Course Faculty IPS 2012 Course 01 Emergency Psychiatry: A Contemporary Paradigm from Theory to Practice Jon S. Berlin, M.D.

Jodi S. Lofchy, M.D. Anthony T Ng, M.D. Leslie Zun, M.D.

THURSDAY, OCTOBER 4, 2012 8:00 AM-12 NOON COURSE 1 EMERGENCY PSYCHIATRY: A CONTEMPORARY PARADIGM FROM THEORY TO PRACTICE EDUCATIONAL OBJECTIVES:

At the conclusion of this session, the participant should be able to: 1) Identify the history of the development of Psychiatric Emergency Services (PES); 2) Recognize unique clinical needs to the care of psychiatric patients in the emergency setting; 3) Identify challenges to incorporating and integrating psychiatric care in the emergency setting; 4) Identify a paradigm to develop PES in collaboration with emergency medicine and 5) Incorporate identified strategies into the ongoing quality matrix.

Course Time Schedule/Agenda

1. Introduction Introduction of faculty and topics and review of participants PES experience (10 min) 2. Overview of Emergency Psychiatry and PES Introduction on PES Ng (15 min) 3. The Initial Presentation and Evaluation Introduction to the concepts of engagement; emergency medication; and cycles of data collection, identification of precipitants, formulation and intervention - Berlin (40 min) 4. Risk Assessment Overview of issues and pragmatic skills for psychiatrists in evaluating suicidal and homicidal risks Ng (30 min) 5. Break (15 min.) 6. Evaluation and Management in PES Using example from an existing emergency room, evaluation and management of patients as well as how programmatic and environmental factors in both evaluation and management Lofchy (45 minutes) 7. Medical Clearance and Collaboration with Emergency Medicine Overview of medical clearance issues and collaboration between psychiatrist and emergency medicine Zun (45 min) 8. Wrap up, Questions and Course evaluation (10 min) *Each speaker will include at least 5 minutes of questions/answers and questions at the end of his/her presentation.

Emergency Psychiatry: A Contemporary Paradigm of Care I. Introduction II. Historic overview 1. Emergency services evolution 2. Community mental health legislation (early 1960s) required programs to have emergency services to qualify for federal funding. 3. In the 1970s and 1980s psychiatric emergency services began to appear with > 3000 services reported in 1994. 4. By 1980, PES was chief entry point into mental health system for many and only source of treatment for some chronically mentally ill. Current Emergency Psychiatry Issues 1. Increased demand 2. Increasing complicated co-morbidity 3. Increased quagmire of social issues 4. Increased safety concerns 5. Increased medico-legal concerns 6. Insufficient knowledge base and research 7. System vs. clinical concerns 8. Inadequate interface between emergency psychiatry and community psychiatry The Changing Psychiatric Emergency Service (PES) Through the 1980s and 1990s: 1. Specialized teams of professionals were formed. 2. Specialized treatment options followed with advent of newer safer drugs, resources for community alternatives to hospitalization. 3. Just as emergency medicine evolved from triage to treatment, and then to specialized treatment that reached into the community, so did emergency psychiatry. Basic Functions and Structure of PES Consultation vs. formal Crisis care: assessment and intervention Gatekeeper role Continuity care Community support services: suicide hotlines, linkage to services Additional functions of PES VI. Implications of Emergency Psychiatric Services Use 1. Maintain narrow focus only on pathology 2. Overshadow other problems (i.e., psychosocial, financial)

III.

IV.

V.

3. 4. 5. 6. VII.

Reliance on the quick fix Labeling patient Disability issues System overload

Opportunities in PES 1. Be proactive and shift focus away from the acute crisis 2. Look beyond the psychiatric pathology 3. Recognize patients concerns and preferences 4. Empower the patient 5. Elicit social support/family 6. Empower the community 7. Decrease burden on existing emergency medical services 8. Decrease stigma Future of Emergency Psychiatry 1. Patient-centered care 2. PES role within overall health system 3. Knowledge and evidence-based practice 4. Future research 5. Integration of technology

VIII.

Oct 2011 Jon Berlin MD IPS Course on Emergency Psychiatry, Oct 2011 2 OUTLINES Initial Presentations and Evaluation 1. Emergency work often requires rapid, repeated cycles of data collection, synthesis, intervention 2. Early focus on safety and engagement 3. Also focus on patient request and the reason for presenting now 4. Involuntary status and the challenge of engagement 5. Adversarial presentations 6. Narcissistic injury 7. Countertransference 8. Acute agitation 9. New concepts and emphasis 10. Hearing and being heard 11. Authoritativeness, not authoritarianism 12. Medicationgraduated approach 13. Second generation antipsychotics

14. Classic and contemporary goals of treating agitation Risk Assessment 1. Centrality of psychiatric assessment 2. Enigma of the mental status exam 3. Risk factors 4. Protective factors 5. Documentation 6. Consultation 7. Impossibility of prediction and the standard of care 8. Enhancing interview skills for better MSE 9. Reformulating the chief complaint as attempt at self-cure 10. Common deficit of words and trusting relationships 11. Common reliance on action-oriented coping skills 12. Creation of false self to avoid examination 13. Appreciate defenses while probing 14. Risk reduction and alliance building

Management of Risk Dr. Ng I: Goal of risk management II: Crisis a. Why do patients have crisis b. How does crisis affect patients c. How does crisis affect clinicians III: Risk assessment a. Extrinsic factors b. Intrinsic factors IV: Response to crisis a. Environmental management b. Situational management c. Project BETA a. Medical Evaluation and Triage b. Psychiatric Evaluation c. Verbal De-escalation d. Psychopharmacology of Agitation e. Use and Avoidance of Seclusion and Restraint V: Review of Involuntary commitment VI: Brief Overview of Project BETA

Jodi Lofchy, MD Organizing Emergency Services in Psychiatry: The University Health Network Experience I: Overview Emergency Psychiatry- what is it? II: Models of best practice III: Psychiatric Emergency Services Unit [PESU]- the model IV: Systems and supports V: Evaluation- what works and what doesnt VI:A work in progress

Evidenced Based Evaluation of the Psychiatric Patient Leslie Zun, MD I: Medical Clearance Purpose a. Primary Purpose - To determine whether a medical illness is causing or exacerbating the psychiatric condition. b. Secondary Purpose - To identify medical or surgical conditions incidental to the psychiatric problem that may need treatment.

II: Primary Purpose Etiology a. Drug and alcohol intoxication or withdrawal b. Medical c. Hypoglycemia d. Hyperthyroidism e. Delirium f. Dementia g. Head Trauma h. Temporal Lobe Epilepsy/Psychiatric III: Delirium vs. dementia Excited Delirium (2009 ACEP Statement) Features Pain intolerance Tachypnea Sweating Agitation Tactile hyperthermia

Underlying associations Stimulant drug use Psychiatric disease Psychiatric drug withdrawal Metabolic disorders Treatment Agitation-Benzodiazepines, Anti-psychotics, Ketamine Hyperthermia Acidosis Rhabdomyolysis IV: Primary Purpose - Differentiate Medical from Psychiatric Etiology Age >45 years old Prior psychiatric/medical history Abnormal vital signs Physical examination findings Cognitive deficits Focal neurologic findings New or different psychiatric complaints Laboratories? Advanced testing? V: Secondary Purpose - Incidental Medical Problems

VI:What are the capabilities of the receiving psychiatric facility? Assessments Monitor vital signs Routine neurological monitoring Glucose finger sticks Fluid input and output Clinical laboratories Radiographic procedures Treatment Insertion and maintenance of urinary catheters Oxygen administration and suction Fracture care Intramuscular and subcutaneous injections

VII: Medical Clearance Components History Physical exam Mental status examination Testing

VIII: How to reconcile testing? Is testing clinically driven or routine? What labs are done? CBC, electrolytes, Patients on meds Drug screen, alcohol level Altered mental status without etiology When is more advanced testing indicated? EKG CT Scan Head Chest radiograph Which patients? All comers or selected patients What do the experts say? IX: Evaluation of Intoxication? Clinical Assessment of intoxication Cognitive function Neurologic function Coordination Gait Nystagmus Mood Behavior Perception Types of intoxicants Depressed level of consciousness Alcohol, Sedatives, Opioids, Marijuana Elevated level of consciousness Amphetamine, Cocaine, Phencyclidine Altered Mood, cognition, concentration or orientation Alcohol, Inhalants, Hallucinogens, Steroids, Withdrawal states

Emergency Psychiatry: A Contemporary Paradigm of Care

Faculty

Anthony T. Ng, MD Jon Berlin, MD Jodi Lochy, MD Leslie Zun, MD

Disclosure

Consultant to Alexza Pharmaceuticals

Glick, et al (eds) Emergency Psychiatry: Principles and Practice, Lippincott, Williams and Wilkins, 2008.

