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Nugent SM, Anderson J, Young SK. Behavioural mental health interventions delivered in the emergency department for suicide, overdose and psychosis: a scoping review. BMJ Open 2024; 14:e080023. [PMID: 38531581 DOI: 10.1136/bmjopen-2023-080023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Abstract
OBJECTIVE To identify and describe evidence on brief emergency department (ED)-delivered behavioural and care process interventions among patients presenting with suicide attempt or acute ideation, substance overdose or psychosis. DESIGN We employed a scoping review design and searched multiple data sources, clinical trial registries and references lists through March 2023. We included English-language trials and rigorously designed observational studies. In alignment with scoping review guidelines, we did not assess the quality of included studies or rate the strength of evidence of intervention effectiveness. POPULATION Our population of interest was adults presenting to the ED with suicidality (eg, attempt or acute ideation), any substance overdose or acute psychosis from a primary mental health condition. INTERVENTION We included studies of brief behavioural or care process interventions delivered in the ED. OUTCOME MEASURES Health outcomes (eg, symptom reduction), healthcare utilisation and harms. RESULTS Our search identified 2034 potentially relevant articles. We included 40 studies: 3 systematic reviews and 39 primary studies. Most studies (n=34) examined ED interventions in patients with suicide attempt or suicidal ideation, while eight studies examined interventions in patients with opioid overdose. No studies examined ED interventions in patients with acute psychosis. Most suicide prevention studies reported that brief psychological, psychosocial or screening and triage interventions reduce suicide and suicide attempt following an ED visit. Most clinical trial interventions were multicomponent and included at least one follow-up. All substance overdose studies focused on opioids. These studies often contained medication and referral or consultation components. Multiple studies reported increases in substance use disorder treatment utilisation; evidence on repeat overdose events was limited. CONCLUSIONS A wide range of multicomponent ED-delivered behavioural health interventions for suicidality and opioid use disorder show short-term improvement on primary outcomes such as suicide reattempt. Few studies on non-opioid substances and psychosis are available.
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Affiliation(s)
- Shannon M Nugent
- Center to Improve Veteran Involvement in Care, Portland VA Medical Center, Portland, Oregon, USA
- Department of Psychiatry, Oregon Health & Science University, Portland, Oregon, USA
| | - Johanna Anderson
- Evidence Synthesis Program, Portland VA Medical Center, Portland, Oregon, USA
| | - Sarah K Young
- Evidence Synthesis Program, Portland VA Medical Center, Portland, Oregon, USA
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Brown AC, Evans DD, Tucker P. Is Ketamine an Effective Treatment of Acute Agitation in the Emergency Department? Implications for APRN Practice. Adv Emerg Nurs J 2023; 45:253-259. [PMID: 37885076 DOI: 10.1097/tme.0000000000000479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
This article reviews the results of a randomized controlled trial, "Rapid Agitation Control with Ketamine in the Emergency Department: A Blinded, Randomized Controlled Trial" by D. Barbic et al. (2021), comparing time to sedation, level of sedation, and adverse outcomes between intramuscular ketamine versus intramuscular midazolam and haloperidol among acutely agitated patients presenting to the emergency department (ED). The findings are discussed in the context of practice change for patient stabilization within the ED. Emergency department nurse practitioners must employ continuing education and remain current with clinical practices and treatment options to ensure that patients receive optimal safe care. Although the use of midazolam and haloperidol has historically been the first-line treatment for the acutely agitated patient, use of ketamine shows promise in providing a safe alternative for expedited patient stabilization for acutely agitated patients presenting to the ED.
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Affiliation(s)
- Andrea C Brown
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
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Keller S, Tilbor E, Shwiki A, Florentin S, Laufer S, Bonne O, Canetti L, Reuveni I. Psychiatric referrals to the general hospital emergency department: are we being effective? Front Psychiatry 2023; 14:1166191. [PMID: 37599892 PMCID: PMC10433187 DOI: 10.3389/fpsyt.2023.1166191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 07/10/2023] [Indexed: 08/22/2023] Open
Abstract
Introduction General hospital emergency departments (GHEDs) are notoriously overcrowded. This is caused, in part, by ineffective referrals, that is to say referrals that do not require medical examination or other interventions in the context of a general hospital. This study aims to investigate the contribution of psychiatric referrals to this issue, to identify potential determinants of these referrals and offer means to reduce them. Materials and methods Retrospective data were collected from psychiatric admission files within a GHED of a tertiary-care city hospital over a 1 year period. Two experienced clinicians separately reviewed each file to determine rationale of referrals according to predetermined criteria. Results A total of 2,136 visits included a psychiatric examination, 900 (42.1%) were determined "effective," and 1,227 (57.4%) were deemed "potentially ineffective." The leading causes for potentially ineffective referrals to a GHED were psychiatric illness exacerbation (43.4%), and suicidal ideations (22%). Most referrals (66.9%) were initiated by the patient or their family, and not by a primary care physician or psychiatrist. Conclusion More than half of the psychiatric referrals did not necessarily require the services of a general hospital, and may be more suitable for referral to a dedicated psychiatric facility. Ineffective referrals to the GHED pose a burden on general hospital resources, and may be less effective for the psychiatric patients. This calls for clear guidelines for the provision of optimal emergency treatment for mental-health patients.
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Affiliation(s)
- Shikma Keller
- Department of Psychiatry, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Einat Tilbor
- Department of Psychiatry, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Afnan Shwiki
- Department of Psychiatry, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sharon Florentin
- Department of Psychiatry, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sofia Laufer
- Department of Psychiatry, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Omer Bonne
- Department of Psychiatry, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Laura Canetti
- Department of Psychiatry, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Psychology, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Inbal Reuveni
- Department of Psychiatry, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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4
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Strayer RJ, Friedman BW, Haroz R, Ketcham E, Klein L, LaPietra AM, Motov S, Repanshek Z, Taylor S, Weiner SG, Nelson LS. Emergency Department Management of Patients With Alcohol Intoxication, Alcohol Withdrawal, and Alcohol Use Disorder: A White Paper Prepared for the American Academy of Emergency Medicine. J Emerg Med 2023; 64:517-540. [PMID: 36997435 DOI: 10.1016/j.jemermed.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 01/06/2023] [Indexed: 03/30/2023]
Affiliation(s)
- Reuben J Strayer
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York.
| | - Benjamin W Friedman
- Department of Emergency Medicine, Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Rachel Haroz
- Cooper Medical School of Rowan University, Cooper University Healthcare, Camden, New Jersey
| | - Eric Ketcham
- Department of Emergency Medicine, Department of Behavioral Health, Addiction Medicine, Presbyterian Healthcare System, Santa Fe & Española, New Mexico
| | - Lauren Klein
- Department of Emergency Medicine, Good Samaritan Hospital, West Islip, New York
| | - Alexis M LaPietra
- Department of Emergency Medicine, Saint Joseph's Regional Medical Center, Paterson, New Jersey
| | - Sergey Motov
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Zachary Repanshek
- Department of Emergency Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Scott Taylor
- Department of Emergency Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Scott G Weiner
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lewis S Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
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5
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Berg JS, Payne AS, Wavra T, Morrison S, Patel SJ. Implementation of a Medical Clearance Algorithm for Psychiatric Emergency Patients. Hosp Pediatr 2023; 13:66-71. [PMID: 36575918 DOI: 10.1542/hpeds.2022-006672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Despite evidence demonstrating limited benefit, many clinicians continue to perform routine laboratory testing of well-appearing children to medically clear them before psychiatric admission. METHODS We conducted a quality improvement project to reduce routine laboratory testing among pediatric patients requiring admission to our psychiatric unit. We convened key stakeholders whose input informed the modification of an existing pathway and the development of a medical clearance algorithm. Our outcome was a reduction in routine laboratory testing for children requiring psychiatric admission. Our balancing measure was the number of patients requiring transfer from the inpatient psychiatry unit to a medical service. We used run charts to evaluate nonrandom variation and demonstrate sustained change. RESULTS Before the introduction of the new medical clearance algorithm, 93% (n = 547/589) of children with psychiatric emergencies received laboratory testing. After implementing the medical clearance algorithm, 19.6% (n = 158/807) of children with psychiatric emergencies received laboratory testing. Despite a decreased rate of routine testing, there were no transfers to the medical service. CONCLUSIONS Implementing a medical clearance algorithm can decrease routine laboratory testing without increasing transfers to the medical service among children requiring psychiatric admission.
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Affiliation(s)
- Julie S Berg
- Children's National Hospital, Washington, District of Columbia.,The George Washington School of Medicine & Health Sciences, Washington, District of Columbia
| | - Asha S Payne
- Children's National Hospital, Washington, District of Columbia.,The George Washington School of Medicine & Health Sciences, Washington, District of Columbia
| | - Theresa Wavra
- Children's National Hospital, Washington, District of Columbia
| | - Sephora Morrison
- Children's National Hospital, Washington, District of Columbia.,The George Washington School of Medicine & Health Sciences, Washington, District of Columbia
| | - Shilpa J Patel
- Children's National Hospital, Washington, District of Columbia.,The George Washington School of Medicine & Health Sciences, Washington, District of Columbia
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Wilson MP, Hamrick E, Stiebel V, Nordstrom K. Contemporary Practices for Medical Evaluation of the Psychiatric Patient in the Emergency Department. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2023; 21:28-34. [PMID: 37205042 PMCID: PMC10172537 DOI: 10.1176/appi.focus.20220063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Although emergency department (ED) visits for patients with mental illness are frequent, medical evaluation (i.e., "medical screening") of patients presenting with psychiatric complaints is inconsistent. This may largely be related to differing goals for medical screening, which often vary according to specialty. Although emergency physicians typically focus on stabilization of life-threatening diseases, psychiatrists tend to believe that care in the ED is more comprehensive, which often places the two fields at odds. The authors discuss the concept of medical screening, review the literature on this topic, and offer a clinically oriented update to the 2017 American Association for Emergency Psychiatry consensus guidelines on medical evaluation of the adult psychiatric patient in the ED.
