[Necessity for treatment of psychiatric emergencies in the emergency medical service. Evaluation of the "indicator for psychiatric pharmacotherapy"]

[The situation of emergency psychiatry in Germany]

The impact of psychiatric emergencies for the care of patients in preclinical emergency medicine, in emergency departments and in psychiatric hospitals has been underestimated for a long time. There is still insufficient knowledge and a need for further research. There are, however, sufficient reasons to assume that annually approximately 500,000 patients with a psychiatric emergency receive treatment from a preclinical emergency physician and another 1.5 million in emergency departments in Germany. Further, approximately 500,000 patients are admitted to psychiatric hospitals as an emergency. The most frequent reasons are intoxication, agitation, aggressiveness and suicidal ideation, posing a threat of self-harm to the patient or to other persons and evoking other life-threatening conditions. Emergency psychiatry also plays a role in collective injuries, such as mass disasters, catastrophes and rampage situations. There is some evidence that the number of psychiatric emergencies is increasing. Reasons are, among others, changes in the services provided for inpatient and outpatient treatment, a reduction in stabilizing psychosocial factors and a general increase in the utilization of emergency healthcare services.

[Social aspects of emergency calls in the rescue service]

BACKGROUND

Many missions in the preclinical emergency services seem to be triggered by false indications as defined by the Federal State Rescue Act. These emergency calls are often a result of or associated with social issues. Emergency rescue personnel are confronted with social problems and as a result often feel left alone with the problem.

AIM

This article promotes the understanding of emergency service personnel for the associations between social problems and health. Solution strategies for frequent social emergencies are described.

MATERIAL AND METHODS

This article demonstrates the associations between socioeconomic status, health and disease. Typical indications for missions in which social aspects play an important role are presented and solution strategies for the approach are suggested. A discussion is presented on how to deal with cases of child abuse and domestic violence. Three classical psychiatric problem areas with common social components are explained: psychomotor state of excitation, suicide and alcohol-associated incidents and special attention is paid to danger to third parties and aggressive patients. In addition to the treatment of medical conditions, social problems play an important role particularly for the elderly and chronically ill patients.

RESULTS AND CONCLUSION

Emergency personnel have only limited options for dealing with such problems; however, it is important to be aware of regional structures and non-medical organizations, which might be of help in such situations. These include social services, youth welfare services, crisis interventions teams and social psychiatric services.

[Psychopharmacotherapy in emergency medicine]

Part two of the CME article Psychotropic agents and psychopharmacotherapy in emergency medicine aims to give an understanding of the pharmacotherapy of psychiatric disorders in emergency medicine. In contrast to somatic emergencies, many emergency physicians are not familiar with the treatment of psychiatric emergencies, although there are guidelines and recommendations. In the following article, treatment recommendations for the 5 most common and relevant syndromes in emergency medicine (i.e., suicide, delirium, agitation, stupor, and syndromes due to psychopharmaceutical use) are described based on the German S2-Guideline Emergency Psychiatry that will be published soon.

[Psychiatric care in emergency departments]

BACKGROUND

Psychiatric emergency situations (PES) are frequent in emergency departments (EDs). There are, however, only few investigations that focus on the prevalence of these patients or on diagnostic and therapeutic standards. These PESs in EDs should be treated according to standards comparable to medically disabled patients. Thus it is necessary to learn more about the diagnostic and therapeutic possibilities in EDs, about the procedures and the decision-making process whether these patients are transferred to further outpatient or inpatient treatment.

MATERIALS AND METHODS

A survey was conducted in EDs throughout Germany and 1,073 were contacted and asked to participate. The questionnaire consisted of questions concerning the size of the ED and of the hospital (e.g. number of patients and physicians), the prevalence of psychiatric disorders, the diagnostic and therapeutic possibilities, standard procedures for dealing with PES and the method of care in six typical case reports.

RESULTS

A total of 74 EDs participated (76% interdisciplinary EDs) with an average of 22,827 ± 12,303 patients per year in the ED. Psychiatry as a medical discipline was integrated into 10 EDs (14%) and psychiatric competence could be activated in 84% of EDs. Participating EDs reported prevalence rates of 15% mentally disordered patients and 9% of patients who required psychiatric diagnostic and therapeutic procedures. Of the patients 2% presented after suicide attempts and 3% were considered to be aggressive. Approximately 50% of all PESs were related to substance abuse disorders. An average of 2.5 ± 4.2 (range 0-25) members of the medical and nursing staff were injured during a 1-year period by violent patients. Legal actions against the will of patients were initiated in 81% of EDs. Standardized diagnostic screening instruments or self-rating questionnaires were used in only four EDs. As standard procedures for the diagnostic work-up of psychiatric patients (medical clearance) physical examination, measurement of heart rate and blood pressure and conducting of some laboratory tests (glucose, blood cell count, electrolytes and renal function) were named. Diazepam (91%), lorazepam (88%) and haloperidol (87%) were considered to be indispensable psychopharmacological agents in the ED.

CONCLUSIONS

In the majority of participating EDs, diagnostic standards for PES were known but were not routinely applied. It has to be assumed that many psychiatric disorders, in particular suicide attempts and suicidal ideation are not discovered. In many EDs psychiatric knowledge was available but a psychiatric consultation was only rarely requested. Physicians in the ED report a high degree of legal uncertainty with psychiatric patients. The use of screening instruments is recommended.