The Community Mental Health Movement

Community mental health legislation (early 1960s) required programs to

have emergency services to qualify for federal funding.

In the 1970s and 1980s psychiatric emergency services began to appear

with > 3000 services reported in 1994.

As the number of services grew, so did the number of patients utilizing

the services. -deinstitutionalization -increased drug use -increased homelessness -maldistribution of resources
By 1980, PES was chief entry point into mental health system for many

and only source of treatment for some chronically mentally ill.

Allen, Psychiatric Quarterly 1996;67:247-262.

Current Trends

ED visit increased by 20% and mental health visits by 28% (48.7 to 62.5 per 1000 ED visits) between 1992-2001
Larkins, et al. 2005

Between 1992 and 2001, anxiety-related visits were common (16% of all mental health visits) and increased significantly from 3.5 to 5.0 visits per 1000 U.S. population over the decade (p = .011)
Smith, et al., 2008

Psychiatric emergencies are a frequent reason for calls for EP (12%) equaling trauma-related and neurological emergencies The most frequent reasons for calls were alcohol intoxication, states of agitation and suicidal behavior.
Pajonk, et al., 2008

Emergency Psychiatry Pyramid

Individual Patient

Families/Friends/ Psychiatric Professionals

Public At Large

Current Emergency Psychiatry Issues

Increased demand Increasing complicated co-morbidity Increased quagmire of social issues Increased safety concerns

Current Emergency Psychiatry Issues

Increased medico-legal concerns Insufficient knowledge base and research System vs. clinical concerns Inadequate interface between emergency psychiatry and community psychiatry

What is a Psychiatric Emergency?

The Changing PES

Throughout these decades of growth, most PESs remained sites of

triage and referral often run entirely by non-specialized medical ER staff or by none medical community mental health staff.
As the PES became recognized as the unintended gateway to mental

health care, it made sense for emergency services to play a central access role because: -visibility of ER in community -concentration of medical and psychiatric resources in one location -better medication options -psychoeducational and self-help strategies -rising costs -decreased access to care (managed care, lack of insurance)
Allen, Psychiatric Quarterly 1996;67:247-262.

Psychiatric Emergency Services

Intake sources may include:
Family Walk-in Clinics using CPEP as off-hours coverage Police AOT ACT Emergency commitment Supportive housing
Modified from presentation by Sederer, L., 2008

Presently, PESs are often thought of as a location rather than a process of crisis resolution.

Dispositions may include:

PES

Hospitalization Outpatient clinic Home

Structure and Function of the PES

Structure Consultation only services -psychiatrist/mental health professional (MSW) consults to medical ED in a general hospital -in some areas (rural) an outreach team member comes from community mental health center to consult VS. Formal psychiatric emergency services with staff and space dedicated to management of behavioral emergencies -in the general hospital -in psychiatric hospital -free-standing

Structure and Function of the Full-Service or Enhanced, Autonomous PES

Basic Functions -Crisis care: assessment and intervention -Gatekeeper role -Continuity care -Community support services: suicide hotlines, linkage to services The least restrictive interventions should be offered with alternatives to hospitalization

Structure and Function of the Full-Service or Enhanced, Autonomous PES

Additional Functions -Extended observation/crisis hospitalization (24-72 hour) -Training -Research -Links to consumer groups: warm lines -Links to community agencies: police, schools, others

The Structure and Function of the Full-Service or Enhanced, Autonomous PES

Additional Functions: Disaster response and development of disaster psychiatry First point of contact for psych emergencies PES staff are trained to deal in crisis Need to work in chaotic and under-resourced settings Interface with ED and emergency workers (police, fire, EMS) Knowledge and relationship with community resources

The Structure and Function of the Full-Service or Enhanced, Autonomous PES

Physical layout -Based in a general hospital in or near medical ED or it can be a stand alone unit. -In addition secure interview rooms and appropriate staff work areas, also has areas for safe seclusion and restraint, and may have observation and stabilization beds to which patients can be admitted for 24-72 hours. -Might also have a secure community room for patients to wait.

History of the American Association for Emergency Psychiatry (AAEP)

Founded in 1988, after attempts to create working group within the APA failed Support group created to prevent burnout From 1990-1992: started an emergency psychiatry column in Hospital and Community Psychiatry, published first set of PES standards. Mid 90s regular publication of a newsletter, permanent administrative offices established, AAEP begins consultations to institutions with questions about the organization of emergency services. First Janssen Award for Contributions to Emergency Psychiatry 1995

AAEP Mission Statement

AAEP promotes timely, compassionate, quality mental health services for persons with mental illnesses, regardless of their ability to pay, in all crisis and emergency care settings. AAEP represents a multidisciplinary professional membership by: -developing standards to promote excellence in care, -educating the public and health professionals about crisis and emergency mental health care, -encouraging research in all aspects of crisis and emergency psychiatric care, -promoting training and the continuing education of health professionals working in crisis and emergency care settings, -providing opportunities for fellowship among its membership.

AAEP Standards for Psychiatric Emergency Care

Accessibility 24 hr phone and walk-in capability, coordination with police and other agencies, written transfer policies, services provided despite inability to pay. Clinicians with training in emergency mental health care, psychiatrist available 24 hr/day, security, medical consultation and services available, translators available. All patients will receive comprehensive assessment including vital signs and screening medical assessment, mental status exam, medication history, history of recent psychiatric care, and brief psychosocial assessment. and..

Staffing

Management

AAEP Standards for Care

...Management -documented effort to contact current mental health care providers -logs kept on all patients and callers -records and assessments should be standardized -patients should not stay beyond 24 hours, unless licensed holding beds available -lists of dispositions and resource, psychiatric and medical reference materials should be should be readily available -quality assurance and improvement programs should exist Facilities & Equipment Privacy, immediate access to medical emergency services, ability to seclude and restrain, information on patient rights and educational materials for patients available

Danger

= Opportunity

Implications of Emergency Psychiatric Services Use (Danger)

Maintain narrow focus only on pathology Overshadow other problems (i.e., psychosocial, financial) Reliance on the quick fix Labeling patient Disability issues System overload

Opportunities

Be proactive and shift focus away from the acute crisis Look beyond the psychiatric pathology Recognize patients concerns and preferences Empower the patient Elicit social support/family Empower the community Decrease burden on existing emergency medical services Decrease stigma

Next Steps

Better collaboration between the emergency psychiatry, emergency medicine and community psychiatry Greater research into evidence based psychiatric interventions in overlapping system environments Develop benchmark to measure quality of care as well as disease prevention Ongoing advocacy to address public health concerns in emergency psychiatry Develop and sustain alternative crisis intervention to minimize use of emergency psychiatry resources Develop a more user friendly emergency psychiatry system for both patients and mental health clinicians

CRISIS STATES OF MIND: Focusing the Interview in the Assessment of Risk

Jon S Berlin MD AMERICAN PSYCHIATRIC ASSOCIATION 2011

DISCLOSURES & BACKGROUND

No industry ties or conflicts of interest Overseen 150,00 psychiatric emergency cases

JOE & BOBBY

Breathalyzer Urine Blood Walk a straight line

EM PHYSICIAN ROLE IN PSYCH

1.

Medical evaluation Danger to self Danger to others

2.

3.

ROLE OF THE INTERVIEW

Gathering of data, esp. mental status Subjective data (SI & HI) essential if reliable Assessing capacity for engagement

10-MINUTE FOCUSED INTERVIEW

Increases reliability of SI, HI Enhances or evaluates engagement

DISPOSITIONAL ASSESSMENT
A.

Support System Dangerousness Ability to cooperate (engagement)

Bengelsdorf, H, et al. A Crisis Triage Rating Scale: Brief Dispositional Assessment of Patients at Risk for Hospitalization. Journal of Nervous and Mental Disease 172: 424-430. Lippincott Williams & Wilkins, 1984.

B.

C.

CASE EXAMPLE

P.A.s WORK UP
63 yo wf, presents vol Mon 8am, urging of family all w/e. Lives alone, came alone. CC: +AH. Wants meds this morning, has meeting with building contractor at 11am. MSE: 1 wild eye, condescending, polite, rational, cooperative, SI/HI, AOX3, no command AH, not depressed/agitated Voices for years, but neg hx of psych treatment, neg H&P, BAL, UDS, CMP, CBC, TSH, head CT. On no meds. Past legal hx + for stabbing 1st husband and going to prison years ago. Recovering alcoholic since a DV charge 5 yrs ago. Heiress, twice divorced. Sister had schizophrenia, went to prison for murder, committed suicide in prison. Psych can see pt this afternoon, but shes pressed for time.

ACUITY

Low? Moderate? Indeterminate or latent

DIAGNOSIS

Some type of functional psychosis Odd lack of treatment history

ANTIPSYCHOTICS

Give early, if needed and requested Medium strength Stabilizes for more probing exam Softens bad reaction to adverse decisions

FALLACIES OF ED STAFF
SUSAN STEFAN

Its our responsibility to solve problems that wont get solved in the ED or the hospital We are immunizing ourselves from liability by admitting everyone with risk factors.
Stefan, S. Emergency Department Treatment of the Psychiatric Patient. pp 65-72. Oxford University Press, 2006.

MEDICO-LEGAL PERSPECIVE
SUSAN STEFAN

We may reduce risk more by accepting some risk, making the visit a good experience, increasing interest in treatment. Prolonging the stay of persons by force who are not high risk may be agitating. They may escalate, strike out, end up in restraints, get hurt.

PATIENT RESISTANCE

Why now? unanswered Underlying precipitant unclear Creates false self to escape examination

SENSITIVE PERSISTENCE

Appreciate protective function of defensiveness: withheld intent (Shea) Alexithymia: using words is unnatural Persistent search for crisis state of mind

Shea SC. Suicide Assessment. Psychiatric Times. Vol 26 No 12 Dec 3, 2009

CRISIS STATE OF MIND?

Counter patient resistance with sensitive persistence:

What is it like to live with this? What do you think about doing about it? What led to your decision to seek help now?

PRACTITIONER PITFALLS

Allow imperfections of setting to delay or compromise exam with undivided attention

Collude with pts avoidance of emotion Not my job

TEN-MINUTE FOCUSED INTERVIEW

LATENT PSYCHOPATHOLOGY

DYNAMIC MENTAL STATUS

Increased realness, reliability More genuine interaction with examiner

Berlin, J, Gudeman, J. Interviewing for Acuity and the Acute Precipitant, in Emergency Psychiatry: Principles & Practice. Edited by Glick, R et al. Lipincott Williams & Wilkins, 2008.

SHARPENED ASSESSMENT

Crucial new data on SI, HI, engagement Better formulation Unambiguous plan

NASCENT ALLIANCE

Overcoming a guarded or adversarial relationship Engagement in clinical relationship

COLLATERAL HISTORY

Fast Corroborating or not Assessment of support system If premature, hurts doctor-pt relationship

ASSESSMENT IS TREATMENT

Unbearable feelings receive attention Help pt to begin acknowledging them, bearing them, getting them in perspective

Semrad EV. Teaching Psychotherapy of Psychotic Patients. New York: Grune & Stratton; 1969.

PATIENT BOARDING
A.

Secure family or community support Reduce psychosis, promote non-violent coping Promote engagement with treatment

B.

C.

See Benglesdorf Crisis Triage Rating Scale

DISCUSSION
Contact Information: jberlinmd@gmail.com Jon S. Berlin, MD Associate Clinical Professor, Psychiatry & Emergency Medicine Medical College of Wisconsin 8701 Watertown Plank Road Milwaukee, WI 53226 W: (414) 955-8964

INTELLECTUAL SCHEMATA
1.

Gathering data Estimating risk Intervening Documenting

S&O

2.

3.

4.

Meloy, JR. Violence Risk and Threat Assessment. Specialized Training Services, 2000.

SAFE-T

Jacobs

Suicide Assessment Five-step Evaluation and Triage

1. 2. 3. 4. 5.

Modifiable risk factors Modifiable protective factors Suicide inquiry Estimate risk level and intervene Document
Douglas Jacobs, Chair, APA Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors, 2003

C.A.S.E.-Shea
Chronological Assessment of Suicidal Events

Risk factors & protective factors Clinical examination for real suicidal intent Synthesize data into a formulation & plan

Shea SC. The Practical Art of Suicide Assessment. John Wiley & Sons, Inc. Hoboken NJ 2002.

Management of Risk
Anthony T. Ng, MD Medical Director Psychiatric Emergency Services Acadia Hospital
Tel: (207) 973-6345 Email: atng@emh.org

Costs of Agitation

eight patient-to-staff assaults per facility annually, with some centers reporting more than 25 assaults per year1 Most of these assaults resulted in staff injury severe enough to miss work1 one-third of assaults random, but two-thirds occur during containment procedures2
Allen, Currier, Hughes et al. Postgraduate Medicine 2001 Carmel, Hunter. Hospital and Community Psychiatry 1989

1. 2.

Aim of Risk Management

Resolve distress Eliminate or lessen risks of harm to self and others Use of least restrictive and coercive methods Reduce risk of higher level of care Preserve patient dignity

Why Patients have Crisis

Inadequate and inappropriate coping skills Secondary gains Treatment noncompliance Drugs and alcohol relapse Treatment incongruence (patient vs. clinician/clinician vs. clinician) Personality disorder

How Does Crisis Affect Patient?

Fear Anger Anxiety Sadness Loss of control Management of future crisis

How Does Crisis Affect Provider?

Anxiety Sense of failure Disappointment Anger Frustration Empathy

Risk Assessment

Needs to be stratified: high, medium, low risk. (can never say no risk). Based on a combination of static and dynamic risk factors. When asked to evaluate risk - will need to appraise the above expediently, as part of risk assessment.

Risk Assessment Self vs. Others

A.S.S.A.U.L.T.S.

A Assess S Safety S - Suicidality A Aggressive/assaultive behavior U Underlying medical condition L Lethality T Trauma S Substance use/abuse

Extrinsic Factors Affecting Risk Assessment

Level of risks (objective) History of risk behavior Accessibility to means of harm Insight into need for treatment Past psychiatric history Defensive psychiatry

Extrinsic Factors Affecting Risk Assessment

Patient support level Collateral information Ease of procedure Access to psychiatric resources Geography Work load Bed availability

Intrinsic Factors Affecting Risk Assessment

Subjective interpretation Clinician risk tolerance Level of training Past experiences Counter-transferences Ethical considerations (individual vs. group) Collective influences

Risk Assessment is hard to predict (and over-predicted in most cases)

Dilemmas in Risk Assessment and Management of Violence/Suicide

Lack of standardized evaluation Overassessment of violence/suicide potential Concern for the rights of patients Role of treatment vs social enforcer/caretaker

Responses to Patient Crisis

Identify concrete, practical and attainable steps Explain to client steps in resolving the crisis, including referrals Consult colleagues and supervisors Referral to medical treatment More intensive client follow-up

Responses to Patient Crisis

Referral to mobile crisis team Referral to higher level of care, i.e., ACT, crisis bed, partial hospitalization Referral to voluntary hospitalization Referral to involuntary hospitalization

** Hospitalization should be last resort

Partnership vs. Paternalism

Standard of Care for Risk Assessment and Management

Assessing intention Assessing history of suicide and treatment Assessing family history of suicide Assessing for access to means Discussing safety plans Documenting all of the above, including follow-up contacts Documenting least coercive approaches Documenting reasons for coercive approaches DOCUMENT, DOCUMENT

Environmental Management

Secure loose and dangerous objects Secure infrastructure of concerns Egress accessibility Visibility Security Respect patients space Manage acuity

Situation Management What To Do

Check yourself Observe environment Observe dynamics Identify assets and liabilities Find a buddy Empathic/supportive Recognize your limits Take breaks

Best Practices in Evaluation and Treatment of Agitation:

Project BETA

Project BETA Mission

The Project BETA mission was to develop and disseminate guidelines that represent Best practices for the Evaluation and Treatment of Agitation in the emergency setting.

Project BETA Approach

The Project BETA team determined that the guidelines would be ascertained through a synthesis of the best available research and the expert consensus of our seasoned clinicians. Workgroups were established based on the treatment goals of emergency psychiatry.

Treatment Goals of Emergency Psychiatry

Exclude medical etiologies of symptoms Rapidly stabilize the acute crisis Avoid coercion Treat in the least restrictive setting Form a therapeutic alliance Formulate an appropriate disposition and aftercare plan
from Zeller, Primary Psychiatry, 2010

Project BETA Workgroups

Medical Evaluation and Triage Psychiatric Evaluation Verbal De-escalation Psychopharmacology of Agitation Use and Avoidance of Seclusion and Restraint

The six Project BETA articles are the most downloaded articles in the history of the

Western Journal Of Emergency Medicine.

Stories about Project BETA have appeared in

Emergency Medicine News, Psychiatric Times, Psychiatric News, and

many other publications.

Project BETA
Available for free reading or download at the Western Journal of Emergency Medicine Website: http://escholarship.org/uc/uciem_westjem ?volume=13;issue=1 Or through PubMedCentral

Project BETA

Recommendations and Guidelines

Verbal De-escalation

The goal is to help the patient regain control so that he can participate in his evaluation and treatment. While engaging the patient in verbal de-escalation, the clinicians observations and medical judgment must drive decisions regarding management of the patient. Successful de-escalation of the patient is the key to avoiding seclusion and restraint.

Medical Evaluation Psychiatric Evaluation Medication

Deescalation

Seclusion Restraint

Knowledge and Skills are Required

One needs to master techniques of verbal de-escalation and the concurrent evaluation and management of the patient. Like managing other medical emergencies, this requires both knowledge and skills. As in Advanced Cardiac Life Support training, knowledge can be learned in the classroom, but skills require practice.

Benefits of Mastering Skills

Verbal de-escalation usually takes less time than the process of restraint and involuntary medication. Avoiding containment procedures will result in less injuries to both staff members and patients. Patients are more trustful when not restrained or forcibly medicated. Receiving facilities may be more willing to accept a patient who has not been restrained, improving throughput.

The Ten De-Escalation Commandments

I You Shall be non-provocative: calm demeanor, facial expression soft-spoken with no angry tone, empathic - genuine concern relaxed stance- arms uncrossed.. hands open..knees bent II You shall respect personal space 2x arms length Normal eye contact Offer a line of egress expand space if paranoid Move if told to do so III You Shall establish verbal contact: tell them who you are, establish you are keeping them safe, you will allow them no harm you will help them regain control ONE COMMUNICATOR

from Fishkind, Current Psychiatry, 2002

The Ten De-Escalation Commandments

IV You shall be concise: use short phrases or sentences repeat yourself, repeat yourself Get the patients attention..dont confuse V You Shall identify their wants and feelings VIII You shall agree or agree to disagree IX You shall have a moderate show of force and be prepared to use it You Shall debrief with patients and staff

VI You Shall lay down the law: set limits offer choices; propose alternatives establish consequences use positive reinforcements VII You Shall listen: Dont argue Dont up the ante Listen and agree Check understanding

from Fishkind, Current Psychiatry, 2002

Medical Evaluation of Agitation

New onset agitation should be presumed agitation from a general medical condition. There should be a high level of suspicion of agitation from a medical condition in a patient with a concerning past history or where onset is outside of the normal age ranges of psychiatric disease. Routine laboratory testing of agitated patients is not indicated, rather directed testing should be based on the most likely diagnosis.

Goals of Treating Agitation

Reduce dangerous behaviors, distress, anguish Minimize side effects Calm to tranquility, not unconsciousness Minimize need for physical restraints Treat while creating therapeutic alliance Help decrease future episodes of acute agitation

To Use or Not to Use

Broad spectrum of differential diagnosis Age What is pts past experience with meds Perceptions of benefit Co-morbid conditions Clinician comfortability Clinician attitude Clinician rationale for its use

Implications of Medication Use

Risk to patient and/or staff Overshadow other de-escalation techniques Reliance on medication Labeling pt Negatively impacting therapeutic relationship Increase throughput

General medication recommendations

Medications are not chemical restraint, but appropriate agents chosen to treat symptoms Non-pharmacologic approaches first Medication is used to calm, not induce sleep Patients should be involved in the process of selecting medication

Oral medications are preferred over IM

Agitation from a psychiatric illness

Oral meds preferred

Less coercive, therapeutic alliance, reduced risk from needle use, easy to administer with cooperative patient

SGAs preferred for both PO and IM

PO: best evidence for risperidone and olanzapine

Both also available in rapid-dissolving forms

If IM injection needed, best evidence for ziprasidone and olanzapine

If first dose insufficient, benzodiazepine may be added

Why use IM SGA over FGA?

Similar efficacy, but better side effect profile

Less risk of dystonia, akathesia, EPS with SGAs One injection rather than two or three Haloperidol can cause dysphoria; patients often complain of the way it makes them feel later

IM SGAs alone replace the FGA cocktail

Patient Preference

Much less chance of oversedation with SGAs

Complications of Oversedation

Prevents ability to do full medical/psychiatric evaluation, and can mask medical comorbidities Patients unable to answer questions Patients unable to keep self hydrated, other self care Psychiatric consultant will typically not come to evaluate until patient is awake Receiving hospitals/programs unwilling to consider patient transfers until alert, leading to boarding, dispositional delays Unconscious patient not receiving treatment but taking up vital space in ED thus not helping patient while preventing other ED patients from treatment

Agitation from intoxication

Drugs
Benzos are first-line for most drugs (especially stimulants) SGAs for minority of users with psychotic symptoms

Alcohol
Use meds sparingly If needed, FGAs probably safer

Agitation from delirium

Find the cause and correct it If meds needed

Benzos for alcohol/benzo withdrawal SGAs or low-dose haloperidol for agitation from delirium that is not due to alcohol, benzo withdrawal, or sleep deprivation

Restraint/Seclusion

S&R traumatizing to patients and staff

identification and intervention using deescalation techniques Use of protocols and management techniques to guide clinical interventions

Early

Does it work?
A California psychiatric ER using BETA recommendations:
6 months 1/2010 to 6/2010 compared to 6 months 7/2011 to 12/2011

Seclusion/Restraint Assaults

43% 58%

Project BETA
Available for free reading or download at the Western Journal of Emergency Medicine Website: http://escholarship.org/uc/uciem_westjem?vol ume=13;issue=1 Or through PubMedCentral

Timely Medication
Dont rush Dont delay

Legal Process vs. Psychiatry

Involuntary Commitment deprives people of their rights is like arrest is a legal process Psychiatric Treatment pursues a diagnosis attempts amelioration or cure is a medical practice

Elements of Involuntary Commitment

Diagnosis Treatability Least Restrictive High Acuity

Implications of Involuntary Commitment - Short Term

Deprivation of liberty Jeopardizing therapeutic alliance Stigmatizing Quick fix Social control Higher likelihood of hospitalization

Implications of involuntary Commitment - Long Term

Deprivation of other rights Jeopardizing therapeutic alliance Stigmatizing May overshadow other issues Potential for discrimination

Involuntary Commitment

Appropriate medical and psychiatric workup Attempt to develop therapeutic alliance (individually or collectively) Assess for support resources and coping skills Clearly identify benefits of treatment and risks of nontreatment Against Medical Advice discharge (AMA) Must be last option Inform patient of his/her rights

Involuntary Commitment

NEVER mislead a patient

Special Populations

Children Elderly Individuals with past traumatic experiences Individuals with disabilities Cultural groups Medical illnesses Guardianship/Power of attorney Forensic

Organizing Emergency Services in Psychiatry: The University Health Network Experience

Jodi Lofchy MD FRCPC
Director Psychiatric Emergency Services University Health Network, Associate Professor, University of Toronto

Institute of Psychiatric Services New York, October 2012

Learning Objectives
At the end of this session, attendees will have:
1.