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Affiliation(s)
- Michael P Wilson
- Department of Emergency Medicine and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Wilson); Department of Psychiatry (Hamrick, Stiebel) and Department of Emergency Medicine (Stiebel), West Virginia University, Morgantown; Department of Psychiatry, University of Colorado Denver, Denver (Nordstrom)
| | - Edward Hamrick
- Department of Emergency Medicine and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Wilson); Department of Psychiatry (Hamrick, Stiebel) and Department of Emergency Medicine (Stiebel), West Virginia University, Morgantown; Department of Psychiatry, University of Colorado Denver, Denver (Nordstrom)
| | - Victor Stiebel
- Department of Emergency Medicine and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Wilson); Department of Psychiatry (Hamrick, Stiebel) and Department of Emergency Medicine (Stiebel), West Virginia University, Morgantown; Department of Psychiatry, University of Colorado Denver, Denver (Nordstrom)
| | - Kimberly Nordstrom
- Department of Emergency Medicine and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Wilson); Department of Psychiatry (Hamrick, Stiebel) and Department of Emergency Medicine (Stiebel), West Virginia University, Morgantown; Department of Psychiatry, University of Colorado Denver, Denver (Nordstrom)
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7
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Long B, Keim SM, Betz M, Gottlieb M. Do All Adult Psychiatric Patients Need Routine Laboratory Evaluation and an Electrocardiogram? J Emerg Med 2022; 63:711-721. [PMID: 36274002 DOI: 10.1016/j.jemermed.2022.09.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 09/05/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Acute psychiatric presentations account for a significant number of emergency department (ED) visits. These patients require assessment by the emergency physician and often need further evaluation by a psychiatrist, who may request routine laboratory evaluation and an electrocardiogram (ECG). CLINICAL QUESTION Do all adult psychiatric patients need routine laboratory evaluation and an ECG? EVIDENCE REVIEW Studies retrieved included 2 prospective, observational studies and 7 retrospective studies. These studies evaluate the utility of laboratory analysis in all patients presenting a psychiatric complaint and its impact on patient management and disposition. CONCLUSION Based upon the available literature, routine laboratory analysis and ECG for all patients presenting with a psychiatric complaint are not recommended. Clinicians should consider the individual patient, clinical situation, and comorbidities when deciding to obtain further studies such as laboratory analysis. © 2022 Elsevier Inc.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Samuel M Keim
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, Arizona
| | - Marian Betz
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
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Im DD, Scott KW, Venkatesh AK, Lobon LF, Kroll DS, Samuels EA, Wilson MP, Zeller S, Zun LS, Clifford KC, Zachrison KS. A Quality Measurement Framework for Emergency Department Care of Psychiatric Emergencies. Ann Emerg Med 2022; 81:592-605. [PMID: 36402629 DOI: 10.1016/j.annemergmed.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 09/10/2022] [Accepted: 09/14/2022] [Indexed: 11/19/2022]
Abstract
As a primary access point for crisis psychiatric care, the emergency department (ED) is uniquely positioned to improve the quality of care and outcomes for patients with psychiatric emergencies. Quality measurement is the first key step in understanding the gaps and variations in emergency psychiatric care to guide quality improvement initiatives. Our objective was to develop a quality measurement framework informed by a comprehensive review and gap analysis of quality measures for ED psychiatric care. We conducted a systematic literature review and convened an expert panel in emergency medicine, psychiatry, and quality improvement to consider if and how existing quality measures evaluate the delivery of emergency psychiatric care in the ED setting. The expert panel reviewed 48 measures, of which 5 were standardized, and 3 had active National Quality Forum endorsement. Drawing from the measure appraisal, we developed a quality measurement framework with specific structural, process, and outcome measures across the ED care continuum. This framework can help shape an emergency medicine roadmap for future clinical quality improvement initiatives, research, and advocacy work designed to improve outcomes for patients presenting with psychiatric emergencies.
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Corwell BN, Motov SM, Davis N, Kim HK. Novel uses of ketamine in the emergency department. Expert Opin Drug Saf 2022; 21:1009-1025. [PMID: 35822534 DOI: 10.1080/14740338.2022.2100883] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION : Ketamine is gaining renewed interest among healthcare providers due to its novel clinical applications in the emergency department (ED) setting. AREAS COVERED : This article provides a comprehensive discussion of ketamine's pharmacological properties, including safety profile and adverse effects, in addition to an overview of current evidence for ketamine (racemic formulation) in the management of ED patients with acute agitation, pain, and depression/suicide ideation. EXPERT OPINION : Ketamine is an effective adjunct to opioids, providing greater pain relief than morphine alone. As an analgesic agent, administration of ketamine (0.1-0.3 mg/kg IV) alone can provide analgesia similar to that of morphine in patients with acute visceral and musculoskeletal pain. Moreover, ketamine provides equal analgesic efficacy to morphine in a variety of chronic painful conditions including pain associated with cancer, vaso-occlusive pain crisis associated with sickle cell disease, and in patients with high opioid tolerance and/or opioid dependency. Available literature shows that ketamine (1-2mg/kg IV or 4-5 mg/kg IM) is a safe, rapid (<5 minutes) and effective tranquilization agent for ED patients with acute agitation. Finally, there is growing evidence that suggests ketamine may have a potential utility in the management of patients with self-harm ideation or acute depressive episodes. Intravenous infusion of ketamine (0.5 mg/kg over 40 mins) has been shown to produce an antidepressant effect and decrease in suicidal ideation within 4 hours with effects lasting up to one week.
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Affiliation(s)
- Brian N Corwell
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Sergey M Motov
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY
| | - Natalie Davis
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Hong K Kim
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
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10
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Altaqi A, Grover P. An Initiative to Improve Efficiency of Emergency Department Adolescent Behavioral Health Visits. Pediatr Emerg Care 2022; 38:e1336-e1338. [PMID: 35559899 DOI: 10.1097/pec.0000000000002739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Pediatric mental illnesses are quite prevalent in the United States and worldwide. Prevalence has been increasing, and it is estimated that 13% to 20% of US children have a mental illness that costs an estimated $247 billion per year and affects children's social, emotional, and cognitive development (Perou et al. MMWR Suppl. 2013;62:1-35). Pediatric behavioral health visits to the emergency department (ED) have been on an exponential rise constituting 5% to 7% of ED visits (Kalb et al. Pediatrics. 2019;143(4):e20182192). This requires pediatric emergency physicians to frequently manage pediatric mental health illnesses and interact with pediatric psychiatrists to create an integrated system.There is no universally accepted protocol for medical clearance of psychiatric patients (Corl et al. Med Health R I. 2008 91(11):339-341). Our medical clearance protocol comprised complete blood counts, complete metabolic panel, thyroid panel, urine toxicology screen, blood alcohol, urine human chorionic gonadotropin for females, and electrocardiogram for patients 16 years and older. These tests are obtained and have to result in pediatric ED before admission to the adolescent psychiatry unit, therefore occupying space and contributing to pediatric ED overcrowding. In an attempt to decrease our length of stay (LOS), we worked with multiple stakeholders to modify this protocol.Based on results of the data extrapolated from adult psychiatry studies (Olshaker et al. Acad Emerg Med. 1997;4(2), 124-128; Parmar et al. West J Emerg Med. 2012;13(5), 388-393; Janiak and Atteberry. J Emerg Med. 2012;43(5), 866-870). The medical clearance process was adjusted, and laboratory tests, electrocardiogram, and other ancillary studies were waived. The new protocol indicates testing based on a detailed history, physical examination, and clinical judgment. The new medical clearance protocol was initiated in December 2018. The median ED LOS for patients seen in the ED and admitted to our inpatient unit from January to November 2018 was 290 minutes in comparison with median LOS for December 2018 to December 2019 period, which was 204 minutes, showing a median reduction of 86 minutes with no adverse outcomes.The median number of encounters requiring admission in both these periods was comparable. A downstream effect of this process was also cost savings. The estimated cost savings ranged from $37.45 to $47.5 per patient, not including labor and other indirect costs. The medical clearance process is a daunting process for both patients and their families and emerging data questioning its use. Goal-directed medical clearance may be an efficient and cost-saving medical clearance for patients requiring emergent psychiatric evaluation.
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Affiliation(s)
- Aiman Altaqi
- From the Department of Pediatric Emergency Medicine, Cleveland, Clinic, Cleveland, OH
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van Bockxmeer JJ, Lau A, Varshney V. Ketamine-precipitated syndrome of inappropriate antidiuretic hormone secretion in a patient with persistent lumbar pain: a case report. Can J Anaesth 2022; 69:624-629. [DOI: 10.1007/s12630-022-02221-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/12/2022] [Accepted: 01/17/2022] [Indexed: 01/22/2023] Open
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Bonadio W, Welsh C, Rosen C, Lam D, Spiro W, Legome E. Efficacy of emergency department screening tests for children admitted to an inpatient psychiatric unit for acute mental health emergencies. Acad Emerg Med 2022; 29:789-791. [PMID: 35254694 DOI: 10.1111/acem.14478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 11/26/2022]
Affiliation(s)
- William Bonadio
- Mount Sinai Morningside Medical Center New York New York USA
| | - Connor Welsh
- Mount Sinai Morningside Medical Center New York New York USA
| | - Carly Rosen
- Mount Sinai Morningside Medical Center New York New York USA
| | - David Lam
- Mount Sinai Morningside Medical Center New York New York USA
| | - Wesley Spiro
- Mount Sinai Morningside Medical Center New York New York USA
| | - Eric Legome
- Mount Sinai Morningside Medical Center New York New York USA
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13
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Gewahrsamsfähigkeitsuntersuchungen in der Notaufnahme. Notf Rett Med 2022. [DOI: 10.1007/s10049-021-00971-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Miller J. Managing acute agitation and aggression in the world of drug shortages. Ment Health Clin 2021; 11:334-346. [PMID: 34824958 PMCID: PMC8582771 DOI: 10.9740/mhc.2021.11.334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/28/2021] [Indexed: 11/13/2022] Open
Abstract
Acute agitation and aggression create safety risks for both patients and staff, often leading to psychiatric emergencies. Quick and appropriate treatment is necessary to achieve safe and effective outcomes. Unfortunately, there are several factors that hinder timely interventions, such as medication shortages and delay in staff preparedness. Ultimately, the goal of managing acute agitation and aggression in the clinical setting is to de-escalate the situation and prevent harm to patients and staff. This article will explore useful interventions in realizing treatment goals for the management of agitation and aggression in adults while navigating limitations faced in practice.
