While hospital systems and local mental health law and policies may vary by state or even individual hospital settings, an overall approach to the psychiat-ric emergency patient involves an understanding of systems and a focus on pa-tient and clinician safety.
Understanding Health Care Systems
Psychiatrists and mental health workers, including psychologists, social work-ers, and psychiatric nurses, work in a variety of different capacities within emergency departments. Delivery of efficient care requires that clinicians in the emergency department know their role within the overall health care sys-tem in which they are practicing. Issues that commonly arise include admis-sion privileges, follow-up planning, insurance issues, safety, medical care, available facilities at the emergency department or at affiliate hospitals, and supervision, particularly for trainees or nonphysician consultants. Every hospital has its own method of dividing responsibility and varying levels of support staff. The answer to the question, “Who does what?” is primarily de-termined by the training of the clinician within the emergency department and the department’s overall policy for handling psychiatric cases (Brown 2005).
The settings of emergency psychiatric care delivery exist on a spectrum.
In most community hospitals, the volume of psychiatric cases is not high
enough to warrant dedicated psychiatric evaluation space or a comprehensive psychiatric evaluation team. Typically, in primary care and community-based centers, the mental health clinician acts as consultant to the emergency de-partment. The facility may not have dedicated space for psychiatric evalua-tion and assessment, and the nursing and support staff may be less familiar with psychiatric issues (Woo et al. 2007). In facilities with more psychiatric cases, particularly in hospitals with active inpatient psychiatric services, emer-gency departments may set aside space or have more support services available for psychiatric emergencies, as advocated by the American Psychiatric Asso-ciation (Allen et al. 2002). A true comprehensive psychiatric emergency de-partment is most common in large, urban settings, where a higher volume of psychiatric cases is common. For example, dedicated social work staff, psy-chiatrically trained nursing and support staff, a separate locked area, and the possibility of extended observation (up to 72 hours) are features of the Com-prehensive Psychiatric Emergency Program in New York State. Variations on this model have developed across the country. Although a comprehensive psychiatric emergency department can be a stressful work environment, the role of each clinician working in such a setting is clearer and more support is available.
Regardless of the system in which the clinician works, the same basic prin-ciples apply. The patient should receive as comprehensive an evaluation as possible, followed by a thorough disposition plan—whether admitted or dis-charged—in a setting that is safe and as therapeutic as possible.
Assuring Safety
Although the idea of emergency department psychiatry commonly brings to mind wildly out-of-control patients, the reality is much more mundane. The vast majority of psychiatric patients are not violent toward others, and self-harm in a supervised setting is not common. However, one must still act to assure the safety of the patient, the doctor, the staff, and other patients in the area.
Hospital systems play a large role in how safety is achieved, so it is impor-tant for the clinician to know the particular challenges in his or her emergency department and have a plan in mind for ensuring patient and staff safety when a potentially dangerous situation arises. If contingency plans for safety
are already established, the staff can execute them more easily. Emergency de-partments should establish policies regarding searching patients for weapons and specifying when and how to call for backup support if a patient becomes violent. Ideally, all patients should be searched prior to the interview. If a search is not performed routinely, the clinician should request a search or at least request that the patient change into hospital gowns or pajamas prior to the interview, thereby making it harder to conceal weapons. At the start of a shift, consultants—particularly those who work only occasionally in the emergency department—should introduce themselves to security staff so staff know whom to contact if backup support is needed. Although some facilities have security cameras or panic buttons, it is also helpful to notify staff prior to meeting with a patient so they can be ready to respond if a crisis situation arises.
Approaching Agitated or Violent Patients
Asking staff how the patient has been behaving prior to the clinician’s arrival can help the clinician tailor an initial approach. If the patient has been calm and cooperative, then the clinician may elect to interview the patient follow-ing the hospital’s standard safety protocol. However, if the patient has been agitated, then additional precautions may be warranted prior to interviewing the patient.