2. 3.

Enhanced knowledge of models of best practice in Emergency Psychiatry An appreciation of the PESU model of care An awareness of the systems challenges in creating a Psychiatric Holding unit in an Emergency Department

Overview

Emergency Psychiatry- what is it? Models of best practice The way we were Psychiatric Emergency Services Unit [PESU]- the model Systems and supports Evaluation- what works and what doesnt A work in progress

Psychiatric Emergency Defined

an acute disturbance of thought, mood, behavior or social relationship that requires an immediate intervention as defined by the patient, family or the community It may also be defined as a set of circumstances in which: 1. The behavior or condition of an individual is perceived by someone, often not the identified individual, as having the potential to rapidly eventuate in a catastrophic outcome and 2. The resources available to understand and deal with the situation are not available at the time and place of the occurrence.

APA Task Force on Psychiatric Emergency Services 2002

Trends in Emergency Psychiatry

Deinstitutionalization Accelerated urbanization Increased drug and alcohol abuse Increased appreciation of the role of medical conditions underlying alterations in mental status Homelessness

Trends in Emergency Psychiatry

Aggravation of violence and the increasing numbers of victims of violence Increasing involvement of the patient & family The less central role of the family physician Mental health reform/best practice models

Models of best practice

Goals: Timely rendering of psychiatric emergency care Access to care Safety/stabilization and assessment Continuity of care

(Breslow R., Structure and Function of Psychiatric Emergency Services from Emergency Psychiatry, ed Allen M., 2002)

Models of {best} practice

{Consultation} Psychiatric Emergency Services in Medical Emergency Settings Psychiatric Emergency Service Facility Crisis hospitalization Crisis outpatient follow-up Mobile teams Crisis residences
Breslow, 2002 APA Task Force on Psychiatric Emergency Services 2002

Shifting Objectives in Emergency Psychiatry

Triage Model

Treatment Model

Rapid evaluation Containment Rapid Referral

Comprehensive assessment Broad range of effective services.

An Organizationally Unique Treatment Facility Gerson and Bassuk 1980

Organization and function of academic psychiatric emergency services:

Currier and Allen, General Hosp Psych 25 (2003) 124-129

Survey AAEP PES medical directors US- 51/56 (91%) response 77% (39/51) PES in general hospital

64% (25/39) separate PES; 21% (8/39) component of med ED; 13% (5/39) consultation 96% > 8 hr/d [26% 24/d] 77% had locked area in PES 69% (35/51) informal crisis beds; x = 9.2 beds

Admission rates: approx 1/3 (34%) admitted inpt Length of stay [LOS]: x = 9.0 hrs (SD = 11.3 hr)

Hospital Based Services

Key System Components Space

Takes into account the needs of many, varied patients Nursing and other professional staff Security officers Psychiatric assistants Psychiatrists and other medical specialists Students Toxicology Therapeutic drug levels Laboratory assays and imaging capability

Core Staff

Support Services

The Views of the Client

Initial in-community contact Alternatives to traditional services More hopeful first contact Intake and Waiting Comfortable physical environment Interpersonal emotional support Availability of peer advocate support Assessment and Service Planning Respected person orientation Improved staff training

Treatment Interventions

Patient-practitioner partnerships
Allen, M., (2003) What do Consumers Say they Want and Needs During a Psychiatric Emergency Journal of Psychiatric Practice Vol 9, No. 1.

Emergency Psychiatry at UHN

University Health Network [UHN] =

Toronto General Hospital [TGH] + Toronto Western Hospital [TWH] + Princess Margaret Hospital [PMH] + Toronto Rehabilitation Institute [TRI]

ER at TWH Inpatient at TGH:

18 general psych beds 6 acute care [ACU]

Outpatient at TWH, TGH, PMH

Proportion of Mental Health and Addictions Emergency Department (ED) visits referred to Psychiatry Emergency Services (PES)
Numberofvisits,numberofreferralstoPES,July September,2010

8,769 UHN
1672 9000

TEGH

1139

8000

No.ofMHAvisits

7000

SMH

1418

Not PES 4,813

6000

SJHC

1742

5000

SHSC

457

4000

3000

MSH

1015 2000

Referrals to PES 3,294

CAMH

1326

1000

500

1000

1500

2000

0 All hospitals

Source:DecisionSupportServices;teamanalysis

The Way we Were. Early 1990s until 2005

24 hr psychiatric consultation to the TGH and TWH EDs

Crisis Response Service 1996-2005 Multidisciplinary clinicians 16 hrs/day 7 days/week Psychiatry assistants information collection, collateral, monitoring/escorting patients

Emergency Psychiatry Assessment Unit [EPAU] 8 bed secure unit NOT in ED Urgent Care Clinic [UCC] patients mostly referred through the EDs 4 clinics/week appointments within 1 week of referral

What We Struggled with.

Responsiveness to Psychiatric consultation in ED Lack of space in the ED for psychiatric assessment

2 designated beds Long waiting times frequency of LWBS [left without being seen], agitation, prolonged police stays

Length of Stay [LOS] on the inpatient unit EPAU as satellite acute care unit

Form 3s, 4s! Review boards Inpatient charts, discharge summaries Too many beds (2/8 Impact)

What We Struggled with.

Excessive use of resources to manage agitation

security codes chemical & mechanical restraint

beyond brief therapy 50% f/u visits > 20 session guideline Goal: 95% pts < 20 sessions

UCC

Insufficient time and resources to apply principles of crisis intervention in the ED

PESU- the evolution

CTAS modification [Canadian Triage and Acuity Scale*] Development of the PES Model PES/ED Integration Committee Training and education New unit design/function* * Maintenance of the consultation model within the ED-based PESU
*Beveridge R et al. Canadian Emergency Department Triage and Acuity Scale Can J Emerg Med 1999; 1(3 suppl):S2-28

From EPAU to PESU x 2

March 2005: closure of EPAU 03-07/05: RNs to EDs, PAs - training July 2005: opening of PESU #1 Sept. 2005: problems identified with design 09/05- 12/06: planning for rebuild Dec. 2006- Sept 2007: PESU rebuilding September 2007: opening of PESU #2

PES MODEL Triage Level

PES MODEL Consult Level

PESU

Physically situated in the TWH Emergency Department Safe, secure setting with a capacity for 8 patients, 4 stretchers, 2 lounges, 2 wait spaces Dedicated psychiatric nursing staff, psychiatry assistants, crisis clinicians and on-site resident and staff psychiatrists PES Model supports decisions made by the team

PES MODEL - Disposition

PESU: who are the patients in our unit?

