Our patients who are most critically sick still come to us via the emergency department (ED).
1 It is true that the number of psychiatrists in training is growing, but despite this, many persons with mental illness still arrive to emergency departments (EDs) all throughout the nation in need of treatment and mental health care. Training programs for future psychiatrists need to focus on preparing them to safely and effectively diagnose, treat and care for this specific group.
It has become clearer since the release of the CPA policy paper on emergency psychiatry in 2004,2 that the Royal College of Physicians and Surgeons in Canada (RCPSC) has outlined more precise training criteria in this field.
3 Both systemically and therapeutically, ED paradigms of treatment for the mental patient have developed. The focus of this article will be on training and education in emergency psychiatry.
The authors conducted a survey of all psychiatry resident programs in June of 2013 to get a clear picture of how emergency psychiatry training is presently delivered in the field. Residents, program directors, and self-identified emergency psychiatrists were all asked to complete a survey on their school’s emergency psychiatric training. Since there were 194 psychiatry residency seats available each year, there were around 970 residents in Canada at the time. A total of 105 questionnaires were completed by participants in Canada’s 17 psychiatric programs, with responses coming from 13 of them. Survey participants were not required to provide any identifying information, other from their university and their position in a residency program (for example, resident and program director).
Damian Sendler
Programs were found to be very variable, according to the study. As a consequence, the rotation’s design, oversight, and participation with other healthcare professionals varied widely from one facility to the next. Programs for emergency psychiatric clinical exposure offered between one and five weeks of training, however replies from the same institution were inconsistent, showing that even the idea of devoted training was ambiguous. Most programs had a specialized mental emergency unit inside a regular hospital emergency department, however this was not always the case. Emergency psychiatry might be practiced in non-psychiatric settings, such as mental hospitals, crisis clinics, and general hospital emergency departments, thanks to the availability of additional sites in many programs. Although emergency psychiatry residents worked alongside a broad variety of healthcare specialists throughout their training, there were times when teams were made up only of psychiatrists and crisis or social workers (with or without particular emergency psychiatric training). Nurses, psychologists, patient attendants, security guards, and interpreters were all part of multidisciplinary teams at university-affiliated health centers that had extra resources. More than half of those surveyed said their program included safety instruction and robust security measures.
All programs apparently included instruction in emergency psychiatry in addition to clinical experience. There was a broad range in the length and substance of this instruction. Residents were most often instructed via lectures, small group sessions, and workshops. The use of online courses and structured patient interviews was limited in many programs. Programs involving local police and medical students were available, as well as a program that offered weekly challenging case reviews for medical students. According to those surveyed, most programs offered fewer than ten hours of instruction every semester, with a few offering more. The breadth of material taught was impressive, given the little time residents had to learn from their instructors. Suicide, aggressiveness, chemical restraint, medical clearance and comorbidity, interviewing tactics, medico-legal concerns, drugs and typical ED presentations were some of the more prominent subjects covered in these trainings. Mental health legislation was taught in all of the curricula.
Emergency psychiatric training was also provided while on call. Across the nation, there was wide variation in the on-call experience’s structure. When people were anticipated to stay in the hospital for a certain amount of time and then be allowed to return to their homes, this was known as a mixed structure. Most programs required residents to be on call once a week at the most. After an on-call shift, handover happened at most locations, although residents were not always present. However, there was a lot of variation in how this was done among and within programs. Even though the multidisciplinary team was engaged in the majority of handovers, a few programs reported that handovers only happened between residents, and even then, only on weekends in certain circumstances.
We need more uniformity of both clinical training and didactic teaching programs throughout Canada to meet the demands of the emergency population, as shown by the survey replies.
Emergency psychiatry may be provided in a variety of settings, including general and mental hospitals, outpatient clinics, and mobile units.
More and more people are realizing the need of conducting crisis assessments on mental patients in settings that are intelligently constructed and that prioritize the safety of both patients and staff. As mentioned during triage, individuals with mental health issues should be assessed at the main hospital in a dedicated area for this purpose. For example, having an emergency physician as the first line of defense for acute medical issues at a general hospital is a significant benefit. In addition, there are on-site laboratory facilities and easy access to investigations and experts. Without the assistance of the psychiatric team, the emergency physician may triage patients who are less urgent.
Damian Jacob Sendler
All-inclusive hospital As previously said, EDs benefit from medical assistance, but a psychiatric hospital’s emergency department is staffed by medical professionals who specialize in treating patients with mental illnesses. The patient will be seen by professionals who have been educated to evaluate and treat mental illness with empathy and competence. There should always be an emergency psychiatry team that includes psychiatrists, psychiatric nurses, mental health doctors, and psychiatric assistants with access to security, regardless of the location in which the patient is being treated. 5
If a patient does not need a complete hospital admission but needs more time for evaluation or a brief stay to recover after an emergency, extended observation beds are perfect.
5 Patients who are in drug-induced states benefit from a hold like this since the toxidrome disappears and their symptoms improve.
No matter whether the emergency evaluation takes place in a general or mental hospital, it is essential that the location be fully secure. To ensure the safety of patients in the psychiatric ED, interview rooms should be equipped with elements such as alarms, video monitors, sight lines to nursing stations, and sensibly constructed furniture (weighted or bolted).6
There are several alternatives to the typical paradigm of emergency evaluations conducted in hospitals. In many cases, patients with mental illnesses are unable to reach family doctors or follow up on appointments in the community. The lack of a specialized psychiatric emergency care at smaller urban and rural hospitals is due to funding and personnel constraints. Another alternative is to use specialist mental health units within police forces to handle emergencies involving mental health issues in the community. 7,8 Depending on where a program is located and what regions it serves, the extra models of care that its residents are exposed to will differ. These concepts may be taught in core classes and then further explored in optional settings, if time permits.
One of the most prevalent reasons for psychiatric referrals is acute agitation. Agitation was shown to be a factor in 50% of mental visits to the ED in a US research. 9 A psychiatry resident’s assessment of an agitated patient may be a stressful encounter. Resident training programs must include both the evaluation and treatment of disturbed patients in the emergency department.. Medical, drug, and mental health conditions may all lead to agitation. Prior to psychiatric referral, it is ideal that medical reasons of agitation be checked out, however this is not always the case when patients arrive in the ED in an agitated condition. Whenever feasible, vital indicators, such as oxygenation and blood glucose, should be included in the triage of an agitated patient. 10
In order to begin an evaluation of an agitated patient, a psychiatrist or trainee in the ED must be assured of a safe atmosphere. The emergency psychiatrist is responsible for determining whether additional staffing is necessary. Having a conversation with the referring physician and going through previous medical records may assist determine whether or not there is a history of violence in the patient. It’s a good idea to picture the patient in the waiting area so you can get a sense of how he or she is feeling. A patient’s degree of agitation must be assessed before to interviewing in order to plan the interview technique. Anxiety, verbal threats, and overt aggressiveness are all forms of agitation, and the interview and intervention must be tailored to match the agitation in order for de-escalation to occur.
Accurate and patient-centered recommendations for treating agitation have been released by the American Association of Emergency Psychiatry (AAEP).
11 For the first time, a complete document has been prepared covering all areas of intervention, from medical triage, through evaluation, verbal de-escalation, and, finally, pharmacologic treatment.
In order to produce a state of calm, mechanical and chemical procedures are used. The capacity to interview and appraise would be hindered if the patient was too drowsy. