Spanish experts consensus on emergency psychiatric care in hospital emergency departments.

BACKGROUND: The demand for urgent psychiatric care is increasing, but in Spain there are no clear recommendations for emergency departments (ED) on how to optimize care for patients with psychiatric emergencies. We aimed to provide expert consensus recommendations on the requirements for general hospitals´ emergency departments to treat patients with urgent psychiatric symptoms. METHODS: We used a modified Delphi technique. A scientific committee compiled 36 statements based on literature search and clinical experience. The statements covered the organizational model, facilities, staffing, safety, patient interventions, and staff training. A panel of 38 psychiatry specialists with expertise in psychiatric emergencies evaluated the questionnaire in two rounds. RESULTS: After two rounds of voting, 30 out of 36 proposed items (83%) were agreed upon. The panel agreed that psychiatric emergencies should be managed in a general hospital, with dedicated facilities for patient assessment, direct supervision of patients at risk, and an observation unit run by the psychiatric service. In addition to the psychiatrist, the ED should have specialist nurses and security staff available 24/7. Social workers should also be readily available. ED and consulting rooms should be designed to ensure patient and staff safety. A triage system should be established for patients with psychiatric symptoms, with medical evaluation preceding psychiatric evaluation. Guidance on supplies, equipment, and staff training is also provided. CONCLUSION: All ED in general hospitals should have adequate resources to handle any psychiatric emergency. This paper provides recommendations on the minimum requirements to achieve this goal.

Implementing and Evaluating a Standard of Care for Clinical Evaluations in Emergency Psychiatry.

BACKGROUND: Psychiatric presentations are common in emergency departments (EDs), but the standard of care for treatment remains poorly defined. We introduced standards for emergency psychiatric evaluations that included obtaining collateral information, writing a safety plan for discharging patients, identifying the next best provider, and alerting that provider to the patient's visit. OBJECTIVE: We sought to demonstrate the feasibility and clinical impact of implementing standards for emergency psychiatric evaluations. METHODS: To evaluate feasibility, physicians attested to completion in the electronic health record. To evaluate the effect on clinical outcomes, we compared admission rates, 30-day return rates, and median length of stay from a 4-month pre-implementation period to a 4-month post-implementation period. Data were extracted from a quality-improvement database. RESULTS: There were 1896 patient encounters in the pre-implementation period and 1937 encounters post-implementation. Pre-and post-cohorts were similar demographically. Collateral was obtained for 1035 (86%) encounters, a written safety plan was completed for 793 (77%) eligible patients, the next-best provider was identified for 1094 (91%), and that provider was contacted for 837 (70%). There was no difference from pre to post periods in admission rates (17% vs. 18%; p = 0.36), median length of stay (13.3 ± 0.6 vs. 12.5 ± 1.4; p = 0.35), or 30-day return rates (15% vs. 16%; p = 0.66). CONCLUSIONS: This standard work for emergency psychiatric evaluations was feasible even in a highly acute patient population. However, the benefits of this intervention are less clear. We question the utility of prevailing metrics in emergency psychiatry.

Does the U Stand for Useless? The Urine Drug Screen and Emergency Department Psychiatric Patients.

BACKGROUND: Behavioral emergencies account for a significant portion of emergency department (ED) visits in the United States. Substance abuse is common in this population and may precipitate or exacerbate preexisting psychiatric illness. Contrary to ED policy guidelines, many behavior health centers (BH) require a urine drug screen (UDS) in stable patients prior to transfer. OBJECTIVE: We sought to determine the role of the UDS in ED length of stay (LOS), cost, and charges to patients and inpatient psychiatric care. METHODS: We performed a retrospective chart review of all patients transferred to an in-network BH from September 1-30, 2014. Clinical data were extracted and analyzed from our electronic medical record, including records from both the ED visit and the BH stay. RESULTS: There were 205 patient encounters identified; 89 patients had a UDS performed in the ED and 89% were obtained after the ED medical clearance. LOS were similar between the two groups, however, time to ED departure from time of medical clearance was delayed in the UDS group. BH providers mentioned UDS results < 25% of the time and no confirmatory tests were performed. There was no difference in BH LOS or discharge diagnosis of substance-abuse disorder. Patient charges for UDS over the month totaled $21,093. CONCLUSION: The UDS did not seem to have any significant effect on inpatient psychiatric care; whereas ED LOS and cost were both negatively affected. Based on these results, the UDS seems to be of little-to-no benefit in the setting of acute psychiatric illness.