Emergency
ER MD = MRP* Pt. s/b ED Physician +/clinician or PESU nurse 1. Pt. discharged from ED by ER MD 2. Pt referred to psychiatry for consultation then d/cd by

Hold
= MRP Pts referred to psychiatrydecision to hold as an emergency patient for following reasons: stabilization Risk assessment Further collateral required Not likely to require admission
Crisis

Admit
= MRP Disposition after psychiatric consultation: diagnosis Known pt. with pattern of high risk decompensation Will need further stabilization and /or treatment
Complex

*MRP= Most Responsible Physician

Systems and supports

Departmental Emergency department Hospital ER Alliance Computerization Communication

High risk pts: EMIs Cross-site meetings ER/Psych meetings M&M ER/Psych rounds PALC

PESU Staffing (2011)

Days:

1 Staff Psychiatrist (0830-1700) Resident and/or Clinical Clerk (0830-1700) 2 RNs (0730-1930) 2 Clinicians (0800-2000 and 1100-2300) 2 Psychiatric Assistants (0730-1930 and 1100-2300)

Nights:

1 Resident on call/Staff Psychiatrist 2 RNs (1930-0730) 1 Psychiatric Assistant (1930-0730)

Whats Working

Patients are seen straight from triage if presenting with a Mental Health complaintless wait time

Average Crisis Response Times Under 2 Hours

90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 83% 64% 70% 82% 81% 80% 83% 82% 82%

2004

2005

2006

2007

2008

2009

2010

2011

2012

EPAU

PESU

Whats Working

Patients are seen straight from triage if presenting with a Mental Health complaint- less wait time Decrease in number of admits Increased overall volumes

PRE AND POST PESU COMPARISON

Avg. % Admits vs. Total Pts Seen 2004-2005 38.6% 2005-2012 avg. 13.9%*

*Currier & Allen, 2003: x = 34%

EPAU PESU

Whats Working

Patients are seen straight from triage if presenting with a Mental Health complaintless wait time Decrease in number of admits Increased overall volumes Current average LOS in PESU 10.0 hrs Less use of chemical restraint Less use of security

Other variables.
Length of Stay Pre-PESU/EPAU

[ - 2005]
[2006-11] [2011-12]

Avg. LOS:
Avg. LOS

8 days

Post-PESU

13.7 hours* Avg. LOS 10.0 hours*

*Currier & Allen, 2003: x = 9 hrs

Chemical Restraint PESU vs. EPAU: less chemical restraint - received fewer meds overall, less multiple medications, less Haldol used Hypotheses:

Less wait time to see De-escalation by psychiatric staff Containment of a locked unit

(Venos et al, 2006)

Whats Working

Patients are seen straight from triage if presenting with a Mental Health complaint- less wait time Current LOS in PESU @ approx 10.0 hrs Decrease in number of admits Increased overall volumes Less use of chemical restraint

More capacity for crisis intervention work in the ER More capacity for crisis f/u: 4 UCC clinics, max 10 sessions Improved staff morale- recruitment/retention; consumer satisfaction Increased communication, collegiality with ER

Rich educational venue

Morning report revised- resident driven Increasing numbers of students: Medical student electives

2003-04: 20 2005-12: 72

Resident electives:

2008-12: 15

Nursing Social work Sharing model with other centres across the country 18 Local 11 National

A Work in progress

Inpatient beds located at TGH site Challenges unique to UHN and PESU Ongoing communication! Model refinement Medical consultation Managing change Outcome measures-best practices HOLDING AND HELPING.

Evidenced Based Evaluation of the Psychiatric Patient

Leslie S Zun, MD, MBA, FAAEM Chairman and Professor Department of Emergency Medicine RFUMS/Chicago Medical School Mount Sinai Hospital Chicago, Illinois

Learning Objectives
To understand the medical clearance process To understand the controversy that surrounds laboratory testing of the psychiatric patient To use protocols in the evaluation of the psychiatric patients To discuss optimal communication between the ED and psychiatry

Concurrent with Medical Clearance Process

AAEP: Medical Evaluation and Triage of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry BETA De-escalation Work Group, West J Emerg Med 2012:13:3-10.

Simultaneously start medical evaluation and determine the need for immediate treatment Assess glucose and oxygenation levels Pursue symptoms indicating medical problems Treat agitation

Case #1

64 year old female is brought to the hospital for manic behavior. Patient has multiple medical problems but no prior psychiatric history. What further information is needed? What to look for in the physical exam? What testing is indicated?

Case #2

36 year old male with schizophrenia was brought in by the family because he stopped taking his medication and is getting violent at home. What further information is needed? What to look for in the physical exam? What testing is indicated?

Medical Clearance Purpose

Primary Purpose - To determine whether a medical illness is causing or exacerbating the psychiatric condition. Secondary Purpose - To identify medical or surgical conditions incidental to the psychiatric problem that may need treatment.

Primary Purpose Etiology

Schizophrenia Bipolsr Illness Depression

Drug and alcohol intoxication or withdrawal Medical Hypoglycemia Hyperthyroidism Delirium Dementia Head Trauma Temporal Lobe Epilepsy Psychiatric

Psychiatric

Drug intoxication/ withdrawal

Medical

Delirium Dementia Hyperthyroidism Head Trauma Temporal Lobe Epilepsy

Delirium vs.. dementia

Delirium Onset Awareness Alertness Orientation Memory Perception Thinking Language Acute Reduced Fluctuates Impaired Impaired Hallucinations Disorganized Slow Dementia Slow Clear Normal Impaired Impaired Intact Vague Word finding difficulty

Excited Delirium
2009 ACEP Statement

Features

Pain intolerance Tachypnea Sweating Agitation Tactile hyperthermia Stimulant drug use Psychiatric disease Psychiatric drug withdrawal Metabolic disorders Agitation-Benzodiazepines, Anti-psychotics, Ketamine Hyperthermia Acidosis Rhabdomyolysis

Underlying associations

Treatment

Primary Purpose - Differentiate Medical from Psychiatric Etiology

Age >45 years old Lack of psychiatric history Abnormal vital signs Significant physical examination findings Cognitive deficits Focal neurologic findings

Secondary Purpose - Incidental Medical Problems

What are the capabilities of the receiving psychiatric facility?

Assessments

Monitor vital signs Routine neurological monitoring Glucose finger sticks Fluid input and output Clinical laboratories Radiographic procedures Insertion and maintenance of urinary catheters Oxygen administration and suction Fracture care Intramuscular and subcutaneous injections

Treatment

Medical Clearance Components

History Physical

exam Mental status examination Testing

What part of the evaluation is useful?

Olshaker, JS, Browne, B, Jerrard, DA, Prendergast, H, Stair, TO: Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med 1997;4:124-128.

Retrospective, observation study of psychiatric patients over 2 month period 352 patients with 19% having medical problems Sensitivity History 94% Physical exam 51% Vital signs 17% Laboratory testing 20%

History: Is the patient reliable?

Olshaker, JS, Browne, B, Jerrard, DA, Prendergast, H, Stair, TO: Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med 1997;4:124-128.

Patients asked about drug and alcohol use Patients had alcohol and toxicological screening Reliability of patients self-reported history Sensitivity Specificity Drugs 92% 91% ETOH 96% 87%

Type of Mental Status Examination

Zun LS and Gold I: A Survey of the form of mental status examination administered by emergency physicians, Ann Emerg Med,15: 916-922, 1986.

Random sample of 120 EPs in 1983 <5 minutes to perform the test (72%) Tests Used: Level of consciousness 95% Orientation 87% Speech 80% Tests not used: Handedness 35% Calculations 36% Proverbs 38% Majority perceived a need for and would use a short test of mental status (97%) EPs use selected, unvalidated pieces of a standard mental status examination

Appearance, behavior and attitude Disorders of thought Disorder of perception Mood and affect Insight and judgment Sensorium and intelligence

Short Tests
McDowell, I, Newell, C: Measuring Health: A Guide to Rating Scales and Questionnaires 2nd edition. New York: Oxford University Press, 1996. Test

# Items Application Administered by

30 clinical, screening clinical, screening

Time
5-10

Mini-Mental State Exam

interviewer

Clock Drawing 1 Test Short Portable 10 Mental Status Survey Questionnaire Cognitive Capacity Screening Examination 10

self

screening, Interviewer2

clinical

expert

5-15

Use of the Short Tests in the ED

Kaufman, DM, and Zun, LS: A Quantifiable, brief mental status examination for emergency patients: J Emerg Med, 13:449-456, 1995.

