Intramuscular medication for treatment of agitation in the emergency department: A systematic review of controlled trials.

BACKGROUND: Severely agitated patients in the emergency department (ED) are often sedated with intramuscularly-administered medications. The evidence base underlying particular medication choices is surprisingly sparse, as existing reviews either have methodological limitations or have included data collected outside of emergent settings. OBJECTIVES: The objective of this review was to examine all controlled trials in emergent settings that have used standardized scales to measure the effectiveness of intramuscular medication for the treatment of acute agitation. METHODS: This review was registered in Prospero as CRD42018105745. PubMed, International Pharmaceutical Abstracts, Web of Science, PsycINFO, and clinicaltrials.gov were searched for prospective controlled trials investigating intramuscular antipsychotics for agitation. Articles were assessed for bias across five domains using the revised Cochrane Risk of Bias Tool. RESULTS: Eight studies were eligible for inclusion in the systematic review, none of which had a low risk of bias. Five studies had a moderate risk of bias with heterogenous designs, populations, and treatments. These studies seemed to suggest that second generation antipsychotics (SGAs) likely reduce agitation as effectively as first generation antipsychotics (FGAs) plus an adjunctive medication with similar or lower risk of side effects. CONCLUSIONS: Existing trials on the use of intramuscular antipsychotics in the ED/psychiatric ED setting were small, heterogenous, and at a moderate or high risk of bias. Given the clinical importance of this topic, further prospective investigations are desperately needed but are currently unfeasible under Food and Drug Administration Exception From Informed Consent regulations.

The utility of a statewide prescription drug-monitoring database vs the Current Opioid Misuse Measure for identifying drug-aberrant behaviors in emergency department patients already on opioids.

BACKGROUND: The most recent guidelines on prescribing opioids from the United States Centers for Disease Control recommend that clinicians not prescribe opioids as first-line therapy for chronic non-cancer pain. If an opioid prescription is considered for a patient already on opioids, prescribers are encouraged to check the statewide prescription drug monitoring database (PDMP). Some additional guidelines recommend screening tools such as the Current Opioid Misuse Measure (COMM) which may also help identify drug-aberrant behaviors. OBJECTIVE: To compare the PDMP and the Current Opioid Misuse Measure (COMM), a commonly-recommended screening tool for patients on opioids, in detecting drug-aberrant behaviors in patients already taking opioids at the time of ED presentation. METHODS: Patients on opioids were enrolled prospectively in a mixed urban-suburban ED seeing approximately 65,000 patients per year. The sensitivity, specificity, likelihood ratios, and diagnostic odds ratios of the PDMP and COMM were compared against objective criteria of drug-aberrant behaviors as documented in the electronic medical record (EMR) and medical examiner databases. RESULTS: Compared to the COMM, the PDMP had similar sensitivity (36% vs 45%) and similar specificity (79% vs 55%), but better positive predictive value, better negative predictive value, and better diagnostic odds ratio. The combination of the PDMP and the COMM did not improve the detection of drug-aberrant behaviors. CONCLUSIONS: The PDMP alone is a more useful as a screening instrument than either the COMM or the combination of the PDMP plus COMM in patients already taking opioids at time of ED presentation. However, the PDMP misses a majority of patients with documented drug-aberrant behaviors in the EMR, and should not be used in isolation to justify whether a particular opioid prescription is appropriate.

Screening Tools Validated in the Outpatient Pain Management Setting Poorly Predict Opioid Misuse in the Emergency Department: A Pilot Study.

BACKGROUND: Currently, no universally accepted methods exist to assess drug-related aberrant behaviors in emergency department (ED) patients. There are several screening tools to identify opioid misuse in patients with chronic pain, however, the validity of these screening tools to assess for misuse within the ED remains unclear. OBJECTIVES: This study investigated the effectiveness of three commonly used screening tools, previously validated in outpatient pain management settings, to assess risk of opioid misuse in ED patients. METHODS: This was a prospective observational study of 154 participants (median age 50 years; 49.6% female) presenting to an academic ED for a chief complaint of pain ≥ 6 months or an opioid refill request. Participants completed the Opioid Risk Tool, the Screener and Opioid Assessment for Patients with Pain-Revised, and the Current Opioid Misuse Measure. Scores for each were compared with electronic medical record (EMR) data alone or a reference standard comprising EMR + statewide prescription drug monitoring program (PDMP) + medical examiner database. RESULTS: Using the combined reference standard, 55.8% of participants displayed at least one aberrant behavior. Regardless of the reference standard, the test characteristics of these screening tools were modest at best, with likelihood ratios close to 1. CONCLUSION: Three screening tools previously validated in outpatient pain management settings poorly categorized risk among ED patients with chronic noncancer pain or requests for opioid refills, and should not be used to assess drug-aberrant behaviors in the ED. Review of the EMR alone or together with the PDMP may be more useful methods to assess drug-aberrant behaviors in the ED setting.

