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									                                                                              Psychiatric Emergencies




                  Psychiatric Care in the Emergency Depar tment—Chaos or Crisis?

        a report by
        Patricia Howard, RN, PhD, CEN

        Immediate Past President, Emergency Nurses Association (ENA)




Providing safe and effective care for psychiatric patients         • what testing, if any is needed to determine medical
in the emergency department (ED) has become an                       stability;
increasing challenge in recent years. Crowded, chaotic
EDs have experienced a rising number of visits by                  • whether the results of a urine drug screen influence
patients in need of mental health services.1 According               the management of alert patients with normal vital
to the Centers for Disease Control and Prevention                    signs in the ED with a psychiatric complaint; and
(CDC) in 2003 there were nearly four million ED
visits for mental disorders or related complaints.2                • whether an elevated blood alcohol concentration in
                                                                     an alert and cooperative patient should preclude                 Patricia Kunz Howard, RN, PhD,
Despite this large number of visits, fewer than 20% of               psychiatric evaluation.5                                         CEN, is the Immediate Past
EDs have a mental health center.3 It is the position of                                                                               President of the Emergency Nurses
                                                                                                                                      Association (ENA). The ENA is the
the Emergency Nurses Association (ENA) that                        These are a few examples of the increasing awareness               specialty nursing association serving
psychiatric patients receive the same timely and                   emergency care professionals have of the impact                    the emergency nursing profession
compassionate care as all other patients in a safe                 psychiatric patients have on the ED environment.                   through research, publications,
                                                                                                                                      professional development, and injury
environment.4 Emergency care professionals are                                                                                        prevention. Dr Howard is the
expected to have the knowledge and expertise to care               Psychiatric patients present to the ED for a variety of            emergency department (ED) staff
for these patients as well as systems in place to assure           complaints, ranging from a need for medical clearance              development specialist at the
                                                                                                                                      University of Kentucky Hospital, and
specialty evaluation as needed.                                    for psychiatric in-patient care to life-threatening self-          emergency medical services (EMS)
                                                                   harm situations requiring emergent intervention.The                training coordinator for Lexington
Utilization of ED resources by psychiatric patients                chaotic physical environment in the ED may                         Fire and Emergency Medical
                                                                                                                                      Services. She speaks nationally on
has reached crisis. Professional organizations such as             exacerbate the psychiatric patient’s behavior. Caring              emergency nursing, and is a
the ENA and the American College of Emergency                      for patients with acute mental health issues in the ED             contributing author to the Journal
Physicians (ACEP) have recognized the increased                    can be challenging, requiring additional resources and             of Emergency Nursing and Sheehy’s
                                                                                                                                      Emergency Nursing Principles and
prevalence of mental-health-related complaints. The                expertise. It is essential that the healthcare system              Practices (4th & 5th eds). Dr
ENA has produced a position paper addressing care of               recognizes the need to reduce the disparity of                     Howard has served on the ENA
psychiatric patients in the ED since 1974; the                     emergency care for psychiatric patients.                           board since 2000 and is a member
                                                                                                                                      of the ENA Foundation Management
2006 ENA board of directors identifies care of                                                                                        Board. She has been a member of
the psychiatric patient in the ED in its 2006 strategic            The impact of hospital crowding on ED throughput                   ENA since 1985. She earned her
plan and continues collaborative efforts with                      and the boarding of in-patients is well known. Rising              ADN from Salem College, a BSN,
                                                                                                                                      MSN, and PhD in Nursing from the
mental health nursing specialty organizations.                     demand for emergent psychiatric care and limited                   University of Kentucky. She is a
                                                                   capacity have increased the burden of already                      member of Sigma Theta Tau
The ACEP approved a clinical policy about                          overburdened EDs. It has been reported that                        International (Honor Society of
                                                                                                                                      Nursing), American Nurses
psychiatric patients in the ED dealing with three                  psychiatric patients are boarding in EDs more                      Association (ANA), and American
specific clinical questions:                                       frequently and for greater lengths of time than other              Association of Colleges of Nursing
                                                                                                                                      (AACN).
1. American College of Emergency Physicians ACEP  ,“Emergency departments see dramatic increase in people with mental illness”,
   July 2004. http://www.acep.org/webportal/Newsroom/NR/general 2004/EmergencyDepartmentsSeeDramaticIncreasein
   PeoplewithMentalIllnessEmergencyPhysiciansCIteHealthCa.htm
2. Centers for Disease Control, “Advance Data From Vital and Health Statistics”, 358; May 26, 2005.
   http://www.cdc.gov/nchs/data/ad/ad340.pdf
4. Emergency Nurses Association,“Position statement: medical evaluation of suspected intoxicated and psychiatric patients”, (1999),
   Des Plaines, IL: ENA.
3. Emergency Nurses Association, “2005 ENA National Benchmark Guide”, in progress (2006) Des Plaines, IL: ENA.
5. American College of Emergency Physicians, “ACEP approves clinical policy about psychiatric patients”, (2006)
   www.acep.org/webportal/membercenter/periodicals/an/2006/feb/clinicalpolicy.htm