Prior to initiating an encounter with an agitated patient, the clinician should first determine some key points about the patient, both through the clinician’s own observation and by asking the staff for their input. Who is the patient, including his or her basic physical characteristics and presenting complaint?
Is the patient upset about a specific issue or psychotic and disorganized? What is the patient’s behavior? Is he or she yelling? Throwing things? Making any specific threats? Finally, are there any indicators as to the etiology of the agi-tation, such as appearing ill, smell of alcohol on the patient’s breath, or obvi-ous head trauma?
Once the nature of the situation is clear, the clinician can determine the environment in which to further assess the patient. For example, the degree of agitation may warrant interviewing the patient in a more public area than usual so that other staff members can monitor the interaction directly. Addi-tionally, the clinician may request that security staff be present on standby in
the emergency department to provide assistance rapidly if needed. Finally, the clinician may elect to begin the interaction with the patient by addressing the agitation directly rather than trying to determine the chief complaint, the his-tory of the presenting illness, and so forth. For example, the clinician may start by pointing out the level of agitation to the patient and then offering to help.
This may include an offer of a medication to calm the patient. Given that sit-uations may not always be as they appear, the clinician should always err on the side of caution and containment of the patient in the least restrictive method possible.
Maintaining a calm demeanor goes a long way toward preventing escala-tion of agitaescala-tion to violence. Many patients will resonate with the nonverbal communication of the clinician, and a clinician who is becoming more agi-tated may cause the patient to become more agiagi-tated as well (Flannery 2007).
The clinician should be vigilant for signs of escalating tension, such as clench-ing fists, increased respiratory rate, threatenclench-ing postures, or restlessness, and be ready to terminate an interview or interaction before a situation escalates, even if little information has been obtained.
General Rules for Approaching Agitated Patients
When encountering an agitated patient, the following general principles are helpful in maintaining safety and perhaps deescalating the situation.
1. Take charge and make a plan. Staff members or other patients, meaning well, may try to intervene in various ways. This is confusing to the patient and can escalate the situation. The team leader should identify himself or herself as such and ask staff to follow his or her directions.
2. Keep a safe distance. Crowding someone who is already upset is not gener-ally a soothing tactic, and keeping a safe distance lowers the risk of inad-vertent injury by a flailing or agitated patient.
3. Ask for backup. Whether security should be present depends on the nature of the situation at hand. If the clinician is concerned that the patient may require a medication or restraints, he or she should ask someone to be pre-paring those ahead of time.
4. Provide an easy out. People who are upset and confused generally want a way to resolve the issue rather than escalating it further. Providing a quick and safe alternative to further escalation allows the patient a way out. For
example, the clinician might say, “I can see you are very upset. Would you be willing to sit down with me and we can figure out a way to resolve this situation?”
5. Give clear instructions. Specifically asking the patient to sit down in a cer-tain place, lower his or her voice, put down the chair, and so on, is much more likely to yield a result than general directives to “calm down,” “relax,”
or “take it easy.”
Dealing With Escalation
If a patient escalates to violence during an interview, the clinician’s priority should always be his or her own safety. Escape is the first priority, followed by alerting other staff and then containment of the patient. A clinician who is injured or incapacitated should leave the situation and get help, because the immediate fear and pain will make being an effective team leader difficult.
Particularly for trainees, who may feel that they are letting other staff down or appearing cowardly if they protect themselves, violent situations can pro-voke intense feelings of guilt or self-blame. Clinicians who are injured may feel that they provoked the attack or feel intense anger that is unfamiliar and dif-ficult to reconcile with their values and ideals of what constitutes good patient care. Clinicians need to remember that they are also human beings, who exhibit a full range of normal human emotions in response to trauma. Clini-cians are advised to seek support from friends, colleagues, or a mental health pro-fessional after a frightening incident. There is no one right answer regarding whether the clinician should press charges against an assaulting patient; that decision is best left to the discretion of the clinician.
