR=$497). Mean ED LOS decreased by 5.5 hours, and the proportion of patients with no blood lab orders increased from 22% to 40%. No increases in consultations or transfers were noted. No patients died at any point. CONCLUSIONS A policy that avoids routine laboratory screening tests for patients admitted to inpatient psychiatry can save money, improve patient care, and decrease LOS, without increasing adverse outcomes.
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Affiliation(s)
- Michael D Zwank
- Department of Emergency Medicine, Regions Hospital, Saint Paul, Minnesota
| | - Paula E Rupp
- Department of Emergency Medicine, Regions Hospital, Saint Paul, Minnesota
| | - Joshua G Salzman
- Department of Emergency Medicine, Regions Hospital, Saint Paul, Minnesota
| | - Hrafn P Gudjonsson
- Department of Emergency Medicine, Regions Hospital, Saint Paul, Minnesota
| | - Robert C LeFevere
- Department of Emergency Medicine, Regions Hospital, Saint Paul, Minnesota
| | - Kurt M Isenberger
- Department of Emergency Medicine, Regions Hospital, Saint Paul, Minnesota
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Impact of changes in community psychiatric service provision on mental health presentations to the emergency department. Ir J Med Sci 2020; 190:1195-1200. [PMID: 33222076 PMCID: PMC7680212 DOI: 10.1007/s11845-020-02442-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 11/18/2020] [Indexed: 11/18/2022]
Abstract
Background The reconfiguration of many Irish stand-alone psychiatric units has led to many patients in acute mental health need now being assessed in emergency departments (EDs). This has implications for ED resources and raises questions about appropriate assessment location for this group. Aims This report aims to examine the impact of removal of a direct community access point for patients in acute mental health need on ED presentations in a Dublin hospital. Methods We examined data on ED referrals to psychiatry over 5 years: 12 months before the service change, and four subsequent 12-month periods. We compared numbers referred, mode of referral, average ED length of stay, proportion with no physical issue requiring psychiatric assessment only, and numbers who did not wait for psychiatry assessment. Results In the year directly after the service change, referrals to psychiatry from ED increased by 200%, remaining at this level for the subsequent 3 years. Of these, 32.5% were referred by a GP—more than a threefold increase in numbers from the previous year, with both numbers remaining similarly elevated over subsequent years. In the year after the service change, 52.1% of total ED to psychiatry presented solely for mental health reasons—nearly a fourfold increase in cases from the previous year, and remained high. Conclusions Removing a direct community access point for this group resulted in a substantial increase in ED presentations, many of which did not have physical needs. This study has implications for future policy to address the needs of this group, especially in light of the pandemic.
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Roppolo LP, Morris DW, Khan F, Downs R, Metzger J, Carder T, Wong AH, Wilson MP. Improving the management of acutely agitated patients in the emergency department through implementation of Project BETA (Best Practices in the Evaluation and Treatment of Agitation). J Am Coll Emerg Physicians Open 2020; 1:898-907. [PMID: 33145538 PMCID: PMC7593430 DOI: 10.1002/emp2.12138] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 12/26/2022] Open
Abstract
Agitated patients presenting to the emergency department (ED) can escalate to aggressive and violent behaviors with the potential for injury to themselves, ED staff, and others. Agitation is a nonspecific symptom that may be caused by or result in a life-threatening condition. Project BETA (Best Practices in the Evaluation and Treatment of Agitation) is a compilation of the best evidence and consensus recommendations developed by emergency medicine and psychiatry experts in behavioral emergencies to improve our approach to the acutely agitated patient. These recommendations focus on verbal de-escalation as a first-line treatment for agitation; pharmacotherapy that treats the most likely etiology of the agitation; appropriate psychiatric evaluation and treatment of associated medical conditions; and minimization of physical restraint/seclusion. Implementation of Project BETA in the ED can improve our ability to manage a patient's agitation and reduce the number of physical assaults on ED staff. This article summarizes the BETA guidelines and recent supporting literature for managing the acutely agitated patient in the ED followed by a discussion of how a large county hospital integrated these recommendations into daily practice.