EMERGENCY MEDICINE & CRITICAL CARE REVIEW 2006                                                                                                                        41
                 Psychiatric Emergencies



     in-patient populations.1 Access to acute psychiatric        health complaint and clinical condition should serve
     care has been strained by psychiatric hospital closures     as the guiding premise that dictates what diagnostic
     and bed reductions nationwide.6                             examinations or procedures are used to determine
                                                                 whether the patient is medically stable.
     Many hospitals do not have in-patient psychiatric
     care and arrangements for mental health coverage can        Patients requesting detoxification from alcohol or
     be difficult to arrange in some areas. ED closures have     other substances are usually required to obtain
     only added complexity to the growing concerns               medical clearance prior to initiation of in-patient
     related to safe and effective care for psychiatric          treatment. Elevated blood alcohol levels often
     patients in the ED. Most EDs do not have dedicated          complicate this process in spite of evidence that
     psychiatric space. In the 2006 ENA Benchmark study          suggests that assessment of cognitive function is more
     only 18.9% of the 444 EDs that participated                 important than blood alcohol levels. Despite this
     responded that there was emergency care space               evidence, emergency care professionals often
     dedicated to mental healthcare within their                 encounter unwillingness by mental health
     department. 3 Mental health emergencies will                professionals to evaluate patients until blood alcohol
     continue to impact ED volume and it is essential            levels are clearly below the recognized legal level for
     that emergency care professionals are able to               intoxication of 0.08mg/dl.
     anticipate their needs as readily as that of the patient
     in cardiac arrest.                                          This is a source of growing concern in EDs as
                                                                 delaying evaluation until alcohol limits are low or, in
     ED visits for psychiatric-related complaints are not        some facilities, essentially zero increases ED length of
     always perceived as medical emergencies. It should be       stay, may occupy staff time and attention when these
     recognized that these patients should be evaluated in       patients are placed on a protective hold and there
     the same manner as all patients who present to the          have been instances where the associated acute
     ED for care. Ensuring that the professional staff have      agitation has disrupted departmental function.
     the resources they need to care for patients with
     psychiatric complaints is essential. This includes          While there has been collaboration among the
     facility considerations such as treatment areas that are    specialties caring for these patients there is a definitive
     free of medical equipment and in some instances free        need to develop even greater collaboration to meet
     of fixtures that the patient may use to harm                the needs of these patients while ensuring their safety
     themselves or others.                                       and the safety of staff as well as other patients.

     Psychiatric patients require closer monitoring in the       The challenges of caring for psychiatric patients in a
     typical ED environment and additional staff may be          crowded ED are not going away in the near future.
     required to maintain a safe environment.                    Healthcare systems are in crisis and the chaos that has
     Determining care needs will be largely dependent on         resulted has made caring for psychiatric patients with
     the reason the patient sought care in the ED.               complex needs all the more difficult. Emergency
                                                                 professionals have to receive adequate training in
     One of the most frequent reasons psychiatric patients       non-violent crisis intervention, have proper staffing
     seek emergency care is a need for medical clearance.4,5     and be able to consult mental health professionals
     There is a lack of consensus in the literature regarding    when needed to provide safe and effective care for
     what constitutes medical clearance. It has been             psychiatric patients in the ED.
     suggested that a focused medical assessment may
     better reflect the ED evaluation needed to ensure           It is also imperative that there is clear understanding of
     appropriate disposition of psychiatric patients. 5          the reasons why psychiatric patients present to the ED
     Diagnostic evaluation should be guided by clinical          for care. Emergency care professional organizations
     presentation as no support was found in the literature      have been diligent in their efforts to respond to the
     to suggest that there is a pre-determined diagnostic        issues contributing to this growing crisis.
     panel that constitutes medical clearance.5
                                                                 Clarity of these issues will provide emergency care
     Expert opinion failed to find evidence that routine         professionals better evidence to address care needs for
     urine drug screens were beneficial in the performance       this patient population and, hopefully, lessen the chaos
     of medical clearance. Rather, the patient’s mental          psychiatric patients in need encounter. ■

     6. National Association of Psychiatric Health     Systems “Challenges      facing   behavioral   health   care”, (2003)
        http://www.naphs.org/news/WhitePaper4031.pdf


42                                                              EMERGENCY MEDICINE & CRITICAL CARE REVIEW 2006
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