Service Models for Urgent and Emergency Psychiatric Care: An Overview.

There is variation in the way mental health services respond to urgent and emergency presentations, with few evidence-based models reported in the literature, and no agreed on best practice models. To inform the development of urgent and emergency psychiatric care models, a literature review was performed. The review sought to identify strengths and critiques of varying models, evidence gaps, and areas for future research. After review, significant variation was found in the design and scope of urgent and emergency care models. Most models are either community or hospital based, with few integrated models that span community and hospital care. The development of integrated models has the potential to reduce service duplication and support a shift toward provision of least restrictive care. The overall evidence base of urgent and emergency care models is limited, with few studies in the area, and there is a need for further research. [Journal of Psychosocial Nursing and Mental Health Services, 56(8), 23-30.].

The Impact of Mental Health Services in a Pediatric Emergency Department: The Implications of Having Trained Psychiatric Professionals.

OBJECTIVES: This study assessed improvement in the emergency department (ED) length of stay and costs after implementation of an ED program which added board-certified psychiatrists and trained psychiatric social workers to the pediatric ED. METHODS: A retrospective medical record and administrative data review were conducted for all pediatric psychiatric visits of children aged 5 to 18 years who were seen and discharged from the Greenville Memorial Hospital ED between January 1, 2007, and June 31, 2013. These subjects were diagnosed by the ED physician at the time of the visit using codes ranging from 290.0 to 319.0 based on the International Statistical Classification of Diseases and Related Health Problems, Ninth Revision codes. RESULTS: The mean (SD) age of children in the postprogram period (14.3 ± 3.1) was younger than during the preprogram period (14.9 ± 3.1) (P < 0.001) with the greatest increase in the 11- to 15-year age group (42% vs 35%, respectively). Patients in the postprogram period were significantly more likely to be discharged to a psychiatric hospital than during the pre-program period (18% vs 9%, respectively). After the initiation of the program, ED length of stay decreased significantly from 14.7 to 12.1 hours (P < 0.001) and costs per visit decreased slightly from US $602 to US $588 (this difference was not statistically significant). CONCLUSIONS: Although this model of care has significant costs associated with it, the efficiency of care for psychiatric pediatric patients in the ED improved after targeted training of ED staff and provision of these specialized services within the ED.

Resident Workflow and Psychiatric Emergency Consultation: Identifying Factors for Quality Improvement in a Training Environment.

OBJECTIVE: Quality improvement to optimize workflow has the potential to mitigate resident burnout and enhance patient care. This study applied mixed methods to identify factors that enhance or impede workflow for residents performing emergency psychiatric consultations. METHODS: The study population consisted of all psychiatry program residents (55 eligible, 42 participating) at the Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles. The authors developed a survey through iterative piloting, surveyed all residents, and then conducted a focus group. The survey included elements hypothesized to enhance or impede workflow, and measures pertaining to self-rated efficiency and stress. Distributional and bivariate analyses were performed. Survey findings were clarified in focus group discussion. RESULTS: This study identified several factors subjectively associated with enhanced or impeded workflow, including difficulty with documentation, the value of personal organization systems, and struggles to communicate with patients' families. CONCLUSION: Implications for resident education are discussed.

PSYCH: A Mnemonic to Help Psychiatric Residents Decrease Patient Handoff Communication Errors.

