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pSYCHIATRIC eMERGENCIES

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pSYCHIATRIC eMERGENCIES Powered By Docstoc
					Contra Costa Training Consortium
        Quarter III 2010
   Head Trauma?       Seizure Disorder?
   Hypoglycemia?      Drug Abuse?
   Hyperthermia?      Dementia?
   Hypoxia?           Severe Hypertension?
                       Electrolyte Disorder?
   Alcohol?
   Anxiety
       Panic Attacks
       Post Traumatic Stress Disorder (PTSD)
       Conversion Disorder
   Psychosis
       Schizophrenia
       Depression
       Bi-Polar
   Transient Personality Disorders
   A discrete period of intense fear or discomfort
    in which symptoms develop abruptly and
    reach a peak within 10 minutes
   These patients commonly contact Emergency
    Medical Services (especially first time attacks)
   Common Symptoms:

   Palpitations                Chest Pain
   Sweating                    Dizziness/Weakness
   SOB/Hyperventilation        Confusion
   Develops after exposure to any event that
    results in psychological trauma
   Re-experiencing traumatic event is common
    through flashbacks/nightmares.
   Common treatment includes therapy and a
    wide range of medications that are prescribed
    based on the patients specific symptoms.
   A condition in which you show psychological
    stress in physical ways.

   These patients will often exhibit some of the
    following symptoms:

   Paralysis of limb or body      Impaired Vision
   Syncope                        Dystonia
   Psychogenic Seizures           Gait Problems
   Characterized by abnormalities in the
    perception or expression of reality
   Symptoms typically begin to manifest in early
    adulthood.
   Common Symptoms:
         Hallucinations
         Delusions
         Catatonic/Disruptive Behavior
         Disorganized Speech
   AKA: Major Depressive Disorder
   Characterized by all-encompassing low mood,
    low self-esteem, and aversion to activities
   Treatment typically involves therapy and anti-
    depressants
   Major cause of morbidity and typically occurs
    with other psychiatric problems
   Defined by the presence of one or more
    episodes of manic episodes and one or more
    depressive episodes
   Elevated risk of suicide during depressive
    episodes
   Typically treated with Mood Stabilizers such as
    Lithium
   An enduring pattern of inner experience and
    behavior that deviates markedly from the
    expectations of the culture of the individual
    who exhibits
   10+ different types of personality disorders
    ranging from paranoid to dependent
    personality disorders.
       Each type of personality disorder presents with a
        unique set of symptoms and treatment for those
        symptoms
   Section 5150 is a section of the California Welfare and
    Institutions Code which allows a qualified officer or
    clinician to involuntarily confine a person deemed to
    have a mental disorder that makes them a danger to
    him or her self, and/or others and/or gravely disabled.
    A qualified officer, which includes any California
    peace officer, as well as any specifically designated
    county clinician, can request the confinement after
    signing a written declaration. When used as a term,
    5150 can informally refer to the person being confined
    or to the declaration itself.
   The 5150 hold may be written out on Form MH 302, Application for
    72 Hour Detention for Evaluation and Treatment
   Section 5150 is not intended to be used to hold a person reported
    to the police by a non-professional. It is intended for a police
    officer to use to submit a subject for a hold when the officer has
    observed the qualifying symptoms in the routine process of a
    response. This is commonly used to allow the officer to process a
    subject into the psych facility without requiring criminal
    processing.
   It can be used to hold an inebriated person in the drunk tank to be
    released upon sobriety with a citation issued
   During the period of confinement, a confined
    individual is evaluated by a mental health professional
    to determine if a psychiatric admission is warranted.
    Confinement and evaluation usually occurs in a county
    mental health hospital or in a designated ED. If the
    individual is then admitted to a psychiatric unit, only a
    psychiatrist may rescind the 5150 and allow the person
    to either remain voluntarily or be discharged.
   The person under a 5150 hold has a limited ability to
    contest the legality of the hold.
   On or previous to the expiration of the 72 hours, the
    psychiatrist must assess the person to see if they still
    meet criteria for hospitalization. If so, the person may
    be offered a voluntary admission. If it is refused, then
    another hold for up to 14 days, the 5250 (WIC-5250),
    must be written to continue the involuntary
    confinement of the person. A Certification Review
    Hearing (W&I 5256) must occur within four days
    before a judge or hearing officer to determine whether
    probable cause exists to support the 5250.
   The criteria for writing requires probable cause.
    This includes danger to self, danger to others
    together with some indication, prior to the
    administering of the hold, of symptoms of a
    mental disorder, and/or grave disability. The
    conditions must exist under the context of a
    mental illness.
   Assure that all fields are completed prior to
    transporting the patient.
       Ensure that the Patients Name and Date of Birth
        match the form
       Ensure that officer signs and dates the form and
        includes a brief description for the reason the
        application for a hold is being placed.
   The original 5150 Application should
    accompany the patient to the hospital.
   Under California law, the following rights may never be denied (Cal.
    Welf. & Inst. Code § 5325.1):
   The right to treatment services which promote the potential of the person
    to function independently. Treatment should be provided in ways that
    are least restrictive of the personal liberty of the individual.
   The right to dignity, privacy, and human care.
   The right to be free from harm, including unnecessary or excessive
    physical restraint, isolation, medication, abuse, or neglect. Medication
    may not be used as punishment, for the convenience of staff, as a
    substitute for, or in quantities that interfere with the treatment program.
   The right to prompt medical care and treatment.
   The right to religious freedom and practice.
   The right to participate in appropriate programs of publicly supported
    education.
   The right to social interaction.
   The right to physical exercise and recreational opportunities.
   The right to be free from hazardous procedures.
•   New implementation 5/17/2010
•   Ringdown to the CCRMC Emergency
    Department (10-15 minutes out if feasible)
•   Conference call with CSU and ED to determine
    destination of patient
•   Destination of Patient – Either ED or CSU (it is
    estimated that 65-75% of all patients will
    qualify for direct admit to CSU)
•   Turnover of Care
•   ED is requesting the following information PTA:
    –   Patient’s Name
    –   Patient’s Date of Birth
    –   Legal Status (5150, voluntary, under arrest)
    –   Medical History (Dementia, etc.)
    –   Vital Signs
        •   Actual Blood Pressure (if obtainable)
        •   Actual Pulse (if obtainable)
        •   Actual Respiratory Rate
        •   If ALS – Glucose check
    –   Psychiatric History (if patient is willing to give)
    –   ETOH/Drug – Use or abuse
    –   Wounds that may need to be treated in ED prior to being
        moved to CSU
    –   Restraint Status
   Patients who have medical issues will be
    directed to the Emergency Department
   Patients who have behavioral/psychiatric
    issues will be directed to CSU
   Overflow for CSU will be the ED
   Questions or concerns about patient’s medical
    stability, default to the ED.
 All patients must arrive on
  a gurney, with full seat
  belts for security reasons.
 Same turnover of care as
  with any other patient.
•   Patients who are direct admits to the CSU,
    there are 2 parking spots at the entrance next to
    the CCRMC ED.
•   For security reasons, all patients are to be
    brought to the CSU on a gurney.
    –   If the patient refuses gurney transport, this should
        be reported to the ED staff when you call with your
        ringdown.
•   Buzz into CSU to gain admittance
•   Brief history may be requested.
   All patients must arrive on a gurney, with full
    seat belts for security reasons.
   Patient will be evaluated at this time, by the
    CSU Welcome Team (RN, Tech and MD)
   Please do not remove patient from gurney until
    instructed to do so and where to do so.
   Please do not remove any restraints from
    patient until instructed to do so.
   Transport Crew will be instructed to remove
    patient from gurney, or to keep on gurney
    based on the following criteria:
     Cooperative patients will be allowed off the gurney
      and CSU staff will direct them where to go.
     Restrained/uncooperative patients will need further
      evaluation.
     Transport restraints will not be removed until CSU
      restraints are applied and under control
•   All patients on 5150 holds by law enforcement should have been
    searched for weapons (person and belongings) prior to
    transportation
•   If patient is a voluntary committal, law enforcement should be
    requested to do a search of the patient and their belongings (if
    they consent) prior to transport
•   If the patient is voluntary and refuses a search by law
    enforcement, they should be questioned about the presence of
    weapons
•   EMS personnel are NOT responsible to search patients or
    belongings
•   Patients and belongings will be searched again by CSU staff upon
    arrival in CSU
•   Any concerns or issues regarding searches or if no search was
    completed prior, should be brought to the attention of the CSU
    staff as soon as feasible
•   Report will be given to the team admitting the
    patient
•   Do not leave patients unattended on the
    gurney to give report
•   Please leave all paperwork (5150 sheet, PCR)
    with staff
•   Staff will request the PCR at time of patient
    arrival, due to the fact that there may be
    important information pertinent to patient
    status
   This is a new process in the CSU
   There are still bugs to be worked out and
    processes to refine
   Give feedback to your supervisor so that this
    information can be relayed back to the CSU to
    improve the system
   For safety to all patients and caregivers, work
    together
   Behavioral and Psychiatric crisis patients can
    be volatile and should not be taken lightly. Use
    good common sense and caution with this
    group of patients. Safety issues concern all
    parties involved.

				
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