Used the Brief Mental Status Examination in an inner city ED Score 0-8 normal, 9-19 mildly impaired 20-28 severely impaired 100 randomly and 100 with indication 72% sensitivity and 95% specificity in identifying impaired individuals

Brief Mental Status Examination* Item Score (number of errors) x (weight) = total What year is it now? 0 or 1 x4 What month is it? 0 or 1 x3 Present memory phase after me and remember it: Brown, 42 Market Street New York About what time is it? 0 or 1 x3 Count backwards from 20 to 1. 0.1. or 2 x2 Say the months in reverse 0, 1, or 2 x2 Repeat the memory phase 0,1,2,3,4 or 5 x2 (each underlined portion is worth 1 point) Final score is equal to the sum of the total(s) =

= = John = = = =

* Katzman, R, Brown, T, Fuld, P, Peck, A, Schechter, R, Schimmel, H: Validation of a short orientation-memory concentration test of cognitive impairment. Am J Psych 1983; 140:734-9.

Physical Exam Performed and Documented by Canadian EPs

Szakowicz, J Emerg Med 2007

Vital Signs Pulse ox Glucose Neuro system Resp system Cardiovascular system Behavior exam

52% 28% 5% 36% 54% 52% 76%

Evidence to Test

Literature review of 16 studies that found

Prevalence of physical illness 15-80% Newly diagnosed 4-80% Causal or related of 5-46% Caused by medical problem 0-8%

Koran, L, Sox, HC, Maron, KI: Medical evaluation of psychiatric patients: Results in a state mental health system. Arch Gen. Psych 1989;46:733-740.

100 patients admitted to psychiatric receiving facility

Excluded patients included those with physical illness, alcohol and substance abuse All patients had blood chemistries, EKG, EEG, urine drug screen, and urinalysis. 46% of psychiatric patients had unrecognized medical illness. 80% of those needed treatment for their illness

Hall, RC, Gardner, ER, Popkin, MK, et. al: Unrecognized physical illness prompting psychiatric admission: A prospective study. Am J Psych 1981; 138: 629-633.

Evidence Not to Test

patients without medical complaints in the emergency department. J Emerg Med 2000;18:173-176.

Korn Study of 212 patients Korn, CS, Currier, GW, Henderson, SO: Medical Clearance of psychiatric

80 patients had psychiatric complaints and past psychiatric history All received comprehensive medical clearance None of the patients had a positive screening labs or x-rays Patients with primary psychiatric complaints with other negative findings do not need ancillary testing in the ED.

patients in the emergency department. Acad Emerg Med 1997;4:124-128.

Olshaker Study of 352 patients with 19% having medical problems Olshaker, JS, Browne, B, Jerrard, DA, Prendergast, H, Stair, TO: Medical clearance and screening of psychiatric

Retrospective, observation study of psychiatric pys over 2 month p Protocol CBC and Chemistries Sensitivity Laboratory testing had 20% sensitivity Screening with universal testing would have missed 2 asymptomatic patients with hypokalemia

How to reconcile testing?

Is testing clinically driven or done as a routine? What labs are done?

CBC, electrolytes,

Is the patients on meds Altered mental status without etiology

Drug screen, alcohol level

When is more advanced testing indicated?

EKG CT Scan Head Chest radiograph All comers or new onset patients American College of Emergency Physicians (ACEP) American Psychiatric Association (APA)

Which patients?

What do the experts say?

Are they clinically driven or routine?

Broderick, KB, Lerner, B, Mccourt, JD, Fraser, E, Salerno, k: Emergency physician practices and requirements regarding the medical screening examination of psychiatric patients. Acad Emerge Med 2002:9:88-92.

Surveyed 500 EPs Routine testing required in 35%

16% by ED protocol 84% required by the psychiatrist UDS Alcohol CBC Electrolytes 86% 85% 56% 56%

Tests

Most believed certain tests were unnecessary EM trained physicians less likely to believe certain tests necessary

Are they clinically driven or routine?

Compared medical clearance of the psychiatric patients performed by emergency physicians to psychiatrists Routine testing Required testing The surveys were distributed to: 1,055 EPs using the Illinois College of Emergency Physicians Directory 117 psychiatrists from the State of Illinois Department of Mental Health

Zun, LS and Downey, L: Comparison of EPs' and psychiatrists' laboratory assessment of psychiatric patients. Am J Emerg Med 2004

Results
Routine CBC EKG Electrolytes Chest X-Ray BMP EEG CMP Breathalyzer LP UA Blood Alcohol Required UDS No tests

Emergency physicians 53.3% 80.3% 18.3% 40.9% 23.7% 51.5% 2.6% 9.1% 31.4% 54.5% 0.0% 9.1% 10.7% 22.7% 2.2% 15.2% 0.2% 3.0% 19.3% 53.0% 68.6% 50.0% 75.1% 14.6% 47.0% 6.1%

Psychiatrists Significance .000* .000* .000* .015* .000* .013* .008* .030* .036* .000* .030* .000* .000*

Psychiatrists routinely order more tests (11/16) and almost the same set of required tests (3/16) than EPs. The number without testing is higher in the EP group than the psychiatrists (14.6% vs.. 6.1%).

Are drug and alcohol testing indicated?

Most drugs or their metabolites are positive for 1-3 days or longer after use

Routine urine toxicologic screens for drugs in alert, awake, cooperative patients do not affect ED management and need not be performed as part of the ED assessment (ACEP Guideline)

Blood alcohol concentrations do not correlate with the degree of intoxication

The patients cognitive abilities, rather than a specific blood alcohol level, should be the basis on which the clinicians begin the psychiatric assessment. (ACEP Guideline) Does not test for all drugs Interference with meds False negative

Urine drug screen are limited

Intoxication is a clinical diagnosis; not a lab diagnosis

Evaluation of Intoxication?

Clinical Assessment of intoxication

Level of consciousness Cognitive function Neurologic function Coordination Gait Nystagmus Depressed level of consciousness Alcohol, Sedatives, Opioids, Marijuana Elevated level of consciousness Amphetamine, Cocaine, Phencyclidine Altered mood, cognition, concentration or orientation Alcohol,
Inhalants, Hallucinogens, Steroids, Withdrawal states

Types of intoxicants

Which patients? Psych history vs. new onset

Hennenman, PL, Mendoza, R, Lewis, RJ: Prospective evaluation of emergency department medical clearance. Ann Emerg Med 1994;24:672-677.

100 consecutive patients aged 16-65 with new psychiatric symptoms. Patients with fever received CT and LP 63 of 100 had organic etiology for their symptoms

History in 27 PE in 6 CBC in 5 SMA-7 in 10 CPK in 6 ETOH and drug screen in 28 CT scan in 8 LP in 3.

Patients need extensive laboratory and radiographic evaluations including CT and LP.

What do the experts say?

Lukens, TW et al: Clinical Policy: Critical issues in the diagnosis and management of adult psychiatric patient in the emergency department. Ann Emerg Med 2006;46:79-99. APA Practice Guidelines on Psychiatric Evaluation of Adults

American College of Emergency Physicians Guidelines

Routine testing laboratory testing of all patients is of very low yield and need not be performed. In adult ED patients with primary psychiatric complaints, diagnostic evaluation should be directed by the history and physical examination. Psychiatrist may need to request or initiate further general medical evaluation to address diagnostic concerns that emerge from the psychiatric evaluation. Psychiatrists and emergency physicians sometimes have different viewpoints on the utility of laboratory screening.

American Psychiatric Association Guidelines

How do we reconcile the differences in the literature?

Zun, LS, Leiken, JB, Scotland, NL et. al: A tool for the emergency medicine evaluation of psychiatric patients (letter), Am J Emerg Med, 14:329-333, 1996

Medical Clearance Checklist

Yes 1. Does the patient have new psychiatric condition? 2. Any history of active medical illness needing evaluation? 3. Any abnormal vital signs prior to transfer? 4. Any abnormal physical exam (unclothed)? 5. Any abnormal mental status indicating medical illness? If no to all of the above questions, no further evaluation is necessary. If yes to any of the above questions go to question #6, tests may be indicated. No

Prospective Medical Clearance of Psychiatric Patients

Zun, LS, Downey, LA: Prospective evaluation of medical clearance. Primary Psychiatry. 2008:15:59-64.

