Transcript Psychiatric Services in an Emergency Room

Psychiatric Services in
an Emergency Department
Prepared by:
Kathleen Crapanzano, MD
DHH, OMH Medical Director
Presented by:
Patricia Gonzales, LCSW Acting Assistant
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
others.
Mental Health Assessment
Consult the available qualified mental health professional to perform
a mental health assessment, that will include:
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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
others
• An assessment of substance use, abuse, and misuse
Disposition
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
appropriate.
• 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.
UTILIZATION:
• 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
duration
– 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
includes:
• 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 condition
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
care
Physician will write appropriate orders related to
treatment plan.
Considerations for Setting Up
Psychiatric Services in an ED
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Medication use – Pharmacologic needs include:
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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:
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Justification and authorization for use
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Assessment and monitoring
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Provisions of patient needs (food, water, and toilet)
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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:
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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
patient.
– 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
accommodations
– 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
emergencies
– 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.
Reference:
Report and recommendations
regarding psychiatric emergency and
crisis services – A review and model
program descriptions
APA Task Force on Psychiatric Emergency Services
August 2002