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15
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deSouza IS, Thode HC, Shrestha P, Allen R, Koos J, Singer AJ. Rapid tranquilization of the agitated patient in the emergency department: A systematic review and network meta-analysis. Am J Emerg Med 2021; 51:363-373. [PMID: 34823192 DOI: 10.1016/j.ajem.2021.11.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 10/29/2021] [Accepted: 11/04/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Safe and effective tranquilization of the acutely agitated patient is challenging, and head-to-head comparisons of medications are limited. We aimed to identify the most optimal agent(s) for rapid tranquilization of the severely agitated patient in the emergency department (ED). METHODS The protocol for systematic review was registered (PROSPERO; CRD42020212534). We searched MEDLINE, Embase, PsycINFO, and Cochrane Database/CENTRAL from inception to June 2, 2021. We limited studies to randomized controlled trials that enrolled adult ED patients with severe agitation and compared drugs for rapid tranquilization. Predetermined outcomes were: 1) Adequate sedation within 30 min (effectiveness), 2) Immediate, serious adverse event - cardiac arrest, ventricular tachydysrhythmia, endotracheal intubation, laryngospasm, hypoxemia, hypotension (safety), and 3) Time to adequate sedation (effect onset). We extracted data according to PRISMA-NMA and appraised trials using Cochrane RoB 2 tool. We performed Bayesian network meta-analysis (NMA) using a Markov Chain Monte Carlo method with random-effects model and vague prior distribution to calculate odds ratios with 95% credible intervals for dichotomous outcomes and frequentist NMA to calculate mean differences with 95% confidence intervals for continuous outcomes. We assessed confidence in results using CINeMA. We used surface under the cumulative ranking (SUCRA) curves to rank agent(s) for each outcome. RESULTS Eleven studies provided data for effectiveness (1142 patients) and safety (1147 patients). Data was insufficient for effect onset. The NMA found that ketamine (SUCRA = 93.0%) is most likely to have superior effectiveness; droperidol-midazolam (SUCRA = 78.8%) is most likely to be safest. There are concerns with study quality and imprecision. Quality of the point estimates varied for effectiveness but mostly rated "very low" for safety. CONCLUSIONS Available evidence suggests that ketamine and droperidol have intermediate effectiveness for rapid tranquilization of the severely agitated patient in the ED. There is insufficient evidence to definitively determine which agent(s) may be safest or fastest-acting. Further, direct-comparison study of ketamine and droperidol is recommended.
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Affiliation(s)
- Ian S deSouza
- Department of Emergency Medicine, SUNY Downstate Health Sciences University and Kings County Hospital Center, Brooklyn, NY, USA.
| | - Henry C Thode
- Department of Emergency Medicine, Stony Brook University, NY, USA.
| | - Pragati Shrestha
- Department of Emergency Medicine, Stony Brook University, NY, USA.
| | - Robert Allen
- Department of Emergency Medicine, SUNY Downstate Health Sciences University and Kings County Hospital Center, Brooklyn, NY, USA.
| | - Jessica Koos
- Department of Emergency Medicine, Stony Brook University, NY, USA.
| | - Adam J Singer
- Department of Emergency Medicine, Stony Brook University, NY, USA.
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Dimeff LA, Jobes DA, Tyndal T, Zhang I, Stefan S, Kako N, Lawrence H, Ilac M. Using the Delphi Method for Determining Key Performance Elements for Delivery of Optimal Suicide-Specific Interventions in Emergency Departments. Arch Suicide Res 2021; 27:246-260. [PMID: 34632952 DOI: 10.1080/13811118.2021.1984347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Evidence-based suicide prevention interventions directed to those seeking psychiatric crisis services for suicidality in the emergency department (ED) can reduce death by suicide and related suffering. Best practice guidelines for the care of suicidal patients in the ED exist but are not accompanied by fidelity tools for use in determining whether the interventions were applied, particularly when more than one intervention is delivered concurrently. We sought to develop a universal, treatment-agnostic Suicide Care Fidelity Checklist comprised of Key Performance Elements (KPE) across the recommended suicide-specific ED interventions. METHOD A comprehensive review of published care standards was first conducted to determine suicide-specific ED best practice treatment domains and KPEs. Subject matter experts (SMEs) were identified for each domain. Using the Delphi Consensus method, SMEs iteratively revised and refined the KPEs within their domain until achieving KPE item consensus. RESULTS A total of three iterations was required to obtain consensus in five of six domains: comprehensive suicide assessment, lethal means counseling, suicide crisis planning, behavioral skills training, and psychoeducation about suicidality. Consensus was not fully attained for the domain involving engagement with people with lived experience. CONCLUSIONS We successfully identified six intervention domains and 74 KPEs across domains (60 deemed essential, and 14 deemed optional), with full consensus reached for 70 KPEs. While replication of the initial findings is required, the Suicide Care Fidelity Checklist can be used as a fidelity checklist to verify delivery of suicide-specific ED interventions.HIGHLIGHTSApplied Delphi Consensus method with suicide-specific subject matter experts.Generated a treatment-agnostic, universal set of suicide prevention KPEs for EDs.Expert-derived KPEs help real-world settings to assess suicide care fidelity.
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Wilson MP, Kaur J, Blake L, Oliveto AH, Thompson RG, Pyne JM, Wolf L, Walker AP, Waliski AD, Nordstrom K. Adherence to guideline creation recommendations for suicide prevention in the emergency department: A systematic review. Am J Emerg Med 2021; 50:553-560. [PMID: 34547697 DOI: 10.1016/j.ajem.2021.07.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/21/2021] [Accepted: 07/20/2021] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Suicide rates in the United States rose 35.2% from 1999-2018. As emergency department (ED) providers often have limited training in management of suicidal patients and minimal access to mental health experts, clinical practice guidelines (CPGs) may improve care for these patients. However, clinical practice guidelines that do not adhere to quality standards for development may be harmful both to patients, if they promote practices based on flawed evidence, and to ED providers, if used in malpractice claims. In 2011, the Institute of Medicine created standards to determine the trustworthiness of CPGs. This review assessed the adherence of suicide prevention CPGs, intended for the ED, to these standards. Secondary objectives were to assess the association of adherence both with first author/organization specialty (ED vs non-ED) and with inclusion of recommendations on substance use, a potent risk factor for suicide. METHODS This is a systematic review of available suicide-prevention CPGs for the ED in both peer-reviewed and gray literature. This review followed the PRISMA standards for reporting systematic reviews. RESULTS Of 22 included CPGs, the 7 ED-sponsored CPGs had higher adherence to quality standards (3.1 vs 2.4) and included the highest-rated CPG (ICAR2E) identified by this review. Regardless of specialty, nearly all CPGs included some mention of identifying or managing substance use. CONCLUSIONS Most suicide prevention CPGs intended for the ED are written by non-ED first authors or organizations and have low adherence to quality standards. Future CPGs should be developed with more scientific rigor, include a multidisciplinary writing group, and be created by authors working in the practice environment to which the CPG applies.
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Affiliation(s)
- Michael P Wilson
- Division of Research and Evidence-Based Medicine, Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America; Department of Emergency Medicine Behavioral Emergencies Research Lab, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America.