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Affiliation(s)
- Lynn P. Roppolo
- University of Texas Southwestern Medical CenterDepartment of Emergency MedicineDallasTexasUSA
| | - David W. Morris
- University of Texas Southwestern Medical CenterDepartment of PsychiatryDallasTexasUSA
| | - Fuad Khan
- University of Texas Southwestern Medical CenterDepartment of PsychiatryDallasTexasUSA
| | - Rohini Downs
- Parkland Memorial HospitalPharmacy ServicesDallasTexasUSA
| | - Jeffery Metzger
- University of Texas Southwestern Medical CenterDepartment of Emergency MedicineDallasTexasUSA
| | - Tiffany Carder
- Parkland Memorial HospitalEmergency Services DepartmentDallasTexasUSA
| | - Ambrose H. Wong
- Yale School of MedicineDepartment of Emergency MedicineNew HavenConnecticutUSA
| | - Michael P. Wilson
- University of Arkansas for Medical SciencesDepartment of Emergency MedicineLittle RockArkansasUSA
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Sweeny A, Keijzers G, O'Dwyer J, Stapelberg NC, Crilly J. Patients with mental health conditions in the emergency department: Why so long a wait? Emerg Med Australas 2020; 32:986-995. [PMID: 32510774 DOI: 10.1111/1742-6723.13543] [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: 12/30/2019] [Revised: 04/16/2020] [Accepted: 04/27/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Patients presenting with a mental health disorder (MHD) wait longer in the ED compared to those presenting for other reasons, potentially placing vulnerable patients at further risk for deterioration. The present study identified factors associated with a long ED stay for patients with a MHD. METHODS Linked ambulance, emergency, pathology, imaging and admission data for an 18-month period were analysed for ED presentations diagnosed with an MHD ICD-10 at a large teaching hospital. Admissions and discharges were considered separately; a long ED stay was defined as the 90th percentile length of stay. Multivariable generalised linear models were built, identifying predictors of a long ED stay for presentations diagnosed with a MHD. RESULTS The sample comprised 1163 admissions and 2242 discharges. For admissions, significant predictors for long ED stay were investigations (pathology or imaging tests), a triage score of 1 or 2, arrival out-of-hours (18.00-05.59 hours) and arrival by ambulance. For discharges, significant predictors of a long ED stay were investigations (pathology or imaging tests), arrival out-of-hours, arrival by ambulance and increasing age. CONCLUSIONS Some factors predictive of a long ED stay for patients presenting to the ED and diagnosed with a MHD varied based on their disposition. For admissions, the most urgent presentations were likely to stay longest. Strategies to reduce ED stay for both admissions and discharges should consider addressing modifiable aspects, including the need for certain investigations, and non-modifiable aspects, including the need for further access to after-hours mental health services in hospital and in the community.
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Affiliation(s)
- Amy Sweeny
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia.,Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - John O'Dwyer
- The Australian e-Health Research Centre, Health and Biosecurity, Commonwealth Scientific and Industrial Research Organisation, Brisbane, Queensland, Australia
| | - Nicolas Cj Stapelberg
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia.,Gold Coast Mental Health and Specialist Services, Gold Coast Health, Gold Coast, Queensland, Australia
| | - Julia Crilly
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
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14
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Fleury MJ, Grenier G, Bamvita JM, Ferland F. Typology of patients who use emergency departments for mental and substance use disorders. BJPsych Open 2020; 6:e59. [PMID: 32489163 PMCID: PMC7345525 DOI: 10.1192/bjo.2020.39] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Identifying profiles of people with mental and substance use disorders who use emergency departments may help guide the development of interventions more appropriate to their particular characteristics and needs. AIMS To develop a typology for the frequency of visits to the emergency department for mental health reasons based on the Andersen model. METHOD Questionnaires were completed by patients who attended an emergency department (n = 320), recruited in Quebec (Canada), and administrative data were obtained related to sociodemographic/socioeconomic characteristics, mental health diagnoses including alcohol and drug use, and emergency department and mental health service utilization. A cluster analysis was performed, identifying needs, predisposing and enabling factors that differentiated subclasses of participants according to frequency of emergency department visits for mental health reasons. RESULTS Four classes were identified. Class 1 comprised individuals with moderate emergency department use and low use of other health services; mostly young, economically disadvantaged males with substance use disorders. Class 2 comprised individuals with high emergency department and specialized health service use, with multiple mental and substance use disorders. Class 3 comprised middle-aged, economically advantaged females with common mental disorders, who made moderate use of emergency departments but consulted general practitioners. Class 4 comprised older individuals with multiple chronic physical illnesses co-occurring with mental disorders, who made moderate use of the emergency department, but mainly consulted general practitioners. CONCLUSIONS The study found heterogeneity in emergency department use for mental health reasons, as each of the four classes represented distinct needs, predisposing and enabling factors. As such, interventions should be tailored to different classes of patients who use emergency departments, based on their characteristics.