Etiologies of Agitation
After safety has been assured, the overriding principle in addressing agitation is to rule out life-threatening medical causes. The assumption that a patient is suffering from a psychotic break as the result of schizophrenia could be fatal for a belligerent patient with hypoglycemia and diabetes or a patient experi-encing delirium tremens. Table 1–1 covers common causes of agitation and basic approaches to their treatment. Delirium and intoxication/withdrawal syndromes are covered in more detail in later chapters (see Chapter 8, “The Cognitively Impaired Patient,” and Chapter 9, “Substance-Related Psychiat-ric Emergencies”).
Treatment
A general progression of options for dealing with agitation starts with verbal/
behavioral interventions, then consideration and application of medications, with seclusion/restraints as a final option.
Verbal/Behavioral Interventions
As mentioned previously, speaking with a patient in a calm and rational man-ner, addressing his or her needs to the extent possible, and giving specific di-rections for the patient to change behavior may be all that a patient needs to calm down. In a crowded emergency department, moving the patient to a more secluded or quiet area may be helpful. Instituting one-to-one supervi-sion may help by giving the patient someone to talk to, showing that the staff feels that the patient requires supervision, preventing elopement, and provid-ing an early alert for other staff if behavior escalates again. Whenever possible, providing patients with information about how their evaluation is proceed-ing, why they are at the emergency department, and how long they should expect to remain can prevent further disruption.
Medications
Operating on the principle of using the least restrictive alternative for treatment, offering oral medication to an agitated patient is usually the first option. Most oral medications take effect within 20–30 minutes. Dissolving tablets allevi-ate the necessity of swallowing but do not take effect any faster than regular oral medications. Dissolving tablets and liquid medication are more difficult to “cheek” or conceal without swallowing. In circumstances where 1) the pa-tient refuses oral medication and safety is a concern, 2) safety is such a concern that oral medication would act too slowly, or 3) the patient might lack the air-way control to swallow medication, intramuscular medication is the next best option. The most common protocol is a benzodiazepine plus a neuroleptic (Wilhelm et al. 2008). Table 1–2 lists medications commonly used for agita-tion, typical dosing ranges for oral and intramuscular routes, and notable benefits and risks of each.
linical Manual of Emergency Psychiatry
Cause Clinical presentation Treatment approach
Acute cocaine/
stimulant intoxication
Tachycardia, dilated pupils, irritability with or without psychosis, which can present as almost entirely similar to schizophrenia-like symptoms.
Cocaine effects usually time limited, as opposed to PCP or amphetamine psychosis, which can persist longer.
Use benzodiazepines for sedation; hold beta-blockers.
Benzodiazepine/
barbiturate withdrawal
Similar to alcohol withdrawal, but may not show vital sign changes, and may present solely as a delirium with or without tremor. High risk of seizure.
Taper benzodiazepine.
Delirium Waxing and waning level of consciousness, fluctuation in vital signs, confusion. Can be irritable or passive and detached. More common in the elderly or medically frail patient.
Assure safety of the patient, treat the underlying cause, use low-dose neuroleptics to calm the patient so that medical treatment can proceed, provide reorientation cues when possible.
Delirium tremens All signs of delirium, with or without tremors, with or without hallucinations; intense fluctuation in vital signs. Last drink of alcohol 24–72 hours prior.
If patient has intact airway, aggressively sedate with parenteral benzodiazepines to the point of drowsiness, if possible. Provide ICU-level monitoring, if needed.
Hypoglycemia Altered mental status with sweating, tachycardia, and weakness.
If patient has patent airway, use oral glucose; otherwise, use dextrose 50% iv.
Approach to Psychiatric Emergencies9 Postictal states Altered level of consciousness, confusion, ataxia.
May have Todd paralysis or other residual neurological signs, such as slurred speech. May have evidence of tongue biting or incontinence from prior seizure.
Assure patient safety, observe for further seizure activity.