Suicide screening scales may not adequately predict disposition of suicidal patients from the emergency department.

BACKGROUND: Suicide screening scales have been advocated for use in the ED setting. However, it is currently unknown whether patients classified as low-risk on these scales can be safely discharged from the emergency department. This study evaluated the utility of three commonly-used suicide screening tools in the emergency department to predict ED disposition, with special interest in discharge among low-risk patients. METHODS: This prospective observational study enrolled a convenience sample of patients who answered "yes" to a triage suicidal ideation question in an urban academic emergency department. Patients were administered the weighted modified SADPERSONS Scale, Suicide Assessment Five-step Evaluation and Triage, and Columbia-Suicide Severity Rating Scale. Patients who subsequently received a psychiatric evaluation were included, and the utility of these screening tools to predict disposition was evaluated. RESULTS: 276 subjects completed all three suicide screening tools and were included in data analyses. Eighty-two patients (30%) were admitted or transferred. Three patients (1%) died by suicide within one year of enrollment; one was hospitalized at the end of his or her enrollment visit, dying by suicide seven months later and the other two were discharged, dying by suicide nine and ten months later, respectively. The screening tools exhibited modest negative predictive values (range: 0.66-0.73). CONCLUSION: Three suicide screening tools displayed modest ability to predict the disposition of patients who presented to an emergency department with suicidal ideation. This study supports the current ACEP clinical policy on psychiatric patients which states that screening tools should not be used in isolation to guide disposition decisions of suicidal patients from the ED.

Telephoned, Texted, or Typed Out: A Randomized Trial of Physician-Patient Communication After Emergency Department Discharge.

BACKGROUND: Novel means of emergency department (ED) post-discharge communication-telephone callbacks and text messages-are increasingly being utilized to facilitate patient-oriented outcomes, such as ED revisits, patient adherence, and satisfaction. OBJECTIVE: The primary measure of interest is the rate of ED revisits in the week after discharge. The secondary measures of interests are rate of primary medical doctor (PMD) or specialist physician contact in the week after discharge and patient satisfaction. METHODS: Pilot randomized controlled trial with three groups: usual discharge; usual care + phone call 48 h after discharge asking if patients wanted to speak with a physician; or usual care + text message 48 h after discharge asking if patients wanted to speak with a physician. All participants received a 1-week assessment of patient satisfaction. ED revisit and contact with PMD or specialist physician within 7 days of discharge were obtained from electronic medical record and analyzed using χ2 test. RESULTS: Two hundred and fifty-one patients were enrolled and randomized (66 control, 103 phone, 82 text). Although the three groups did not show a statistically significant difference, the phone and text groups had similar and lower proportions of patients revisiting the ED (>50% reduction) and calling or visiting their PMD or specialist physician (approximately 30% reduction) than the control group (χ2 = 4.57, degrees of freedom [df] = 2, p = 0.10; χ2 = 1.36, df = 2, p = 0.51). There was no difference in patient satisfaction (χ2 = 2.88, df = 2, p = 0.24). CONCLUSIONS: Patients who are contacted for ED follow-up by phone and text, though perhaps not more satisfied, may tend to revisit the ED and contact their PMD or specialty physician less often than patients receiving standard written discharge instructions. However, this pilot study is underpowered, so larger randomized studies are needed to confirm.

Medical Screening of Mental Health Patients in the Emergency Department: A Systematic Review.

BACKGROUND: Patients presenting to the emergency department (ED) with psychiatric complaints often require medical screening to evaluate for a medical cause of their symptoms. OBJECTIVE: We sought to evaluate the existing literature on the medical screening of psychiatric patients and establish recommendations for ideal screening practices in Western-style EDs. METHODS: PubMed, PsycINFO, and ClinicalTrials.gov were searched for clinical studies examining the medical screening of adult psychiatric patients in the ED or inappropriate referrals to psychiatry. Articles were graded using the Effective Public Health Practice Project (EPHPP) grading tool and sorted into topics. A 3-level grading algorithm used by other emergency medicine organizations was used to evaluate the strength of the evidence for each recommendation. RESULTS: Sixty articles met the inclusion and exclusion criteria. Most published literature on medical screening consisted of nonrandomized studies with a high risk of bias. Some screening procedures, such as history and physical examination, were extensively recommended. Other screening procedures received mixed recommendations. CONCLUSIONS: Based on available literature, physician experts developed 7 recommendations. For a patient with known psychiatric disease presenting with symptom exacerbation, medical screening should include a full medical and psychiatric history, a targeted physical examination, and a mental status examination. Urine toxicology screening and nonurine drug screen laboratory testing should not be routinely performed. Additional screening tests may be valuable for patients with new-onset psychiatric symptoms who are ≥65 years of age, are immunosuppressed, or have concomitant medical disease. However, additional studies on this topic with more rigorous methodology must be conducted to establish definitive guidelines.