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Affiliation(s)
- Marie-Josée Fleury
- Department of Psychiatry, McGill University; and Douglas Mental Health University Institute Research Centre, Quebec, Canada
| | - Guy Grenier
- Douglas Mental Health University Institute Research Centre, Quebec, Canada
| | - Jean-Marie Bamvita
- Douglas Mental Health University Institute Research Centre, Quebec, Canada
| | - Francine Ferland
- School of Social Work, Laval University; and Addiction Rehabilitation Centre, University Integrated Health and Social Services Centre - Capitale-Nationale, Quebec, Canada
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15
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Nentwich LM, Wittmann CW. Emergency Department Evaluation of the Adult Psychiatric Patient. Emerg Med Clin North Am 2020; 38:419-435. [PMID: 32336334 DOI: 10.1016/j.emc.2020.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Many patients with acute behavioral or mental health emergencies use the emergency department for their care. Psychiatric patients have a higher incidence of chronic medical conditions and are at greater risk for injury than the general population. Patients with acute behavioral emergencies may stress already overcrowded emergency departments. This article addresses high-risk areas of the treatment and management of emergency department patients presenting with behavioral emergencies. This article identifies methods successful in determining whether the patient's behavioral emergency is the result of an organic disease process, as well as recognizing other potential acute medical emergencies in this high-risk population.
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Affiliation(s)
- Lauren M Nentwich
- Department of Emergency Medicine, Boston University Medical Center, One Boston Medical Center Place, BCD Building, Boston, MA 02118, USA.
| | - Curtis W Wittmann
- Department of Psychiatry, Massachusetts General Hospital, Founders 826, 55 Fruit Street, Boston, MA 02114, USA
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16
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Goldsmith LP, Smith JG, Clarke G, Anderson K, Lomani J, Turner K, Gillard S. What is the impact of psychiatric decision units on mental health crisis care pathways? Protocol for an interrupted time series analysis with a synthetic control study. BMC Psychiatry 2020; 20:185. [PMID: 32326915 PMCID: PMC7178744 DOI: 10.1186/s12888-020-02581-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 04/02/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The UK mental health system is stretched to breaking point. Individuals presenting with mental health problems wait longer at the ED than those presenting with physical concerns and finding a bed when needed is difficult - 91% of psychiatric wards are operating at above the recommended occupancy rate. To address the pressure, a new type of facility - psychiatric decision units (also known as mental health decision units) - have been introduced in some areas. These are short-stay facilities, available upon referral, targeted to help individuals who may be able to avoid an inpatient admission or lengthy ED visit. To advance knowledge about the effectiveness of this service for this purpose, we will examine the effect of the service on the mental health crisis care pathway over a 4-year time period; the 2 years proceeding and following the introduction of the service. We use aggregate service level data of key indicators of the performance of this pathway. METHODS Data from four mental health Trusts in England will be analysed using an interrupted time series (ITS) design with the primary outcomes of the rate of (i) ED psychiatric presentations and (ii) voluntary admissions to mental health wards. This will be supplemented with a synthetic control study with the same primary outcomes, in which a comparable control group is generated for each outcome using a donor pool of suitable National Health Service Trusts in England. The methods are well suited to an evaluation of an intervention at a service delivery level targeting population-level health outcome and the randomisation or 'trialability' of the intervention is limited. The synthetic control study controls for national trends over time, increasing our confidence in the results. The study has been designed and will be carried out with the involvement of service users and carers. DISCUSSION This will be the first formal evaluation of psychiatric decision units in England. The analysis will provide estimates of the effect of the decision units on a number of important service use indicators, providing much-needed information for those designing service pathways. TRIAL REGISTRATION primary registry: isrctn.com Identifying number: ISRCTN77588384 Link: Date of registration in primary registry: 27/02/2020. PRIMARY SPONSOR St George's, University of London, Cramner Road, Tooting, SW17 ORE. Primary contact: Joe Montebello.