| | - Jaskiran Kaur
- Department of Emergency Medicine Behavioral Emergencies Research Lab, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America; College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Lindsay Blake
- Academic Affairs, UAMS Library, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Alison H Oliveto
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Ronald G Thompson
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Jeffrey M Pyne
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Lisa Wolf
- Emergency Nurses Association, Schaumburg, Illinois
| | - A Paige Walker
- Department of Emergency Medicine Behavioral Emergencies Research Lab, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America; College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Angela D Waliski
- Department of Health Services Research and Development, Central Arkansas Veteran's Healthcare System, Little Rock, AR, United States of America
| | - Kimberly Nordstrom
- Department of Emergency Medicine Behavioral Emergencies Research Lab, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America; Department of Psychiatry, University of Colorado School of Medicine, Denver, CO, United States of America
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CAEP position statement on violence in the emergency department. CAN J EMERG MED 2021; 23:758-761. [PMID: 34351599 DOI: 10.1007/s43678-021-00182-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/19/2021] [Indexed: 10/20/2022]
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Brodeur J, Ley AF, Bonnet M. A survey of Midwest physicians' experiences with patients in psychiatric distress in the emergency department. J Osteopath Med 2021; 121:773-778. [PMID: 34315193 DOI: 10.1515/jom-2021-0052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 06/08/2021] [Indexed: 11/15/2022]
Abstract
CONTEXT Emergency medicine (EM) physicians commonly stabilize patients with acute psychiatric distress, such as suicidal ideation. Research has shown that suicidal ideation is difficult to manage in emergency department (ED) settings and that patients in psychiatric distress are often "boarded" in the ED while awaiting more definitive care. OBJECTIVES To examine the attitudes and experiences of emergency physicians regarding the care of patients in psychiatric distress. Special attention is given to suicidal ideation due to its prevalence in the United States. METHODS A 19 question anonymous survey was sent via email to 55 emergency medicine residency directors throughout Michigan, Ohio, Indiana, and Illinois, who were identified using an Internet search of residency programs in the region. The program directors were asked to distribute the survey to their colleagues and residents. The intent of this procedure was to generate as many survey responses as possible, while obscuring the identities of the respondents. Responses were gathered from October 29, 2019 until January 16, 2020. The survey was designed to assess respondents' self-reported demographic data as well as their experiences with the boarding process, initial examination, final disposition, reevaluation of the patient, physician training and resources, and follow up care. Statistical analysis was performed using a Mann-Whitney U test, significance was set at p<0.01. RESULTS In total, 47 EM physicians responded to the survey; however, not all of the respondents completed all 19 questions. Ten of 44 respondents (22.7%) reported that they do not perform the initial psychiatric examination themselves and instead defer to a nurse or social worker. Twenty-two of 44 respondents (50.0%) reported that they defer to a social worker when determining the final disposition of psychiatric patients. Respondents reevaluated patients in psychiatric distress statistically significantly less often (p=0.01) compared with patients with cardiac pathology. Additionally, 15 of 38 respondents (39.5%) reported that they did not feel adequately trained to handle psychiatric emergencies, and 36 of 39 respondents (92.3%) of physicians felt that their facility would benefit from additional mental health resources. Thirty five of 39 respondents (89.7%) reported that their facility did not have a system in place to follow up with suicidal patients upon discharge. CONCLUSIONS Caring for patients who are acutely suicidal or in psychiatric distress is complex and more research is needed to optimize treatment strategies. The results of this study indicate that EM physicians may regularly defer to nonphysician providers when evaluating and treating patients in psychiatric distress. A perceived lack of training in psychiatry may contribute to this practice. The results of this study are in accord with previous research that indicated a need for additional psychiatry training in EM residencies.
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Affiliation(s)
- Jack Brodeur
- Michigan State University College of Osteopathic Medicine, East Lansing, MI, USA
| | - Alyse Folino Ley
- Psychiatry Residency Program, Department of Psychiatry, Michigan State University College of Osteopathic Medicine, East Lansing, MI, USA.,Child and Adolescent Psychiatry Fellowship, Department of Psychiatry, Michigan State University College of Osteopathic Medicine, East Lansing, MI, USA
| | - Michelle Bonnet
- PGY IV, Psychiatry Residency Program, Michigan State University College of Osteopathic Medicine, East Lansing, MI, USA
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Farkas A, Lipanot K, Sherman K. Routine Laboratory Screening for Acetaminophen and Salicylate Ingestion in Preadmission Psychiatric Patients Is Unnecessary. Ann Emerg Med 2021; 77:604-612. [PMID: 33840509 DOI: 10.1016/j.annemergmed.2021.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 01/14/2021] [Accepted: 01/27/2021] [Indexed: 10/21/2022]
Abstract
STUDY OBJECTIVE Screening preadmission psychiatric patients for acetaminophen or salicylate overdose is unnecessary in the absence of specific clinical concern for medication ingestion. METHODS This was a multicenter retrospective cohort study of 3 Veteran's Administration emergency departments that medically evaluate patients prior to psychiatric admission. During the 10-year study period, these departments followed screening protocols that required the measurement of acetaminophen and salicylate levels on every patient prior to psychiatric admission. We examined all the acetaminophen and salicylate assays performed to see if any that were sent for screening led to a diagnosis of overdose and/or the administration of antidotal therapy. RESULTS A total of 33,439 combined acetaminophen and salicylate assays were sent on 10,482 unique patients over approximately 17,000 patient encounters. An estimated 29,000 assays were sent for screening purposes only-87% (95% confidence interval [CI] 85% to 89%) of salicylate assays and 85% (95% CI 83% to 87%) of acetaminophen assays. We identified 43 patients with elevated acetaminophen levels and 11 with elevated salicylate levels. Among these patients, only 6 in total had their levels drawn for screening purposes only, with no history of suspected ingestion; in all but 1 patient, the levels were only slightly above the reference range. None of the patients with elevated levels identified by screening had clinical toxicity or received antidotal therapy. CONCLUSION Over a 10-year period, 3 Veteran's Administration emergency departments performed psychiatric preadmission screening protocols with acetaminophen and salicylate assays approximately 17,000 times without diagnosing a single case of toxicity. Our results suggest that this practice is unnecessary and wasteful.
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Affiliation(s)
- Andrew Farkas
- Zablocki Veterans Administration Medical Center, Milwaukee, WI; Medical College of Wisconsin Department of Emergency Medicine, Milwaukee, WI.
| | - Kristin Lipanot
- Medical College of Wisconsin Department of Emergency Medicine, Milwaukee, WI
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Kverno K, Mangano E. Psychiatric Emergencies and the Potential Role of Psychiatric-Mental Health Nurse Practitioners. J Psychosoc Nurs Ment Health Serv 2021; 59:7-12. [PMID: 33647157 DOI: 10.3928/02793695-20210212-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Emergency departments (EDs) are experiencing a worsening crisis of overcrowding, especially during the coronavirus pandemic. Persons experiencing psychiatric emergencies must be evaluated medically and screened for risks of harm to self or others before they can be cleared for transfer to inpatient units or discharged. Severe shortages of inpatient psychiatric beds can lead to hours or even days of costly boarding in the ED. The purpose of this article is to examine the potential role of psychiatric-mental health nurse practitioners in psychiatric ED care, from initial intake and medical clearance, screening for suicide risk, de-escalation, stabilization, and discharge. [Journal of Psychosocial Nursing and Mental Health Services, 59(3), 7-12.].
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22
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Tobin MR, Hartline JR, Sullivan SB, Kang CS, Devita D. Utility of Nonspecific Laboratory Testing for Psychiatric Patients Undergoing Medical Screening in a Military Emergency Department. Mil Med 2020; 185:e1941-e1945. [PMID: 33377494 DOI: 10.1093/milmed/usaa163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Psychiatric complaints account for a sizable and increasing portion of emergency department (ED) visits. Compared with other medical patients, these patients often require substantial resources because of limited specialized resources and prolonged boarding times, which can be detrimental to the safety and satisfaction of other patients. This can prompt early and indiscriminate laboratory testing to expedite early requests for admission consideration. Numerous emergency medicine literature and clinical policies already recommend against indiscriminate screening labs for these patients, yet many psychiatric services require these tests. This study further evidences the limited clinical utility and high associated costs of mandatory protocol screening labs for psychiatric patients evaluated in military EDs. MATERIALS AND METHODS A retrospective chart review of 441 active duty military patients and their families presenting to Madigan Army Medical Center's ED who received psychiatric diagnoses underwent analysis. A 3-physician review panel evaluated each identified patient case to confirm eligibility and determine whether or not laboratory studies led to a change in patient disposition that was not identified by history, review of systems, physical exam, and known past medical history. The review was approved by the hospital's institutional review board. Contemporary laboratory tests ordered in the evaluation of these patients included complete blood count with differential, complete metabolic panel, thyroid-stimulating hormone, serum ethanol, serum acetaminophen, serum salicylates, urine drug screening, urinalysis, urine human chorionic gonadotropin, and electrocardiograms. RESULTS Broad screening labs may have altered dispositions for 0.9% (4) of patients. In total, 93% (202) of admitted patients were dispositioned to a psychiatric service. Of the 15 patients admitted to a medical service, 10 involved overdoses or intoxication. One patient had anemia in addition to opioid use disorder as diagnoses and was dispositioned to a medicine service. One pediatric patient was admitted for observation only. The remaining patients had diagnoses based on physical exam and history requiring medical service admission. In total, 7 patients had unknown dispositions, of which 4 carried solely psychiatric diagnoses. CONCLUSIONS The cumulative reimbursement costs of broad testing in the studied population were estimated at $36,325.17 and rarely altered patient disposition. Further testing does not increase the incidence of disposition altering diagnoses and is associated with increased costs. When individual state laws and the clinical assessment by the responsible emergency physician are considered, future standardized ED lab screening evaluations of psychiatric patients in military EDs may be concentrated to breathalyzer alcohol level, urine drug screen, serum salicylates, serum acetaminophen, and urine human chorionic gonadotropin.
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Affiliation(s)
- Michael R Tobin
- Department of Emergency Medicine, 9040A Jackson Ave, Joint Base Lewis-McChord, 98431 WA
| | - James R Hartline
- Department of Emergency Medicine, 9040A Jackson Ave, Joint Base Lewis-McChord, 98431 WA
| | - Scott B Sullivan
- Department of Emergency Medicine, 9040A Jackson Ave, Joint Base Lewis-McChord, 98431 WA
| | - Christopher S Kang
- Department of Emergency Medicine, 9040A Jackson Ave, Joint Base Lewis-McChord, 98431 WA
| | - Diane Devita
- Department of Emergency Medicine, 9040A Jackson Ave, Joint Base Lewis-McChord, 98431 WA
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Bartlett K, Kane KE, Kane BG, Weaver KR, Barr GC. Appropriate Evaluation of Psychiatric Patients Highlighted by Creutzfeldt-Jakob Disease: A Case Report. Clin Pract Cases Emerg Med 2020; 4:656-659. [PMID: 33217301 PMCID: PMC7676806 DOI: 10.5811/cpcem.2020.7.47384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 07/21/2020] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Determination of medical stability for patients presenting with psychiatric complaints is common for emergency clinicians. A thorough history and physical examination is important. CASE REPORT A 53-year-old male presented to the emergency department (ED) with depression, suicidal ideation, and decline in activities of daily living over six months. While his initial neurologic examination was non-focal, subsequent re-evaluations demonstrated significant changes, and he was ultimately diagnosed with Creutzfeldt-Jakob disease. CONCLUSION This case demonstrates how a detailed history of the present illness could have led to a more accurate and timely medical disposition from the ED.