BACKGROUND: The substantial adverse impact of miscommunication during transitions in care has highlighted the importance of teaching proper patient handoff practices. Although handoff standardization has been suggested, a universal system has been difficult to adopt, given the unique characteristics of the different fields of medicine. A form of standardization that has emerged is a discipline-specific handoff mnemonic: a memory aid that can serve to assist a provider in communicating pertinent information to the succeeding treatment team. A pilot study was conducted in which psychiatry residents were taught a mnemonic to use during their post-call patient handoffs. METHODS: The PSYCH mnemonic was introduced as a guide to help residents identify key information needed in a psychiatric emergency room handoff: Patient information/ background, S ituation leading to the hospital visit, Y our assessment, Critical information, and Hindrance to discharge. Resident post-call patient handoffs were voice recorded and transcribed for 12 weeks. The transcriptions were divided into three time periods: Time 1 (baseline resident handoff performance), Time 2 (natural progression in resident hand-off performance with experience), and Time 3 (resident handoff performance after training in use of the PSYCH mnemonic). RESULTS: There was a statistically significant decrease in the mean number of omissions after the intervention (p = 0.049). The decrease in time spent on handoffs after the intervention was not statistically significant. On the basis of a rating scale ranging from 1 (not clear) to 4 (very clear), the residents' rating of their clarity of expectations increased from a mean of 2.79 to 3.83, and their confidence rating increased from a mean of 2.57 to 3.42. CONCLUSION: The mnemonic helped decrease the residents' handoff omissions. It also helped improve their efficiency, clarity of expectation, and confidence during handoffs.

Improving Quality of Emergency Care Through Integration of Mental Health.

The goal of this study was to better integrate emergency medical and psychiatric care at a large urban public hospital, identify impact on quality improvement metrics, and reduce healthcare cost. A psychiatric fast track service was implemented as a quality improvement initiative. Data on disposition from the emergency department from January 2011 to May 2012 for patients impacted by the pilot were analyzed. 4329 patients from January 2011 to August 2011 (pre-intervention) were compared with 4867 patients from September 2011 to May 2012 (intervention). There was a trend of decline on overall quality metrics of time to triage and time from disposition to discharge. The trend analysis of the psychiatric length of stay and use of restraints showed significant reductions. Integrated emergency care models are evidence-based approach to ensuring that patients with mental health needs receive proper and efficient treatment. Results suggest that this may also improve overall emergency department's throughput.

All tied up: the fine art of balancing regulatory restraint compliance and excellent patient care.

This article presents examples of different resources that can be implemented to help manage a patient in crisis. It discusses challenges and solutions in regard to the ED boarding of behavioral health patients and reviews various restraint types and definitions (violent, non-violent, forensic). It stresses the importance of teamwork between security police and clinicians.

'Too many' in crisis receive poor care, warns watchdog.

PEOPLE FACING mental health crises often think they are being judged and disrespected by emergency care staff, according to evidence compiled by the Care Quality Commission (CQC).

Tactical Psychiatric Care: Proposed Guideline.

There is no concise guideline on how to manage a full range of emergency psychiatric conditions that are likely to be encountered on the battlefield. This article examines the best practices on how to best assess and treat suicidality, psychosis, agitation, malingering, and combat stress reactions in accordance with multiple clinical practice guidelines. The result is a proposed model for battlefield emergency psychiatric care.

Evaluation of the alcohol use disorders identification test and the drug use disorders identification test among patients at a Norwegian psychiatric emergency ward.