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Affiliation(s)
- L P Goldsmith
- Population Health Research Institute, St George's, University of London, Cramner Road, Tooting, London, SW17 0RE, UK.
| | - J G Smith
- Population Health Research Institute, St George's, University of London, Cramner Road, Tooting, London, SW17 0RE, UK
| | - G Clarke
- The Health Foundation, 8 Salisbury Square, London, UK
| | - K Anderson
- Population Health Research Institute, St George's, University of London, Cramner Road, Tooting, London, SW17 0RE, UK
| | - J Lomani
- Population Health Research Institute, St George's, University of London, Cramner Road, Tooting, London, SW17 0RE, UK
| | - K Turner
- Population Health Research Institute, St George's, University of London, Cramner Road, Tooting, London, SW17 0RE, UK
| | - S Gillard
- Population Health Research Institute, St George's, University of London, Cramner Road, Tooting, London, SW17 0RE, UK
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17
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Screening Electrocardiograms in Cocaine-Positive Chest Pain-Free Psychiatric Patients Requiring Medical Screening. J Emerg Med 2020; 58:290-295. [PMID: 32197895 DOI: 10.1016/j.jemermed.2019.11.037] [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: 05/08/2019] [Revised: 11/04/2019] [Accepted: 11/23/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND The current practice at a large urban academic emergency department (ED) is to obtain screening electrocardiograms (ECGs) as part of the medical screening on all psychiatric patients who test positive for cocaine. OBJECTIVE We sought to examine the impact of an ECG in the medical screening of chest pain-free psychiatric patients who test positive for cocaine. METHODS An institutional review board-approved retrospective chart review from January 2014 to December 2015 was performed on charts of adult ED patients requiring medical screening before transfer to a psychiatric facility. Patients who tested positive for cocaine on urine drug screens were included in this study. Patients with chest pain or those who did not have an ECG recorded were excluded. Outcomes evaluated included disposition and subsequent cardiac work-up. RESULTS One thousand nine hundred sixty-eight ED patients were identified who tested positive for cocaine on a urine toxicology screen, and 853 met the inclusion criteria. ECGs were normal in 812 patients (95% [95% confidence interval 93-96%]) and abnormal in 41 patients (5% [95% confidence interval 4-7%]). Of 41 patients with abnormal ECGs, 4 were admitted for cardiac work-up. Two patients had positive troponin values in the ED, 2 had cardiology consultations, and 3 had further cardiac stress testing, all of which were negative or nondiagnostic. No cardiac catheterizations were performed. CONCLUSIONS Most ED patients with recent cocaine use but without chest pain have a normal ECG. Of the minority with an abnormal ECG, no cases of acute myocardial ischemia or infarction were identified.
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Wilson MP, Moutier C, Wolf L, Nordstrom K, Schulz T, Betz ME. ED recommendations for suicide prevention in adults: The ICAR2E mnemonic and a systematic review of the literature. Am J Emerg Med 2020; 38:571-581. [DOI: 10.1016/j.ajem.2019.06.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 06/17/2019] [Accepted: 06/20/2019] [Indexed: 01/28/2023] Open
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19
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Thrasher TW, Rolli M, Redwood RS, Peterson MJ, Schneider J, Maurer L, Repplinger MD. 'Medical Clearance' of Patients With Acute Mental Health Needs in the Emergency Department: A Literature Review and Practice Recommendations. WMJ : OFFICIAL PUBLICATION OF THE STATE MEDICAL SOCIETY OF WISCONSIN 2019; 118:156-163. [PMID: 31978283 PMCID: PMC7215859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Emergency departments have seen increasing numbers of patients presenting with acute mental illness. Currently, there is not a standard for assessing the medical stability of these patients prior to transfer to inpatient psychiatric services, which causes unnecessary delays in patient care. OBJECTIVE Provide a literature review and multidisciplinary expert consensus recommendations to simplify and expedite the medical evaluation of patients requiring admission to inpatient psychiatric facilities. METHODS A task force with representation from emergency physicians (Wisconsin Chapter of the American College of Emergency Physicians) and psychiatrists (Wisconsin Psychiatric Association) met to create this position statement. The members reviewed clinical practice guidelines and primary literature sources to develop evidence-based recommendations. RESULTS Five categories of recommendations were developed: (1) A detailed history and physical exam should constitute the minimum necessary information required for most medical assessments. (2) Clinical information should guide further diagnostic testing; therefore, receiving facility blanket requirements for routine testing should be abandoned. (3) Emergency physicians should understand the limited medical capabilities of institutes of mental disease. Obtaining reasonable diagnostic testing that is not available at these facilities may be appropriate, though this should not delay patient transfer. (4) Structured medical evaluation algorithms should be used to enhance the uniformity of medical assessments for these patients. This task force recommends the Wisconsin SMART Form. (5) Emergency physicians and psychiatrists should communicate more regularly without intermediaries, both at the clinical encounter and beyond. CONCLUSION The recommendations in this paper are endorsed by the Wisconsin Chapter of the American College of Emergency Physicians and the Wisconsin Psychiatric Association, which strongly urge affected medical providers to adopt them into routine practice.