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Affiliation(s)
- Kathryn Bartlett
- Lehigh Valley Hospital and Health Network, Department of Emergency Medicine, Allentown, Pennsylvania
| | - Kathleen E Kane
- Lehigh Valley Hospital and Health Network, Department of Emergency Medicine, Allentown, Pennsylvania.,University of South Florida Morsani College of Medicine, Department of Emergency Medicine, Tampa, Florida
| | - Bryan G Kane
- Lehigh Valley Hospital and Health Network, Department of Emergency Medicine, Allentown, Pennsylvania.,University of South Florida Morsani College of Medicine, Department of Emergency Medicine, Tampa, Florida
| | - Kevin R Weaver
- Lehigh Valley Hospital and Health Network, Department of Emergency Medicine, Allentown, Pennsylvania.,University of South Florida Morsani College of Medicine, Department of Emergency Medicine, Tampa, Florida
| | - Gavin C Barr
- Lehigh Valley Hospital and Health Network, Department of Emergency Medicine, Allentown, Pennsylvania.,University of South Florida Morsani College of Medicine, Department of Emergency Medicine, Tampa, Florida
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Friedman MS, Saloum D, Haaland A, Drapkin J, Likourezos A, Strayer RJ. Description of Adverse Events in a Cohort of Dance Festival Attendees with Stimulant-Induced Severe Agitation Treated with Dissociative-Dose Ketamine. PREHOSP EMERG CARE 2020; 25:761-767. [DOI: 10.1080/10903127.2020.1837311] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Luttrull MD, Boulter DJ, Kirsch CFE, Aulino JM, Broder JS, Chakraborty S, Choudhri AF, Ducruet AF, Kendi AT, Lee RK, Liebeskind DS, Mack W, Moritani T, Roca RP, Shah LM, Sharma A, Shih RY, Symko SC, Bykowski J. ACR Appropriateness Criteria ® Acute Mental Status Change, Delirium, and New Onset Psychosis. J Am Coll Radiol 2020; 16:S26-S37. [PMID: 31054753 DOI: 10.1016/j.jacr.2019.02.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/08/2019] [Indexed: 11/30/2022]
Abstract
Acute changes in mental status represent a broad collection of symptoms used to describe disorders in mentation and level of arousal, including the more narrowly defined diagnoses of delirium and psychosis. A wide range of precipitating factors may be responsible for symptom onset including infection, intoxication, and metabolic disorders. Neurologic causes that may be detected on neuroimaging include stroke, traumatic brain injury, nonconvulsive seizure, central nervous system infection, tumors, hydrocephalus, and inflammatory disorders. Not infrequently, two or more precipitating factors may be found. Neuroimaging with CT or MRI is usually appropriate if the clinical suspicion for an acute neurological cause is high, where the cause of symptoms is not found on initial assessment, and for patients whose symptoms do not respond appropriately to management. There was disagreement regarding the appropriateness of neuroimaging in cases where a suspected, nonneurologic cause is found on initial assessment. Neuroimaging with CT is usually appropriate for patients presenting with delirium, although the yield may be low in the absence of trauma or a focal neurological deficit. Neuroimaging with CT or MRI may be appropriate in the evaluation of new onset psychosis, although the yield may be low in the absence of a neurologic deficit. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | - Daniel J Boulter
- Research Author, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Claudia F E Kirsch
- Panel Chair, Northwell Health, Zucker Hofstra School of Medicine at Northwell, Manhasset, New York
| | | | - Joshua S Broder
- Duke University School of Medicine, Durham, North Carolina; American College of Emergency Physicians
| | - Santanu Chakraborty
- Ottawa Hospital Research Institute and the Department of Radiology, The University of Ottawa, Ottawa, Ontario, Canada
| | - Asim F Choudhri
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Andrew F Ducruet
- Barrow Neurological Institute, Phoenix, Arizona; neurosurgical consultant
| | | | - Ryan K Lee
- Einstein Healthcare Network, Philadelphia, Pennsylvania
| | - David S Liebeskind
- University of California Los Angeles, Los Angeles, California; American Academy of Neurology
| | - William Mack
- University of Southern California, Los Angeles, California; neurosurgical consultant
| | | | - Robert P Roca
- Sheppard Pratt Health System, Towson, Maryland; American Psychiatric Association
| | | | - Aseem Sharma
- Mallinckrodt Institute of Radiology, Saint Louis, Missouri
| | - Robert Y Shih
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | | | - Julie Bykowski
- Specialty Chair, UC San Diego Health Center, San Diego, California
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Knorr AC, Ammerman BA, LaFleur SA, Misra D, Dhruv MA, Karunakaran B, Strony RJ. An investigation of clinical decisionmaking: identifying important factors in treatment planning for suicidal patients in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:383-391. [PMID: 33000061 PMCID: PMC7493507 DOI: 10.1002/emp2.12087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 04/09/2020] [Accepted: 04/13/2020] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE We sought to evaluate the influence of several well-documented, readily available risk factors that may influence a psychiatric consultant's decision to admit an emergency department (ED) patient reporting suicidal ideation for psychiatric hospitalization. METHODS We conducted a retrospective study of adult patients presenting to six affiliated EDs within Pennsylvania from January 2015 to June 2017. We identified 533 patients reporting current active suicidal ideation and receiving a complete psychiatric consultation. Socio-demographic characteristics, psychiatric presentation and history, and disposition were collected. Decision tree analysis was conducted with disposition as the outcome. RESULTS Four of 27 variables emerged as most influential to decisionmaking, including psychiatric consultant determination of current suicide risk, patient age, current depressive disorder diagnosis, and patient history of physical violence. Likelihood of admission versus discharge ranged from 97% to 58%, depending on the variables considered. Post hoc analysis indicated that current suicide plan, access to means, lack of social support, and suicide attempt history were significantly associated with psychiatric consultant determination of moderate-to-high suicide risk, with small-to-medium effect sizes emerging. CONCLUSIONS Only a handful of variables drive disposition decisions for ED patients reporting current active suicidal ideation, with both high and low fidelity decisions made. Patient suicide risk, determined by considering empirically supported risk factors for suicide attempt and death, contributes the greatest influence on a psychiatric consultant's decision to admit. In line with American College of Emergency Physicians (ACEP) recommendations, this study accentuates the importance of using clinical judgment and adjunct measures to determine patient disposition within this population.
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Affiliation(s)
- Anne C Knorr
- Department of Emergency Medicine Geisinger Medical Center Danville Pennsylvania USA
| | - Brooke A Ammerman
- Department of Psychology University of Notre Dame Notre Dame Indiana USA
| | - Sean A LaFleur
- Department of Emergency Medicine Geisinger Medical Center Danville Pennsylvania USA
| | - Debdipto Misra
- Geisinger System Services UDA Data Management Danville Pennsylvania USA
| | | | - Bipin Karunakaran
- Geisinger System Services UDA Data Management Danville Pennsylvania USA
| | - Robert J Strony
- Department of Emergency Medicine Geisinger Medical Center Danville Pennsylvania USA
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Hopelessness is associated with repeated suicidal behaviors after discharge in patients admitted to emergency departments for attempted suicide. J Affect Disord 2020; 272:170-175. [PMID: 32379612 DOI: 10.1016/j.jad.2020.04.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/03/2020] [Accepted: 04/24/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Hopelessness may be associated with an increased risk of suicide. However, findings regarding the long-term predictive ability of the Beck Hopelessness Scale (BHS) for suicide are inconsistent. This study investigated the long-term predictive ability of BHS scores for subsequent self-harm episodes in individuals admitted to an emergency department after attempting suicide. METHODS The BHS was administered to 805 adult patients with a DSM-IV-TR axis I disorder admitted to an emergency department following a suicide attempt. The patients were followed for at least 18 months and up to 5 years. The incidence of the first subsequent suicidal behavior (attempt or dying by suicide) was examined and the numbers per person-year of overall repeat self-harm episodes, suicide attempt episodes, and non-suicidal self-harm episodes were evaluated. RESULTS The total BHS scores showed significant associations with the overall number of self-harm episodes per person-year (incidence rate ratio [IRR], 1.05; 95% confidence interval [CI], 1.03-1.07; p < 0.0001), the number of suicide attempt episodes per person-year (IRR, 1.05; 95%CI, 1.03-1.08; p < 0.0001), and the number of non-suicidal self-harm episodes per person-year (IRR, 1.05; 95%CI, 1.03-1.07; p < 0.0001). LIMITATIONS The study excluded children and adolescents. The sample size, while large, was insufficient to ensure generalizability, or to allow subanalyses based on specific disorders. CONCLUSIONS Hopelessness scores assessed in the emergency department after a self-harming episode were associated with a rate of repetition of suicidal behaviors after discharge. Additional strategies to address hopelessness of these patients are warranted.
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Sweeny A, Keijzers G, O'Dwyer J, Stapelberg NC, Crilly J. Patients with mental health conditions in the emergency department: Why so long a wait? Emerg Med Australas 2020; 32:986-995. [PMID: 32510774 DOI: 10.1111/1742-6723.13543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 04/16/2020] [Accepted: 04/27/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Patients presenting with a mental health disorder (MHD) wait longer in the ED compared to those presenting for other reasons, potentially placing vulnerable patients at further risk for deterioration. The present study identified factors associated with a long ED stay for patients with a MHD. METHODS Linked ambulance, emergency, pathology, imaging and admission data for an 18-month period were analysed for ED presentations diagnosed with an MHD ICD-10 at a large teaching hospital. Admissions and discharges were considered separately; a long ED stay was defined as the 90th percentile length of stay. Multivariable generalised linear models were built, identifying predictors of a long ED stay for presentations diagnosed with a MHD. RESULTS The sample comprised 1163 admissions and 2242 discharges. For admissions, significant predictors for long ED stay were investigations (pathology or imaging tests), a triage score of 1 or 2, arrival out-of-hours (18.00-05.59 hours) and arrival by ambulance. For discharges, significant predictors of a long ED stay were investigations (pathology or imaging tests), arrival out-of-hours, arrival by ambulance and increasing age. CONCLUSIONS Some factors predictive of a long ED stay for patients presenting to the ED and diagnosed with a MHD varied based on their disposition. For admissions, the most urgent presentations were likely to stay longest. Strategies to reduce ED stay for both admissions and discharges should consider addressing modifiable aspects, including the need for certain investigations, and non-modifiable aspects, including the need for further access to after-hours mental health services in hospital and in the community.
