Psychiatric Services in an Emergency Department by nih35233


									Psychiatric Services in
an Emergency Department

Prepared by:                Presented by:
Kathleen Crapanzano, MD     Patricia Gonzales, LCSW Acting Assistant
DHH, OMH Medical Director   Deputy Secretary, OMH
                            Acting CEO, Southeast Louisiana Hospital
 Screening Assessment
 The initial Medical Exam in the ED should include:

 • Vital Signs
 • A cognitive examination that screens for significant cognitive or
   neuropsychiatric impairment
 • A screening neurologic examination that is adequate to rule out
   significant acute pathology
 • A medical history and review of systems
 • A pregnancy test in all fertile women
 • A urine toxicology evaluation
 • Blood levels of psychiatric medications that have established
   therapeutic or toxic ranges
 • Other tests and examinations as appropriate and indicated
Continuous monitoring is required if there is a risk of harm to self or
Mental Health Assessment
Consult the available qualified mental health professional to perform
a mental health assessment, that will include:

• A patient interview
• A review of medical records available to the ED
• History gathering from collateral sources, if possible
• Contact with current mental health providers, when possible
• Identification of social, environmental, and cultural factors that
  may be contributing to the emergency
• A risk assessment assessing risk factors for suicide or harm to
• An assessment of substance use, abuse, and misuse
 Based on this assessment, the patient and qualified mental
 health professional, in consultation with psychiatrist, will
 then make a decision regarding treatment:

• Another level of service other than inpatient treatment is
• Further psychiatric assessment and treatment is needed – the
  patient will be referred to the psychiatric beds of the emergency
  room (M-HERE).
• Every patient under the age of 18 will have an assessment by a
  mental health provider trained in the assessment and treatment
  of children in a crisis setting
Psychiatric Beds in the ED
GOAL: Disposition of each patient to an appropriate setting within
24 hours.
• Observation and intensive emergency intervention is indicated
  for patients with the following
    – Suicidal crisis related to an acute event and/or a pattern of unstable
      mood or behavior that is longstanding
    – Substance induced or related emergency that is of relatively short
    – Conditions that are likely to significantly improve within a short
      period of time
• Staging Area
    – These psychiatric beds will be used as a staging area prior to
      admission for evaluation of all persons who present to the ER with
      BH concerns who are not easily triaged out of the ER

Written models should be utilized to specify which patients are
appropriate or not appropriate for such treatment
Psychiatric Evaluation
A full Psychiatric Assessment is required when a
patient is received in Psychiatric ED setting. It
• Patient interview
• Review of available past records
• History gathering from collateral sources
• Contact with the current mental health provider
  whenever possible
• A psychiatric diagnostic assessment which
  addresses any medical conditions that may cause
  similar symptoms or complicate the patient’s
Psychiatric Evaluation (con’t)

 • Identification of social, environmental, and cultural
   factors that may be contributing to the urgent need
   for care
 • An assessment of the patient’s ability and willingness
   to cooperate with treatment
 • A history of previous treatment and the responses to
   that treatment that includes a record of past
   psychiatric medications, dose, response, side effects,
   and compliance, and an up-to-date record of all
   medications currently prescribed, and the name of
   the prescribers.
Psychiatric Evaluation (con’t)

 • A general medical history that addresses medical
   illnesses that may affect the patient’s general current
   condition (including a review of systems focused on
   conditions that may present with psychiatric
   symptoms or that may cause cognitive impairment)
 • An assessment of substance use, abuse, and misuse
 • A treatment plan that addresses at least immediate
   treatment in the service, the goals of such treatment,
   plans for aftercare, ways of addressing barriers to
Physician will write appropriate orders related to
treatment plan.
Considerations for Setting Up
Psychiatric Services in an ED
•       Medication use – Pharmacologic needs include:
    –      Immediate access to medications commonly used in
           psychiatric disorders and behavioral emergencies
    –      Availability of qualified staff to administer those
           medications and monitor the patient’s response.
    –      Emergency medications
•       Seclusion and Restraint - There must be a policy for use
      of S/R that addresses:
    –     Justification and authorization for use
    –     Assessment and monitoring
    –     Provisions of patient needs (food, water, and toilet)
    –     Staff training in prevention, de-escalation, and proper use.
Considerations for Setting Up
Psychiatric Services in an ED – Con’t

 • Medical Records – Policies and procedures for
   medical record documentation need to be developed:
   – Assessment by a LIP with recommendations for
     treatment and disposition.
   – Provision of a discharge plan to the patient and to
     each agency.
   – Security of the records
Considerations for Setting Up
Psychiatric Services in an ED – Con’t
 • Aftercare – aftercare services should include:
    – A list of resources available in the region for
      inpatient care, outpatient mental health services
      and substance abuse facilities and providers.
    – A discharge process that ensures continuity of
      care for patients with ongoing problems.
    – Procedure for ensuring the availability of specific
      appointments for continued outpatient mental
      health treatment within one week of discharge
      from the ED.
    – Subsequent contact for the purpose of
      ascertaining the patient’s status will be a routine
      part of care.
Considerations for Setting Up
Psychiatric Services in an ED – Con’t
 • Patient Rights – Policies/protocols must be
   developed related to:

  –   Informed consent
  –   Confidentiality/Privacy
  –   Mental Health Rights
  –   Communication
  –   Grievance/complaint
  –   Abuse/neglect
Considerations for Setting Up
Psychiatric Services in an ED – Con’t
 • Space and Equipment – Special consideration
   must be given to the physical environment:
   – Provision must be made that there are no
      dangerous materials accessible to patients who
      may be dangerous to themselves or others to
   – Space should be continuously supervised and
      monitored by staff
   – Controlled access to the space and a process for
      reducing the risk of elopement.
   – Privacy provided for sexes for sleeping
   – Quiet areas that are accessible to all patients
Considerations for Setting Up
Psychiatric Services in an ED – Con’t

 • Staffing – Staffing requires employees that are
   attuned to the needs of patients with mental illness:
    – Recruit and train staff to handle behavioral
    – Security staff should be appropriately trained.
    – Adequate staff to allow reassessment and
       documentation at least every 8 hours and to
       provide active therapeutic interventions.
    – Social worker that completes an assessment and a
       discharge plan for every patient
Staffing – Con’t

    – At least one staff member trained and competent in
      substance abuse assessment and treatment
    – A licensed mental health professional assigned to
      the patient on each shift.
    – An RN that is always in the psychiatric area of ED
      overseeing operations
    – Written procedure for ensuring the ongoing
      assessment of mental health staff competence.
Report and recommendations
 regarding psychiatric emergency and
 crisis services – A review and model
 program descriptions

APA Task Force on Psychiatric Emergency Services
August 2002

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