High rates of substance use disorders (SUD) among psychiatric patients are well documented. This study explores the usefulness of the Alcohol Use Disorders Identification Test (AUDIT) and the Drug Use Disorders Identification Test (DUDIT) in identifying SUD in emergency psychiatric patients. Of 287 patients admitted consecutively, 256 participants (89%) were included, and 61-64% completed the questionnaires and the Mini-International Neuropsychiatric Interview (MINI), used as the reference standard. Both AUDIT and DUDIT were valid (area under the curve above 0.92) and reliable (Cronbach's alpha above 0.89) in psychotic and nonpsychotic men and women. The suitable cutoff scores for AUDIT were higher among the psychotic than nonpsychotic patients, with 12 versus 10 in men and 8 versus 5 in women. The suitable cutoff scores for DUDIT were 1 in both psychotic and nonpsychotic women, and 5 versus 1 in psychotic and nonpsychotic men, respectively. This study shows that AUDIT and DUDIT may provide precise information about emergency psychiatric patients' problematic alcohol and drug use.

Making activity-based funding work for mental health.

The implementation of activity-based funding (ABF) in mental health from 1 July 2013 has significant risks and benefits. It is critical that the process of implementation is consistent with Australia's cherished goal of establishing a genuine and effective model of community-based mental health care. The infrastructure to support the application of ABF to mental health is currently weak and requires considerable development. States and territories are struggling to meet existing demand for largely hospital-based acute mental health care. There is a risk that valuable ABF-driven Commonwealth growth funds may be used to prop up these systems rather than drive the emergence of new models of community-based care. Some of these new models exist now and this article provides a short description. The aim is to help the Independent Hospital Pricing Authority better understand the landscape of mental health into which it now seeks to deploy ABF.

[Pharmacological therapy in emergency psychiatry]. / Päivystyspsykiatrinen lääkehoito.

Pharmacological therapy is often inevitable in psychiatric emergency situations, but does not suffice alone. The onset or exacerbation of a psychiatric illness and acute life crisis may require immediate initiation of psychotropic medication. Evidence-based knowledge of the application of psychotropic medication in emergency call situations is very scarce, because randomization, blinding and placebo control of drug treatments in these situations are ethically very problematic. This is why psychiatric emergency call units have established treatment practices that are based on long-term clinical experience and well-tried routines.

[A young person in psychiatric emergency service]. / Nuori psykiatrisessa päivystyksessä.

In a psychiatric emergency call situation an under-age person is entitled to make decisions concerning her/himself and her/his treatment, and the physician shall act for the young person's best. When necessary, child protection should be informed and in suspected sexual offence, also the police. The assessment of the need for psychiatric treatment must be based on patient history evaluated under undisturbed conditions. The young person and the raisers are interviewed together and separately. The participation of parents in the psychiatric therapy of a young person is the principal rule. Outpatient care is the primary method. Psychotropic medication for a young person in an emergency call situation is started only in exceptional cases.

Pitfalls in the care of the psychiatric patient in the emergency department.

BACKGROUND: Care of the psychiatric patient in the Emergency Department (ED) is evolving. As with other disease states, there are a number of pitfalls that complicate the care of the psychiatric patient. OBJECTIVE: The purpose of this article is to update Emergency Physicians concerning the pitfalls in caring for the psychiatric patient, and possible solutions to deal with these pitfalls. DISCUSSION: The article will address the burden of the psychiatric patient, staff attitudes, medical clearance process, treatment of the agitated patient, suicidal patients, and admission decisions. CONCLUSIONS: Alternative care resources, collaboration with Psychiatry, staff education, improvement in the medical clearance process, proper use of restraint and seclusion, and appropriate choice of medication for agitated patients can help avoid some of the top pitfalls in the care of the psychiatric patient in the ED.

Use of Computer Modeling to Streamline Care in a Psychiatric Emergency Room: A Case Report.

Computer simulation using JaamSim tested the impact of changing the number of providers, proportion of independent to supervised providers, shift provider added, time to hospitalization, and the number of beds in order to identify bottlenecks in a psychiatric emergency department. Adding an independent provider from 4 p.m. to midnight produced the largest improvements: reductions in time to bed, time to provider, and length of stay by 82%, 68%, and 31%, respectively. Decreasing time to hospitalization and adding beds achieved modest improvements. Modeling allows simulated changes to one parameter at a time and provides bespoke analysis for a variety of clinical settings.