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Affiliation(s)
- Amy Sweeny
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia.,Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - John O'Dwyer
- The Australian e-Health Research Centre, Health and Biosecurity, Commonwealth Scientific and Industrial Research Organisation, Brisbane, Queensland, Australia
| | - Nicolas Cj Stapelberg
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia.,Gold Coast Mental Health and Specialist Services, Gold Coast Health, Gold Coast, Queensland, Australia
| | - Julia Crilly
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
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Nentwich LM, Wittmann CW. Emergency Department Evaluation of the Adult Psychiatric Patient. Emerg Med Clin North Am 2020; 38:419-435. [PMID: 32336334 DOI: 10.1016/j.emc.2020.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Many patients with acute behavioral or mental health emergencies use the emergency department for their care. Psychiatric patients have a higher incidence of chronic medical conditions and are at greater risk for injury than the general population. Patients with acute behavioral emergencies may stress already overcrowded emergency departments. This article addresses high-risk areas of the treatment and management of emergency department patients presenting with behavioral emergencies. This article identifies methods successful in determining whether the patient's behavioral emergency is the result of an organic disease process, as well as recognizing other potential acute medical emergencies in this high-risk population.
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Affiliation(s)
- Lauren M Nentwich
- Department of Emergency Medicine, Boston University Medical Center, One Boston Medical Center Place, BCD Building, Boston, MA 02118, USA.
| | - Curtis W Wittmann
- Department of Psychiatry, Massachusetts General Hospital, Founders 826, 55 Fruit Street, Boston, MA 02114, USA
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Screening Electrocardiograms in Cocaine-Positive Chest Pain-Free Psychiatric Patients Requiring Medical Screening. J Emerg Med 2020; 58:290-295. [PMID: 32197895 DOI: 10.1016/j.jemermed.2019.11.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 11/04/2019] [Accepted: 11/23/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND The current practice at a large urban academic emergency department (ED) is to obtain screening electrocardiograms (ECGs) as part of the medical screening on all psychiatric patients who test positive for cocaine. OBJECTIVE We sought to examine the impact of an ECG in the medical screening of chest pain-free psychiatric patients who test positive for cocaine. METHODS An institutional review board-approved retrospective chart review from January 2014 to December 2015 was performed on charts of adult ED patients requiring medical screening before transfer to a psychiatric facility. Patients who tested positive for cocaine on urine drug screens were included in this study. Patients with chest pain or those who did not have an ECG recorded were excluded. Outcomes evaluated included disposition and subsequent cardiac work-up. RESULTS One thousand nine hundred sixty-eight ED patients were identified who tested positive for cocaine on a urine toxicology screen, and 853 met the inclusion criteria. ECGs were normal in 812 patients (95% [95% confidence interval 93-96%]) and abnormal in 41 patients (5% [95% confidence interval 4-7%]). Of 41 patients with abnormal ECGs, 4 were admitted for cardiac work-up. Two patients had positive troponin values in the ED, 2 had cardiology consultations, and 3 had further cardiac stress testing, all of which were negative or nondiagnostic. No cardiac catheterizations were performed. CONCLUSIONS Most ED patients with recent cocaine use but without chest pain have a normal ECG. Of the minority with an abnormal ECG, no cases of acute myocardial ischemia or infarction were identified.
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Guzmán EM, Tezanos KM, Chang BP, Cha CB. Examining the impact of emergency care settings on suicidal patients: A call to action. Gen Hosp Psychiatry 2020; 63:9-13. [PMID: 30077397 DOI: 10.1016/j.genhosppsych.2018.07.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 07/15/2018] [Accepted: 07/19/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The emergency department (ED) offers a critical and unique opportunity to assess and intervene on suicide risk. Despite its potential benefits, the ED setting presents several potential sources of stress. The present paper calls attention to how suicidal patients may be especially vulnerable to stressful ED experiences. METHOD This research synthesis cites the growing literature on ED-related stressors, as they have been shown to affect both psychiatric and nonpsychiatric patient populations. RESULTS We identified specific interpersonal, physical, and temporal features of the ED that have been shown to affect multiple patient populations, including suicidal individuals. Beyond this, there appears to be broad underutilization of therapeutic care in ED settings. CONCLUSIONS It is important to consider how the ED setting may be both helpful and harmful toward suicidal patients. We conclude with recommended domains of study and methodological considerations when pursuing these future directions. The proposed research agenda would help address this known high risk period around hospitalization and discharge, and ultimately optimize suicide prevention efforts.
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Affiliation(s)
- Eleonora M Guzmán
- Department of Counseling and Clinical Psychology, Teachers College, Columbia University, United States of America
| | - Katherine M Tezanos
- Department of Counseling and Clinical Psychology, Teachers College, Columbia University, United States of America
| | - Bernard P Chang
- Department of Emergency Medicine, Columbia University Medical Center, United States of America
| | - Christine B Cha
- Department of Counseling and Clinical Psychology, Teachers College, Columbia University, United States of America.
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Wilson MP, Moutier C, Wolf L, Nordstrom K, Schulz T, Betz ME. ED recommendations for suicide prevention in adults: The ICAR2E mnemonic and a systematic review of the literature. Am J Emerg Med 2020; 38:571-581. [DOI: 10.1016/j.ajem.2019.06.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 06/17/2019] [Accepted: 06/20/2019] [Indexed: 01/28/2023] Open
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Santillanes G, Axeen S, Lam CN, Menchine M. National trends in mental health-related emergency department visits by children and adults, 2009-2015. Am J Emerg Med 2019; 38:2536-2544. [PMID: 31902702 DOI: 10.1016/j.ajem.2019.12.035] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES Examine trends in mental health-related emergency department (ED) visits, changes in disposition and length of stay (LOS), describe disposition by age and estimate proportion of ED treatment hours dedicated to mental health-related visits. METHODS Retrospective analysis of ED encounters in the National Hospital Ambulatory Medical Care Visit Survey with a mental health primary, secondary or tertiary discharge diagnosis from 2009 to 2015. We report survey-weighted estimates of the number and proportion of ED visits that were mental health-related and disposition by age and survey year. We estimate the proportion of ED treatment hours dedicated to mental health-related visits. We analyze trends in disposition and LOS for mental health and non-mental health-related visits using multivariate regression analysis. RESULTS Mental health-related ED visits increased by 56.4% for pediatric patients and 40.8% for adults, accounting for over 10% of ED visits by 15-64 year-olds and nearly 9% by 10-14 year-olds in 2015. Mental health-related visit disposition of admission or transfer declined from 29.8% to 20.4% (p < .001); predicted median ED LOS for admissions or transfers increased from 6.5 to 9.0 hours while median LOS for discharges was stable at 4.4 hours. During the study period, mental health-related visits accounted for 5.0% (95% CI 4.6-5.3) of all pediatric and 11.1% (95% CI 11.0-11.3) of adult ED treatment hours. CONCLUSIONS Mental health-related visits account for an increasing proportion of ED visits and a considerable proportion of treatment hours. A decreasing proportion of mental health-related visits resulted in inpatient disposition and ED LOS increased for admissions and transfers.
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Affiliation(s)
- Genevieve Santillanes
- Department of Emergency Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Sarah Axeen
- Department of Emergency Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA.
| | - Chun Nok Lam
- Department of Emergency Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Michael Menchine
- Department of Emergency Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
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Esang M, Goldstein S, Dhami R. The Role of Physical Examinations in Psychiatry as Illustrated in a Case of Neuroleptic Malignant Syndrome Versus Viral Encephalitis: A Case Report and Literature Review. Cureus 2019; 11:e4840. [PMID: 31410323 PMCID: PMC6684120 DOI: 10.7759/cureus.4840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Although a standard psychiatric evaluation includes a physical examination, there are no guidelines on the components of a comprehensive physical examination during psychiatric patient encounters. The mental status examination is frequently considered the psychiatric physical examination equivalent. We report a 59-year-old male inpatient on a medical unit who had hyperthermia, an altered mental status, muscle rigidity, and elevated white blood cell count and creatine phosphokinase level. He had been taking risperidone 1 mg orally every 12 hours for two months. His primary treatment team suspected Neuroleptic Malignant Syndrome (NMS), but the consulting psychiatrist detected equivocal findings on physical examination and recommended a broader differential diagnosis. Further investigations revealed the possibility of an infection. The patient was positive for immunoglobulin G (IgG) antibodies to HSV-1 and HSV-2 on cerebrospinal fluid analysis. He was then treated for Herpes Simplex Encephalitis (HSE) with an oral course of acyclovir. Although NMS was low in the diagnostic ranking, given the possibility of an atypical form and the lethality of this condition if untreated, he also received intravenous lorazepam at 2 mg every six hours. He experienced full resolution of his symptoms and was stable for discharge. HSE and NMS are two examples of neuropsychiatric disorders with similar presenting symptoms. HSE frequently presents with predominantly psychiatric symptoms, such as paranoia, hallucinations, and an altered mental status. Consequently, it is typically not the first diagnosis that comes to mind, especially when these symptoms occur in a patient already being treated by a psychiatrist. Confirmation bias is the tendency for an individual to focus on the information that aligns with one’s preconceptions and to ignore information that defies it. Due to this bias, physicians may attribute all symptoms of a known psychiatric patient to a psychiatric cause, instead of considering an organic etiology. In this case, the evaluation by the psychiatrist was crucial in guiding the treatment team to a diagnosis of HSE. This is important since a delayed treatment of HSE can be fatal. The literature review reveals a general consensus among psychiatrists on the value of physical examinations in patient care. In spite of this, the majority of psychiatrists seldom perform physical examinations due to concerns over skill atrophy and the potential that doing so may change the therapeutic dynamic. Others have disputed these claims and have argued that physical examinations in a psychiatric setting will not only strengthen the perception of a psychiatrist as a physician by the patient but will also allow for better care of psychiatrically ill patients. Psychiatrists should remember that they are oftentimes the sole healthcare provider for psychiatric patients and that these patients may not have the access to primary care physicians and may lack the ability to explain their symptoms or advocate for themselves. Therefore, incorporating an emphasis on performing physical examinations during psychiatry residency training and in continuing medical education programs for psychiatrists is essential.
