Psychiatric Services in an Emergency Department

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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
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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.
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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 others
• An assessment of substance use, abuse, and misuse

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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

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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
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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 patients
  condition

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Psychiatric Evaluation (cont)

• Identification of social, environmental, and
  cultural factors that may be contributing to the
  urgent need for care
• An assessment of the patients 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.

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Psychiatric Evaluation (cont)

• A general medical history that addresses medical
  illnesses that may affect the patients 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.
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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 patients
  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.

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Considerations for Setting Up Psychiatric
Services in an ED Cont

• 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

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Considerations for Setting Up Psychiatric
Services in an ED Cont

• 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 patients status will be a
  routine part of care.

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Considerations for Setting Up Psychiatric
Services in an ED Cont

• Patient Rights Policies/protocols must be
  developed related to

• Informed consent
• Confidentiality/Privacy
• Mental Health Rights
• Communication
• Grievance/complaint
• Abuse/neglect

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Considerations for Setting Up Psychiatric
Services in an ED Cont

• 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

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Considerations for Setting Up Psychiatric
Services in an ED Cont

• 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

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Staffing Cont

• 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.

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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