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Affiliation(s)
- Tony W Thrasher
- Milwaukee County Behavioral Health Division, Milwaukee, Wisconsin
| | - Martha Rolli
- Mendota Mental Health Institute, Madison, Wisconsin
| | | | - Michael J Peterson
- Department of Psychiatry, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - John Schneider
- Milwaukee County Behavioral Health Division, Milwaukee, Wisconsin
| | - Lisa Maurer
- Emergency Medicine Specialists, Wauwatosa, Wisconsin
| | - Michael D Repplinger
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin,
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20
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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. West J Emerg Med 2019; 20:690-695. [PMID: 31539324 PMCID: PMC6754202 DOI: 10.5811/westjem.2019.6.42422] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [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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21
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Peltzer-Jones J, Nordstrom K, Currier G, Berlin JS, Singh C, Schneider S. A Research Agenda for Assessment and Management of Psychosis in Emergency Department Patients. West J Emerg Med 2019; 20:403-408. [PMID: 30881564 PMCID: PMC6404717 DOI: 10.5811/westjem.2019.1.39263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 01/29/2019] [Accepted: 01/29/2019] [Indexed: 11/23/2022] Open
Abstract
Introduction Emergency departments (ED) manage a wide variety of critical medical presentations. Traumatic, neurologic, and cardiac crises are among the most prevalent types of emergencies treated in an ED setting. The high volume of presentations has led to collaborative partnerships in research and process development between experts in emergency medicine (EM) and other disciplines. While psychosis is a medical emergency frequently treated in the ED, there remains a paucity of evidence-based literature highlighting best practices for management of psychotic presentations in the ED. In the absence of collaborative research, development of best practice guidelines cannot begin. A working group convened to develop a set of high-priority research questions to address the knowledge gaps in the care of psychotic patients in the ED. This article is the product of a subgroup considering “Special Populations: Psychotic Spectrum Disorders,” from the 2016 Coalition on Psychiatric Emergencies first Research Consensus Conference on Acute Mental Illness. Methods Participants were identified with expertise in psychosis from EM, emergency psychiatry, emergency psychology, clinical research, governmental agencies, and patient advocacy groups. Background literature reviews were performed prior to the in-person meeting. A nominal group technique was employed to develop group consensus on the highest priority research gaps. Following the nominal group technique, input was solicited from all participants during the meeting, questions were iteratively focused and revised, voted on, and then ranked by importance. Results The group developed 28 separate questions. After clarification and voting, the group identified six high-priority research areas. These questions signify the perceived gaps in psychosis research in emergency settings. Questions were further grouped into two topic areas: screening and identification; and intervention and management strategies. Conclusion While psychosis has become a more common presentation in the ED, standardized screening, intervention, and outcome measurement for psychosis has not moved beyond attention to agitation management. As improved outpatient-intervention protocols are developed for treatment of psychosis, it is imperative that parallel protocols are developed for delivery in the ED setting.