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Affiliation(s)
- Michael Esang
- Psychiatry and Behavioral Sciences, Nassau University Medical Center, East Meadow, USA
| | - Sabina Goldstein
- Miscellaneous, American University of the Caribbean, Cupecoy, SXM
| | - Ravina Dhami
- Miscellaneous, American University of the Caribbean, Cupecoy, SXM
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Childers R, Vilke G. Ketamine for Acute Agitation. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2019. [DOI: 10.1007/s40138-019-00177-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Shenvi C, Wilson MP, Aldai A, Pepper D, Gerardi M. A Research Agenda for the Assessment and Management of Acute Behavioral Changes in Elderly Emergency Department Patients. West J Emerg Med 2019; 20:393-402. [PMID: 30881563 PMCID: PMC6404700 DOI: 10.5811/westjem.2019.1.39262] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 01/25/2019] [Accepted: 01/29/2019] [Indexed: 11/11/2022] Open
Abstract
Introduction Agitation, mental illness, and delirium are common reasons for older adults to seek care in the emergency department (ED). There are significant knowledge gaps in understanding how to best screen older adults for these conditions and how to manage them. In addition, in areas where research has been performed, implementation has been slow. A working group convened to develop a set of high-priority research questions that would advance the understanding of optimal management of older adults with acute behavioral changes in the ED. This manuscript is the product of a breakout session on "Special Populations: Agitation in the Elderly" from the 2016 Coalition on Psychiatric Emergencies' first Research Consensus Conference on Acute Mental Illness. Methods Participants were identified with expertise in emergency medicine (EM), geriatric EM, and psychiatry. Background literature reviews were performed prior to the in-person meeting in four key areas: delirium; dementia; substance abuse or withdrawal; and mental illness in older adults. Input was solicited from all participants during the meeting, and questions were iteratively focused and revised, voted on, and ranked by importance. Results Fourteen questions were identified by the group with high consensus for their importance related to the care of older adults with agitation in the ED. The questions were grouped into three topic areas: screening and identification; management strategies; and the approach to delirium. Conclusion It is important for emergency physicians to recognize the spectrum of underlying causes of behavioral changes, have the tools to screen older adults for those causes, and employ methods to treat the underlying causes and ameliorate their symptoms. Answers to the identified research questions have great potential to improve the care of older adults presenting with behavioral changes.
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Affiliation(s)
- Christina Shenvi
- University of North Carolina, Department of Emergency Medicine, Chapel Hill, North Carolina
| | - Michael P Wilson
- University of Arkansas for Medical Sciences, Department of Emergency Medicine, Little Rock, Arkansas
| | - Alessandra Aldai
- University of California, San Diego Medical Center, Department of Emergency Medicine San Diego, California
| | - David Pepper
- Hartford Hospital/Institute of Living, Department of Psychiatry, Hartford, Connecticut
| | - Michael Gerardi
- Morristown Medical Center, Department of Emergency Medicine, Morristown, New Jersey
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Abstract
Recently, ketamine has seen increased use among emergency medical services in the prehospital setting as a first-line means of chemical restraint for agitated patients. In this case report, we explore an instance in which ketamine administration for nonpsychotic agitation before emergency department (ED) evaluation may have caused unexpected psychotic symptoms leading to a complicated ED course necessitating admission. As ketamine gains widespread use in the prehospital setting, the safety profile deserves reevaluation. In the following report, we review relevant literature and discuss important factors to consider regarding the use of prehospital ketamine, including psychiatric and substance abuse history.
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Medical Screening of Mental Health Patients in the Emergency Department: A Systematic Review. J Emerg Med 2018; 55:799-812. [DOI: 10.1016/j.jemermed.2018.09.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 08/01/2018] [Accepted: 09/01/2018] [Indexed: 11/17/2022]
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Simpson SA, Monroe C. Implementing and Evaluating a Standard of Care for Clinical Evaluations in Emergency Psychiatry. J Emerg Med 2018; 55:522-529.e2. [DOI: 10.1016/j.jemermed.2018.07.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 07/06/2018] [Accepted: 07/11/2018] [Indexed: 11/28/2022]
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Affiliation(s)
- Jessica Mason
- Department of Emergency Medicine, University of California, San Francisco-Fresno, Fresno, CA.
| | - Christopher B Colwell
- Zuckerberg San Francisco General Hospital and Trauma Center, and the Department of Emergency Medicine, UCSF School of Medicine, San Francisco, CA
| | - Andrew Grock
- Division of Emergency Medicine Greater Los Angeles VA Healthcare System, and the David Geffen School of Medicine at UCLA, Los Angeles, CA
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Ketamine for Rapid Sedation of Agitated Patients in the Prehospital and Emergency Department Settings: A Systematic Review and Proportional Meta-Analysis. J Emerg Med 2018; 55:670-681. [PMID: 30197153 DOI: 10.1016/j.jemermed.2018.07.017] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 07/06/2018] [Accepted: 07/11/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Rapid tranquilization of agitated patients can prevent injuries and expedite care. Whereas antipsychotics and benzodiazepines are commonly used for this purpose, ketamine has been suggested as an alternative. OBJECTIVE The aim of this systematic review is to determine the safety and effectiveness of ketamine to sedate prehospital and emergency department (ED) patients with undifferentiated agitation. METHODS Studies and case series of patients receiving ketamine for agitation were included. Studies were excluded if ketamine was used for analgesia, procedural sedation, asthma, or induction. Information sources included traditional and gray literature. RESULTS The initial search yielded 1176 results from 14 databases. After review of titles and abstracts, 32 studies were reviewed and 18 were included in the analysis, representing 650 patient encounters. The mean dose of ketamine was 315 mg (SD 52) given intramuscularly, with adequate sedation achieved in 7.2 min (SD 6.2, range 2-500). Intubation occurred in 30.5% of patients (95% confidence interval [CI] 27.0-34.1%). In the majority of those patients, ketamine was administered by paramedics during ground transport and the patient was intubated on ED arrival. When ketamine was administered in the ED, the intubation rate was 1.8% (95% CI 0.0-4.4%); in air medical transport, the rate was 4.9% (95% CI 0.0-10.3%). Other reported side effects included: vomiting, 5.2% (2.3-8.1%); hypertension, 12.1% (5.7-18.6%); emergence reactions, 3.5% (1.4-5.6%); transient hypoxia, 1.8% (0.1-3.6%) and laryngospasm, 1.3% (0.3-2.3%). CONCLUSIONS Ketamine provides rapid sedation for undifferentiated agitated patients and is associated with higher intubation rates when used by ground Emergency Medical Services paramedics, compared with ED or air medical transport patients. Other side effects are common but usually self-limiting.
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Mackey KE, Qiu C. Can Mobile Integrated Health Care Paramedics Safely Conduct Medical Clearance of Behavioral Health Patients in a Pilot Project? A Report of the First 1000 Consecutive Encounters. PREHOSP EMERG CARE 2018; 23:1-10. [PMID: 30118361 DOI: 10.1080/10903127.2018.1482390] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 05/15/2018] [Accepted: 05/24/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Mental health patients wait lengthy periods in emergency departments for disposition. This delay is secondary to the process of medical clearance and then placement in an appropriate psychiatric specialty center. ACEP clinical policy questions the necessity of laboratory investigation for medical clearance and favors history and physical exam to determine safe disposition to mental health facilities. This manuscript explores if specially trained paramedics can effectively employ triage algorithms to determine proper disposition of patients suffering an acute mental health crisis in a 9-1-1 system. METHODS Six paramedics working for AMR in Stanislaus County, California underwent 180 hours of specialized training to become Mobile Integrated Healthcare Paramedics (MIHPs). Their training detailed the use of two algorithms designed to identify patients that require evaluation in an emergency department versus those that can be triaged directly to a licensed mental health facility. Patients aged 18-59 with a suspected mental health crisis who are encountered via the 9-1-1 system, law enforcement or who walk in to the mental health facility for treatment were eligible. All patients in the study were evaluated with the well person algorithm (WPA). Those that passed the WPA were evaluated using the mental health clearance algorithm (MCHA). MIHPs directed patients to either the ED or the mental health facility based upon the evaluation results of the WPA and MHCA. RESULTS 1006 patients were evaluated between September 2015 and December 2017. 404 patients failed one or more components of the WPA or MHCA. 326 patients passed both the WPA and the MHCA, but were ultimately transported to a local emergency department, most often because of lack of available psychiatric beds in the community. 276 patients were transported directly to a psychiatric facility. Of these, 10 returned to the emergency department within 6 hours, but none of the 10 were admitted for a previously unidentified medical or traumatic condition. CONCLUSION Specially trained paramedics can effectively employ triage algorithms to screen and select patients experiencing an acute mental health crisis for transport directly to psychiatric treatment facilities.
