Suicide Risk Assessment, Management, and Mitigation in the Emergency Setting.

Suicide is a serious public health issue and is a leading cause of death worldwide. Suicidal ideation is a common presentation in emergency department (ED) settings, with many nuanced complications. Therefore, understanding screening, assessment, and mitigation is paramount to successful encounters with individuals presenting to emergency settings in psychiatric crises. Screening helps to identify the few people at risk within a large group. Assessment seeks to decide whether a specific individual is at significant risk. Mitigation aims to reduce the risk of suicide or of a serious attempt for a person at risk. These aims cannot be achieved with perfect reliability, but some approaches are more effective than others. Suicide screening specifics are important, even to individual practitioners, because a positive screen triggers assessment. Most practitioners understand assessment well: beginning with early psychiatric training, they are taught signs and symptoms suggesting that a patient might be at risk of suicide. Mitigating suicide risk is increasingly important to reduce the misery of ED boarding for patients awaiting psychiatric admission. For many patients, hospital admission is unnecessary if support, monitoring, and contingency plans are workable. For any individual patient, there may be a complicated mix of findings, risks, and interventions. Evidence-based screening and assessment tools are inadequate for the possible complexities, making care of individual patients dependent on good clinical assessment. The authors review the available evidence and offer experienced recommendations for challenges not yet thoroughly researched.

American Association for Emergency Psychiatry Recommendations to Address Psychiatric Staff Shortages in Emergency Settings.

OBJECTIVE: The psychological sequelae of the COVID-19 crisis will increase demands for psychiatric care in already strained emergency and mental health systems. To address the shortage of psychiatrists (and nurse practitioners and physician assistants) in emergency settings (ESs), the American Association for Emergency Psychiatry (AAEP) has established recommendations for utilizing nonprescribing mental health professionals in the evaluation and management of psychiatric patients in these contexts. METHODS: Faced with limited research on the roles and competencies of nonprescribing psychiatric emergency clinicians (PECs), a multidisciplinary committee of members of AAEP was tasked with developing recommendations for use of PECs. RESULTS: The committee developed eight recommendations regarding the role of PECs in evaluation and management of patients who present to ESs with behavioral emergencies. PECs should have the following competencies: conducting independent psychiatric and substance abuse evaluations; managing behavioral emergencies; aiding in the recognition of confounding medical illnesses, intoxication and withdrawal states, and adverse drug reactions; developing appropriate treatment plans; recognizing when consultation from a psychiatrist or emergency physician is indicated; possessing self-awareness and recognizing clinician-patient dynamics; understanding medicolegal issues, such as involuntary holds and decision-making capacity; and collaborating with clinical teams in ESs. PECs are not meant to replace psychiatrists but to extend the psychiatrist's reach. Use of PECs has already been implemented in some areas of the country. CONCLUSIONS: On the basis of the AAEP recommendations, ESs can address staffing shortages while ensuring safe management of patients with behavioral emergencies. With appropriate orientation and training, the PEC can serve effectively and competently in an ES.

Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup.

Agitation is an acute behavioral emergency requiring immediate intervention. Traditional methods of treating agitated patients, ie, routine restraints and involuntary medication, have been replaced with a much greater emphasis on a noncoercive approach. Experienced practitioners have found that if such interventions are undertaken with genuine commitment, successful outcomes can occur far more often than previously thought possible. In the new paradigm, a 3-step approach is used. First, the patient is verbally engaged; then a collaborative relationship is established; and, finally, the patient is verbally de-escalated out of the agitated state. Verbal de-escalation is usually the key to engaging the patient and helping him become an active partner in his evaluation and treatment; although, we also recognize that in some cases nonverbal approaches, such as voluntary medication and environment planning, are also important. When working with an agitated patient, there are 4 main objectives: (1) ensure the safety of the patient, staff, and others in the area; (2) help the patient manage his emotions and distress and maintain or regain control of his behavior; (3) avoid the use of restraint when at all possible; and (4) avoid coercive interventions that escalate agitation. The authors detail the proper foundations for appropriate training for de-escalation and provide intervention guidelines, using the "10 domains of de-escalation."