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Affiliation(s)
| | - Kimberly Nordstrom
- University of Colorado School of Medicine, Department of Psychiatry, Denver, Colorado
| | - Glenn Currier
- University of South Florida, Morsani College of Medicine, Department of Psychiatry, Tampa, Florida
| | - Jon S Berlin
- Medical College of Wisconsin, Department of Psychiatry and Behavioral Medicine, Department of Emergency Medicine, Milwaukee, Wisconsin
| | - Cynthia Singh
- American College of Emergency Physicians, Irving, Texas
| | - 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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22
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Shenvi C, Wilson MP, Aldai A, Pepper D, Gerardi M. A Research Agenda for the Assessment and Management of Acute Behavioral Changes in Elderly Emergency Department Patients. West J Emerg Med 2019; 20:393-402. [PMID: 30881563 PMCID: PMC6404700 DOI: 10.5811/westjem.2019.1.39262] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 01/25/2019] [Accepted: 01/29/2019] [Indexed: 11/11/2022] Open
Abstract
Introduction Agitation, mental illness, and delirium are common reasons for older adults to seek care in the emergency department (ED). There are significant knowledge gaps in understanding how to best screen older adults for these conditions and how to manage them. In addition, in areas where research has been performed, implementation has been slow. A working group convened to develop a set of high-priority research questions that would advance the understanding of optimal management of older adults with acute behavioral changes in the ED. This manuscript is the product of a breakout session on "Special Populations: Agitation in the Elderly" from the 2016 Coalition on Psychiatric Emergencies' first Research Consensus Conference on Acute Mental Illness. Methods Participants were identified with expertise in emergency medicine (EM), geriatric EM, and psychiatry. Background literature reviews were performed prior to the in-person meeting in four key areas: delirium; dementia; substance abuse or withdrawal; and mental illness in older adults. Input was solicited from all participants during the meeting, and questions were iteratively focused and revised, voted on, and ranked by importance. Results Fourteen questions were identified by the group with high consensus for their importance related to the care of older adults with agitation in the ED. The questions were grouped into three topic areas: screening and identification; management strategies; and the approach to delirium. Conclusion It is important for emergency physicians to recognize the spectrum of underlying causes of behavioral changes, have the tools to screen older adults for those causes, and employ methods to treat the underlying causes and ameliorate their symptoms. Answers to the identified research questions have great potential to improve the care of older adults presenting with behavioral changes.
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Affiliation(s)
- Christina Shenvi
- University of North Carolina, Department of Emergency Medicine, Chapel Hill, North Carolina
| | - Michael P Wilson
- University of Arkansas for Medical Sciences, Department of Emergency Medicine, Little Rock, Arkansas
| | - Alessandra Aldai
- University of California, San Diego Medical Center, Department of Emergency Medicine San Diego, California
| | - David Pepper
- Hartford Hospital/Institute of Living, Department of Psychiatry, Hartford, Connecticut
| | - Michael Gerardi
- Morristown Medical Center, Department of Emergency Medicine, Morristown, New Jersey
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Gignac E, Dogbey GY, Capece G, McMichael B, Aldrich J, Brannan GD. Controlled Substance Use Among Psychiatric Patients in a Rural North Carolina Emergency Department. West J Emerg Med 2018; 20:419-425. [PMID: 30881566 PMCID: PMC6404695 DOI: 10.5811/westjem.2018.11.40234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 11/04/2018] [Accepted: 11/01/2018] [Indexed: 11/27/2022] Open
Abstract
Introduction Emergency department (ED) visits for mental health and substance use disorders have been on the rise, with substance use disorders frequently coexisting with mental health disorders. This study evaluated substances commonly used/abused by patients presenting to the ED of a rural, regional medical center with subsequent admission for mental health treatment in Robeson County, North Carolina. Methods This retrospective, single-center study was approved by the Southeastern Health Institutional Review Board. We reviewed medical records of psychiatric patients presenting to the ED with ultimate admission to the inpatient psychiatric unit between January 1, 2016, and June 30, 2016. Frequencies of controlled substances testing positive on urine drug and alcohol screenings in admitted patients were obtained and analyzed. We also made ethnic and gender comparisons. Results A total of 477 patients met inclusion criteria. The percentage of patients testing positive were as follows: tetrahydrocannabinol (THC) (40%); cocaine (28.7%); alcohol (15.1%); benzodiazepines (13%); opiates (9.6%); amphetamines (2.9%); barbiturates (2.3%); and methadone (0.8%). A relatively higher proportion of patients tested positive for THC than any other substance (p≤.0002). We found statistically significant differences for gender (p=.0004) and ethnicity (p<.0001) compositions regarding substance use/abuse. Conclusion The majority of admitted psychiatric patients in this study tested positive for at least one controlled substance. The two substances that most often returned positive on the urine drug screen test in our sample were THC (marijuana) and cocaine. These findings may provide insight into concomitant substance abuse and psychiatric disorders, which could instigate public policy development of preventative health initiatives that explore the relationship between controlled substance use/abuse and mental health disorders in rural counties like Robeson County.