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Rocker JA, Oestreicher J. Focused Medical Assessment of Pediatric Behavioral Emergencies. Child Adolesc Psychiatr Clin N Am 2018; 27:399-411. [PMID: 29933790 DOI: 10.1016/j.chc.2018.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
There is no uniformly accepted standard of care for medical clearance of pediatric patients with psychiatric complaints. Emerging data argue for a thorough history and physical examination and against routine laboratory testing. The differential diagnosis of patients presenting with psychiatric health complaints is extensive and includes both medical and psychiatric disorders. Providers should remain mindful of anchoring or diagnosis momentum bias when caring for these patients, especially patients with a psychiatric history.
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Affiliation(s)
- Joshua A Rocker
- Division of Pediatric Emergency Medicine, Cohen Children's Medical Center of New York, Northwell Health, 269-01 76th Avenue, New Hyde Park, NY 11040, USA.
| | - Jeffrey Oestreicher
- Division of Pediatric Emergency Medicine, Cohen Children's Medical Center of New York, Northwell Health, 269-01 76th Avenue, New Hyde Park, NY 11040, USA
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Hurwitz J. Can We Finally Dispense With Ketamine's Many Myths? J Emerg Med 2018; 54:697-700. [PMID: 29571922 DOI: 10.1016/j.jemermed.2017.12.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 12/22/2017] [Accepted: 12/26/2017] [Indexed: 06/08/2023]
Affiliation(s)
- Joshua Hurwitz
- Department of Emergency Medicine, PeaceHealth Southwest Medical Center, Vancouver, Washington
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Conigliaro A, Benabbas R, Schnitzer E, Janairo M, Sinert R. Protocolized Laboratory Screening for the Medical Clearance of Psychiatric Patients in the Emergency Department: A Systematic Review. Acad Emerg Med 2018; 25:566-576. [PMID: 29266617 DOI: 10.1111/acem.13368] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 12/03/2017] [Accepted: 12/15/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Emergency department (ED) patients with psychiatric chief complaints undergo medical screening to rule out underlying or comorbid medical illnesses prior to transfer to a psychiatric facility. This systematic review attempts to determine the clinical utility of protocolized laboratory screening for the streamlined medical clearance of ED psychiatric patients by determining the clinical significance of individual laboratory results. METHODS We searched PubMed, Embase, and Scopus using the search terms "emergency department, psychiatry, diagnostic tests, laboratories, studies, testing, screening, and clearance" up to June 2017 for studies on adult psychiatric patients. This systematic review follows the recommendations of Meta-analysis of Observational Studies in Epidemiology (MOOSE) statement. The quality of each study was rated according to the Newcastle-Ottawa quality assessment scale. RESULTS Four independent reviewers identified 2,847 publications. We extracted data from three studies (n = 629 patients). Included studies defined an abnormal test result as any laboratory result that falls out of the normal range. A laboratory test result was deemed as "clinically significant" only when patient disposition or treatment plan was changed because of that test result. Across the three studies the prevalence of clinically significant results were low (0.0%-0.4%). CONCLUSIONS The prevalence of clinically significant laboratory test results were low, suggesting that according to the available literature, routine laboratory testing does not significantly change patient disposition. Due to the paucity of available research on this subject, we could not determine the clinical utility of protocolized laboratory screening tests for medical clearance of psychiatric patients in the ED. Future research on the utility of routine laboratory testing is important in a move toward shared decision making and patient-centered health care.
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Affiliation(s)
- Alyssa Conigliaro
- Department of Emergency Medicine Kings County Hospital Center Brooklyn NY
- Department of Emergency Medicine State University of New York Downstate Medical Center Brooklyn NY
| | - Roshanak Benabbas
- Department of Emergency Medicine Kings County Hospital Center Brooklyn NY
- Department of Emergency Medicine State University of New York Downstate Medical Center Brooklyn NY
| | - Eric Schnitzer
- Department of Emergency Medicine Kings County Hospital Center Brooklyn NY
- Department of Emergency Medicine State University of New York Downstate Medical Center Brooklyn NY
| | - Maria‐Pamela Janairo
- Department of Emergency Medicine Kings County Hospital Center Brooklyn NY
- Department of Emergency Medicine State University of New York Downstate Medical Center Brooklyn NY
| | - Richard Sinert
- Department of Emergency Medicine Kings County Hospital Center Brooklyn NY
- Department of Emergency Medicine State University of New York Downstate Medical Center Brooklyn NY
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Bowers A, Meyer C, Hillier S, Blubaugh M, Roepke B, Farabough M, Gordon J, Vassar M. Suicide risk assessment in the emergency department: Are there any tools in the pipeline? Am J Emerg Med 2018; 36:630-636. [DOI: 10.1016/j.ajem.2017.09.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 09/26/2017] [Accepted: 09/27/2017] [Indexed: 11/29/2022] Open
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Riccoboni ST, Darracq MA. Does the U Stand for Useless? The Urine Drug Screen and Emergency Department Psychiatric Patients. J Emerg Med 2018; 54:500-506. [DOI: 10.1016/j.jemermed.2017.12.054] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 12/15/2017] [Accepted: 12/26/2017] [Indexed: 10/17/2022]
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Gottlieb M, Long B, Koyfman A. Approach to the Agitated Emergency Department Patient. J Emerg Med 2018; 54:447-457. [PMID: 29395692 DOI: 10.1016/j.jemermed.2017.12.049] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 12/17/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Acute agitation is a common occurrence in the emergency department (ED) that requires rapid assessment and management. OBJECTIVE This review provides an evidence-based summary of the current ED evaluation and management of acute agitation. DISCUSSION Acute agitation is an increasingly common presentation to the ED and has a broad differential diagnosis including metabolic, neurologic, infectious, toxicologic, and psychiatric etiologies. Missed diagnosis of a dangerous etiology of the patient's agitation may result in severe morbidity and mortality. Assessment and management of the agitated patient should occur concurrently. Focused history and physical examination are recommended, though control of the patient's agitation may be required. All patients should receive a point-of-care glucose test, with additional testing depending upon the specific patient presentation. Initial management should involve verbal de-escalation techniques, followed by pharmacologic interventions, with physical restraints reserved as a last resort. Pharmacologic options include first-generation antipsychotics, second-generation antipsychotics, benzodiazepines, and ketamine. Finally, the management of pediatric, pregnant, and elderly patients warrants special consideration. CONCLUSION Acute agitation is an important presentation that requires prompt recognition and treatment. A focused and thorough examination coupled with appropriate management strategies can assist emergency clinicians to safely and effectively manage these patients.
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Affiliation(s)
- Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
| | - Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
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Mullinax S, Chalmers CE, Brennan J, Vilke GM, Nordstrom K, Wilson MP. Suicide screening scales may not adequately predict disposition of suicidal patients from the emergency department. Am J Emerg Med 2018. [PMID: 29530359 DOI: 10.1016/j.ajem.2018.01.087] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
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.
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Affiliation(s)
- Samuel Mullinax
- Department of Emergency Medicine Behavioral Emergences Research (DEMBER) lab, 4301 West Markham St, #584, Little Rock, AR 72205, United States.
| | - Christen E Chalmers
- Department of Emergency Medicine Behavioral Emergences Research (DEMBER) lab, 4301 West Markham St, #584, Little Rock, AR 72205, United States
| | - Jesse Brennan
- Department of Emergency Medicine Behavioral Emergences Research (DEMBER) lab, 4301 West Markham St, #584, Little Rock, AR 72205, United States; Department of Emergency Medicine, UC San Diego Health System, University of California San Diego, 200 W Arbor Dr, San Diego, CA 92103, United States
| | - Gary M Vilke
- Department of Emergency Medicine Behavioral Emergences Research (DEMBER) lab, 4301 West Markham St, #584, Little Rock, AR 72205, United States; Department of Emergency Medicine, UC San Diego Health System, University of California San Diego, 200 W Arbor Dr, San Diego, CA 92103, United States
| | - Kimberly Nordstrom
- Department of Emergency Medicine Behavioral Emergences Research (DEMBER) lab, 4301 West Markham St, #584, Little Rock, AR 72205, United States; Office of Behavioral Health, State of Colorado, 3824 W Princeton Cir, Denver, CO 80236, United States; Department of Psychiatry, University of Colorado at Denver, 1201 Larimer St, Denver, CO 80204, United States
| | - Michael P Wilson
- Department of Emergency Medicine Behavioral Emergences Research (DEMBER) lab, 4301 West Markham St, #584, Little Rock, AR 72205, United States; Department of Emergency Medicine, University of Arkansas for Medical Sciences, 4301 West Markham St, #584, Little Rock, AR 72205, United States
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Abstract
New psychoactive substances (NPS), namely cannabinoids, cathinones, and opioids, have surged in popularity among school-age children, resulting in serious morbidity and mortality globally. In the last decade, there has been a rapid evolution of NPS resulting in hundreds of new compounds. Little to no evidence for humans is available on most compounds. The clinical presentations of patients intoxicated with cannabinoids and cathinones are highly variable but most commonly present with a sympathomimetic toxidrome, for example, agitation, delirium, and tachycardia. Those with opioids present with a classic opioid toxidrome: coma, dilated pupils, and respiratory failure.
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Affiliation(s)
- Brandon J Warrick
- University of New Mexico, NMPDIC MSC07 4390, 1 University of New Mexico, Albuquerque, NM 87107-0001, USA.
| | - Anita Paula Tataru
- Faculty of Pharmaceutical Sciences, University of British Columbia, British Columbia, Canada
| | - Roy Gerona
- Clinical Toxicology and Environmental Biomonitoring Lab, University of California, San Francisco, 513 Parnassus Avenue, Medical Sciences Building S864, San Francisco, CA 94143, USA
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