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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 The Emergency Nurses Association (ENA) is a U.S.-based international association for professional nurses dedicated to the advancement of emergency nursing practice. Whether you are a staff nurse or manager in an emergency department, an administrator, prehospital, flight, pediatric or trauma emergency nurse, an emergency clinical nurse specialist, nurse practitioner, student or educator, the scope of benefits offered through ENA membership is beyond compare. Since its inception in 1970, ENA has promoted advo- cacy, diversity, and excellence of emergency nursing practice through its publications (Journal of Emergency Nursing, ENA Connection, and Disaster Management & Response), educational seminars and classes, grants and scholarships, continuing education programs, as well as many other programs, products, and services. A Tradition of The first step to success is maximizing your opportunities and that is what ENA does best. That’s why nurses join ENA and that’s why they stay. It’s the best career decision you’ll ever make! For more information about ENA, log Excellence onto our Web site at www.ena.org.