If agitation requires treatment, use benzodiazepines over neuroleptics because latter may lower seizure threshold.
Determine cause of seizure.
Psychosis/mania/
primary psychiatric disorder
Not usually associated with disorientation, no waxing and waning level of consciousness, no vital sign changes. Look for other signs of psychiatric illness or history of same.
Assure safety; offer oral medications or intramuscular medications; or consider restraints if necessary.
Structural brain abnormality
Varies by lesion, but altered mental status with headache, meningeal signs, focal neurological deficit (e.g., agitated patient who wants to leave but cannot walk), or progressive neurological deterioration.
Assure patent airway; use emergent CT scan or other imaging modality.
Toxicologic emergency
Varies by substance, but ingestion of toxic substances can lead to mental status changes.
Watch for pupillary changes, sweating, vital sign changes, or other signs of medical illness.
Attempt to identify toxin and contact poison control.
Note. CT=computed tomographic; ICU=intensive care unit; PCP =phencyclidine.
Source. Adapted from Moore and Jefferson 2004.
Clinical Manual of Emergency Psychiatry
Less risk of EPS or dystonia Less sedating
Not in use for long, less experience Akathisia
More expensive
Chlorpromazine 25–100 mg po 25–50 mg im
Very sedating
Lower risk of EPS/dystonia than other typicals
High risk of orthostatic hypotension
Diazepam 5–10 mg po or im No EPS or dystonia
Also used to treat alcohol or benzodiazepine withdrawal
Respiratory depression
Active metabolite resulting in very long half-life and therefore problematic if impaired liver function
Diphenhydramine 25–50 mg po or im When used with typical antipsychotics, prevents/treats EPS and dystonia Very sedating
Anticholinergic delirium at higher doses or in elderly
Paradoxical activating reaction
Fluphenazine 5–10 mg po or im Sedating
Anecdotally less dystonia than haloperidol
EPS Dystonia
Haloperidol 1–5 mg po (liquid or pill) or im;
can repeat up to 10–15 mg
Sedating
Approach to Psychiatric Emergencies11
Lorazepam 1–4 mg po or im No EPS or dystonia
Also used to treat alcohol or benzodiazepine withdrawal Good for patients with impaired
liver function
Paradoxical disinhibition and agitation
Respiratory depression
Olanzapine 5–10 mg po (tablet or dissolving wafer)
5–10 mg im, up to 20 mg total/
day
Less risk of EPS or dystonia reported Less sedating
Wafers excellent for patients with impaired swallowing
Maximum dosing achieved quickly Expensive
Ziprasidone Only intramuscular administration effective for agitation
10 mg im, maximum 40 mg/day
Less risk of EPS or dystonia reported Less sedating
More expensive Effectiveness unknown
Note. EPS=extrapyramidal symptoms.
Source. Marco and Vaughan 2005; Physicans’ Desk Reference 2008; Rocca et al. 2006; Villari et al. 2008.
Medication Dosing Benefits Risks
Seclusion
If available, the option of placing a patient in locked seclusion may be a slightly less restrictive alternative than restraint. Seclusion is safe, however, only if the room is properly designed and the patient is supervised appropri-ately during the seclusion. Many general emergency departments do not have seclusion rooms.
Restraint
Physical restraint is a last option for assuring safety of an agitated patient and requires training to execute. Careful documentation of the time the patient was restrained, the type of restraint used, and the reasoning behind the deci-sion is essential. Once restrained, the patient should be on one-to-one obser-vation until released, and vital signs should be checked frequently.
More detailed information on restraint and seclusion techniques can be found in Chapter 11, “Seclusion and Restraint in Emergency Settings,” but cer-tain principles are important to emphasize here. Restraint or seclusion should always be a last resort and may lead to patient and staff injury. They should never be used punitively and should be used only to contain behavior so un-safe that it cannot be controlled in any other way (Downey et al. 2007; Herzog et al. 2003).