Oral Medication for Agitation of Psychiatric Origin: A Scoping Review of Randomized Controlled Trials.

BACKGROUND: Understanding more about the efficacy and safety of oral second-generation antipsychotic medications in reducing the symptoms of acute agitation could improve the treatment of psychiatric emergencies. OBJECTIVE: The objective of this scoping review was to examine the evidence base underlying expert consensus panel recommendations for the use of oral second-generation antipsychotics to treat acute agitation in mentally ill patients. METHODS: The Cochrane Schizophrenia Group's Study-Based Register was searched for randomized controlled trials comparing oral second-generation antipsychotics, benzodiazepines, or first-generation antipsychotics with or without adjunctive benzodiazepines, irrespective of route of administration of the drug being compared. Six articles were included in the final review. RESULTS: Two oral second-generation antipsychotic medications were studied across the six included trials. While the studies had relatively small sample sizes, oral second-generation antipsychotics were similarly effective to intramuscular first-generation antipsychotics in treating symptoms of acute agitation and had similar side-effect profiles. CONCLUSIONS: This scoping review identified six randomized trials investigating the use of oral second-generation antipsychotic medications in the reduction of acute agitation among patients experiencing psychiatric emergencies. Further research will be necessary to make clinical recommendations due to the overall dearth of randomized trials, as well as the small sample sizes of the included studies.

Effectiveness of a Self-Administered Computerized Mental Health Screening Tool in the Emergency Department.

OBJECTIVE: The authors sought to determine the effectiveness of a self-administered computerized mental health screening tool in a general acute care emergency department (ED). METHODS: Changes in patient care (diagnosis of a past-year psychiatric disorder, request for psychiatric consultation, psychiatric referral at discharge, or transfer to psychiatric facility) and patient ED return visits (3 months after discharge vs. 3 months before) were assessed among ED physicians (N=451) who received patients' computerized screening reports (N=207) and those who did not (N=244). All patients received copies of screening results. RESULTS: The computerized mental health screening tool identified previously undiagnosed psychiatric problems. However, no statistically significant differences were found in physician care or patient ED return visits. CONCLUSIONS: Computerized mental health screening did not result in further psychiatric diagnoses or treatment; it also did not significantly reduce patient ED return visits. Collaboration among EDs and mental health treatment agencies, organizations, and researchers is needed to facilitate appropriate treatment referrals and linkage.

Study Enrollment When "Preconsent" Is Utilized for a Randomized Clinical Trial of Two Treatments for Acute Agitation in the Emergency Department.

BACKGROUND: Acute agitation in the emergency department (ED) represents a danger to both patients and their caregivers. Medication is often needed, and few high-quality randomized trials have evaluated the optimal drugs for this vulnerable population. In the United States, as of 2017, randomized trials of drugs typically cannot be conducted under Waiver of Consent (46 CFR 45.116), and Exception From Informed Consent trials (21 CFR 50.24) are limited to life-threatening conditions, are onerous, and require filing an investigational new drug application with the FDA. We sought to conduct a randomized double-dummy trial of inhaled loxapine versus intramuscular haloperidol + lorazepam for acute agitation in the ED by obtaining consent in advance ("preconsent") in patients at risk of future agitation, allowing study drug administration up to 3 years later if the patient presented with acute agitation. OBJECTIVE: We sought to report the successful enrollment rate of patients preconsented at an earlier ED visit for this trial. METHODS: This was an analysis of patients age 18 to 64 with bipolar I disorder or schizophrenia preconsented for enrollment in the trial (clinicaltrials.gov, NCT02877108) conducted at a single urban academic center seeing approximately 60,000 patients per year. Eligible patients were assessed for capacity to consent by trained research associates, and informed consent was obtained at an ED visit for the possibility of administering drugs for agitation within the next 3 years. In the event the patient later presented to the ED and the attending physician deemed the patient required treatment for acute agitation, preconsent was confirmed and study drug would be administered. RESULTS: Over 67 days, 1,461 patients were screened in the ED, 269 had bipolar I or schizophrenia, 194 of whom had a contraindication to inhaled loxapine leaving 75 eligible patients; preconsent was obtained in 43 patients. Four additional patients who had not preconsented were consented for the trial in real time (three by surrogate, one patient had capacity while agitated) resulting in a total of 47 consented patients. Of these 47, a total of 12 were later removed from the study: 10 patients had unrecognized exclusion criteria for inhaled loxapine, one preconsented patient contacted the investigators at a later date and asked to be removed, and one surrogate revoked consent immediately after providing it. Only two patients were successfully enrolled, neither by preconsent: one was enrolled via a surrogate the day of enrollment, and the other was mildly agitated and had capacity to consent. The remaining patient with a valid surrogate consent did not receive study medication. CONCLUSIONS: Utilization of preconsent to enroll patients in a randomized trial of treatments for acute agitation in the ED requires substantial resources and may not be feasible.