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Affiliation(s)
- Elizabeth Gignac
- Campbell University School of Osteopathic Medicine, Southeastern Health, Emergency Services, Department of Medicine, Lumberton, North Carolina
| | - Godwin Y Dogbey
- Campbell University School of Osteopathic Medicine, Department of Clinical Research and Medical Education, Lillington, North Carolina
| | - Gregory Capece
- Campbell University School of Osteopathic Medicine, Southeastern Health, Department of Graduate Medical Education, Lumberton, North Carolina
| | - Benjamin McMichael
- Campbell University School of Osteopathic Medicine, Southeastern Health, Department of Graduate Medical Education, Lumberton, North Carolina
| | - Julie Aldrich
- Campbell University School of Osteopathic Medicine, Lillington, North Carolina
| | - Grace D Brannan
- Campbell University School of Osteopathic Medicine, Department of Clinical Research and Medical Education, Lillington, North Carolina
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24
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Medical Screening of Mental Health Patients in the Emergency Department: A Systematic Review. J Emerg Med 2018; 55:799-812. [DOI: 10.1016/j.jemermed.2018.09.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 08/01/2018] [Accepted: 09/01/2018] [Indexed: 11/17/2022]
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25
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Simpson SA, Monroe C. Implementing and Evaluating a Standard of Care for Clinical Evaluations in Emergency Psychiatry. J Emerg Med 2018; 55:522-529.e2. [DOI: 10.1016/j.jemermed.2018.07.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 07/06/2018] [Accepted: 07/11/2018] [Indexed: 11/28/2022]
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Etlouba Y, Laher A, Motara F, Moolla M, Ariefdien N. First Presentation with Psychotic Symptoms to the Emergency Department. J Emerg Med 2018; 55:78-86. [DOI: 10.1016/j.jemermed.2018.04.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 03/29/2018] [Accepted: 04/10/2018] [Indexed: 10/16/2022]
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Moukaddam N, Shah A, Shah AA. Emergency Psychiatry: How Far Have We Come? Psychiatr Ann 2018. [DOI: 10.3928/00485713-20171128-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Moukaddam N, Udoetuk S, Tucci V, Shah AA. Exclusionary Criteria for Inpatient Hospitalization: Quality Safeguards or Unnecessary Roadblocks? Psychiatr Ann 2018. [DOI: 10.3928/00485713-20171205-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Wilson MP, Nordstrom K, Hopper A, Porter A, Castillo EM, Vilke GM. Risperidone in the Emergency Setting is Associated with More Hypotension in Elderly Patients. J Emerg Med 2017; 53:735-739. [PMID: 28987309 DOI: 10.1016/j.jemermed.2017.06.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 03/17/2017] [Accepted: 06/28/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Expert consensus panels have recommended risperidone as first-line treatment for agitation of psychiatric origin. However, there are few if any studies on this medication in the emergency setting. OBJECTIVES To assess the hemodynamic effects of risperidone in an emergency department (ED) setting, stratified by age. METHODS This is a structured chart review of all patients who received oral risperidone over a 6-year period in an ED setting, excluding patients who received this medication as a prescription refill. Vital signs were analyzed for this subset prior to and after medication administration, and changes in vital signs were stratified by age. RESULTS The median dose of risperidone was less in patients aged > 65 years. However, the median drop in systolic blood pressure was larger in this age group compared with younger patients. CONCLUSIONS Clinicians tend to be more cautious with dosing of risperidone to geriatric patients in the ED. Despite this, decreases in systolic blood pressure are larger and more frequent in this age group. When possible, clinicians should consider or attempt nonpharmacologic methods of agitation treatment prior to administering medications such as risperidone to elderly patients.
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Affiliation(s)
- Michael P Wilson
- Department of Emergency Medicine Behavioral Emergencies Research (DEMBER), University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Kimberly Nordstrom
- Department of Emergency Medicine Behavioral Emergencies Research (DEMBER), University of Arkansas for Medical Sciences, Little Rock, Arkansas; Psychiatric Emergency Services, Denver Health Medical Center; University of Colorado at Denver, Denver, Colorado
| | - Austin Hopper
- Department of Emergency Medicine Behavioral Emergencies Research (DEMBER), University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Austin Porter
- Arkansas Department of Health, Little Rock, Arkansas; Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Edward M Castillo
- Department of Emergency Medicine Behavioral Emergencies Research (DEMBER), University of Arkansas for Medical Sciences, Little Rock, Arkansas; Department of Emergency Medicine, UC San Diego Health System, University of California San Diego, San Diego, California
| | - Gary M Vilke
- Department of Emergency Medicine Behavioral Emergencies Research (DEMBER), University of Arkansas for Medical Sciences, Little Rock, Arkansas; Department of Emergency Medicine, UC San Diego Health System, University of California San Diego, San Diego, California
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