Assessed accuracy of medical clearance protocol Used at four test Chicago EDs that transfer a large # of patients to a State of Illinois Operated Psychiatric Facilities. 19.2% had new psychiatric condition 13.4% had a hx of medical problems No significant difference in patients sent back to ED before and after the use of the protocol due to inadequate clearance

Application of a Medical Clearance Protocol

Zun, LS, Downey, LA: Application of a medical clearance protocol. Primary Psychiatry. November 2007;65-69.

Before and after application of the medical clearance protocol based on 50% of hospital charges. Significance Before After $241 $93 $120 $359 $161 $167 $118 $219 F=10.189, p=.002 ns ns F=7.983, p=.006

Labs Radiology EKG Total

Use of a medical clearance protocol reduces the number and cost of testing (ANOVA F=7.894, p=.006)

Advanced Screening Tool

Shah, SJ, Fiorito, M, McNamara, R: A screening tool to medically clear psychiatric patients in the emergency department. J Emerg Med 2010.

Modified prior protocol into five questions

Stable vital signs Prior psychiatric history or age >30yrs old Oriented times four or FOLSTEIN >23 No evidence of medical problems No visual hallucinations

Retrospective chart review of 500 patients

6 pts were returned & 12 had additional testing 6/6 needed outpt prescriptions & 2/12 admits

When is Testing Indicated?

Red

flags of medical etiology New onset of psychiatric symptoms Altered mental status without etiology Accommodating psychiatric facility

Charts What is documented?

Tintinalli, JE, Peacodk, FW, Wright, MA: Emergency medical evaluation of psychiatric patients. Ann Emerg Med 1994; 23:859-862.

Poor documentation of medical examination of psychiatric patients 298 charts reviewed in 1991 at one hospital Triage deficiencies

Mental status Cranial nerves Motor function Extremities Mental status

56% 45% 38% 27% 20%

Physician deficiencies

Term medically clear documented in 80%

The Term Medically Clear

What does Medically Clear mean?

Patient does not have medical problems?

Tintinalli states the term Medically Clear should be replaced by a discharge note

History and physical examination Mental status and neurologic exam Laboratory results Discharge instructions Follow up plans

Other use the term Medically Stable

Case #1 64 year old female is brought to the hospital for

manic behavior. Patient has multiple medical problems but no prior psychiatric history.

What information is needed?

Prior psychiatric history - none History of medical problems DM, HTN, CVAs Use of drugs and alcohol - Denies Vital signs tachycardia & hypertensive Focal deficits right sided weakness Signs of intoxication Heightened consciousness CBC, electrolytes, UDS, alcohol level EKG, CT scan head, CXR

What to look for in the physical exam?

What testing is indicated?

Patient found to have thyroid disease

Case #2 36 year old male with schizophrenia was brought

in by the family because he stopped taking his medication and is getting violent at home.

What information is needed?

Prior psychiatric history - Yes History of medical problems noncontributory Drug and alcohol use admits to alcohol Vital signs normal Mental status exam auditory hallucinations Physical exam unremarkable Signs of intoxication none

What to look for in the physical exam?

What is testing is indicated? None

Communication with PES or Psychiatric Facility

What is the process of patient acceptance and transfer?

What evaluation is required before acceptance? Is a protocol used? Is the communication between physicians, mental health workers or others?

What information needs to be communicated?

How is the chart, testing and assessments transmitted via faxed, copied or emailed? Is it written, verbal or both? What key points need to be communicated?

Communication with PES or Psychiatric Facility

Is there a process for a hand off between the sending and receiving institution or unit?
Is it standardized? Is this process written or verbal? Is it RN to RN, MD to MD, mental health worker to mental health worker?

What continuing medical care needs to be addressed?

What medical problems does the patient have? What treatments are needed in the receiving facility? How is this communicated to the receiving facility?

Communication with PES or Psychiatric Facility

Does EMTALA apply to the transfer?

What are the EMTALA requirements? Has the patient been stabilized prior to transfer? Has the patient been accepted by a physician?

How is the patient being transferred?

Via ambulance, car or other means? How is safety of transport ensured?

Is there a feedback loop for patients who were transferred? What criteria are used to send a patient back to the ED, if needed?

Case #2 36 year old male with schizophrenia was brought

in by the family because he stopped taking his medication and is getting violent at home.

Hospital does not have a psychiatric unit and the patient will need to be transferred. The emergency physician contacts the on call psychiatrist at the state hospital The psychiatrist requests routine laboratories for the patient due to limited testing at the state hospital. Patient found to have normal hemoglobin, electrolytes, negative drug and alcohol screen State psychiatrist accepts the patient Patient transferred with copy of chart, labs and assessment via ambulance

Take Home Point

The use of a protocol is useful for the medical clearance process Short mental status exams better than current process Testing

Test indicated for patients with new onset of psychiatric illness Testing rarely indicated for patients with known psychiatric illness

Appropriate documentation required- Use Medically Stable Emergency physician must communicate the key points in the patients condition to psychiatry

www.behavioralemergencies.com

Contact Information
Leslie Zun, MD Mount Sinai Hospital 1501 S California Chicago, IL 60608 773-257-6957 zunl@sinai.org

CME questions.

1.

Models of best practice in emergency psychiatry include:

a) crisis hospitalization b) psychiatric emergency services in medical emergency settings c) mobile teams d) crisis out-patient follow-up e) all of the above

Answer: e

2.

Challenging issues in emergency psychiatry include all of the following except:

a) increased medico-legal concerns b) insufficient knowledge base and research c) decreased medical co-morbidity d) increased social service concerns e) increased demand

Answer: c

3.

Prolonged throughput causes the following concerns: a. Increased mortality b. Increased morbidity

c. Increased patient satisfaction d. A and b e. A,b, c

Answer: d

4.

Rapid process redesign improves throughput with a cost in additional personnel that is not offset by revenue. a. True b. False

Answer: b

5.

Reasons for increased use of emergency services by psychiatric patients include all but one of the following: a. b. c. d. e. Lack of outpatient mental health resources Increase due to need for psychiatric services ONLY Increased in co-morbid substance use Increased pressure to minimize psychiatric hospitalization All the following

Answer: b

6.

Careful risk assessment would include assessment of one of all the following: a. b. c. d. e. History of substance abuse Support to help patient maintain safety Presence or availability of weapons such as firearms History of previous risk behaviors All of the above

Answer: e

7.

In an extreme emergency, treatment may sometimes need to precede assessment. a. True b. False

Answer: False 8. Which item is NOT true? Psychiatric emergencies are more likely to occur with individuals who: a. Gravitate toward acting out defenses to cope with painful states of mind. b. Paradoxically, respond better to treatment approaches that do not include medication. c. Have trauma in their background. d. Suffer from difficulty finding words to express their emotions. e. Have intrinsic difficulty giving a simple history of present illness or engaging in treatment. Answer: b

General References: Emergency Psychiatry: Principles and Practice. Glick RL, Berlin JS, Fishkind AB, Zeller SL (2008) Lippicott Williams & Wilkins, Philadelphia, PA. Allen MH, Currier GW, Hughes DH, Docherty JP, Carpenter D, Ross R. Treatment of behavioral emergencies: a summary of the expert consensus guidelines. J Psychiatr Pract. 2003;9(1):16-38. Lukens TW, Wolf SJ, Edlow JA, Shahabuddin S, Allen MH, et al. Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med. 2006;47(1):79-99.

Slade M, Taber D, Clarke MM, et al. Best practices for the treatment of patients with mental and substance abuse illnesses in the emergency department. Dis Mon. 2007;53(11-12):536-580.

References
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Med. 2009; 10-104-109.

4. Daniel W. Spaite DW, Bartholomeaux, F, Guisto J, et al: Rapid process redesign in a

university-based emergency department: Decreasing waiting time intervals and improving patient satisfaction. Rapid Process Redesign, Ann Emerg Med 2002;39:168177.
5. Friedman R, Soreff S, Barton G. The development of emergency psychiatry. Emerg

Health Serv Rev. 1985/1986;3(2/3):3-8.

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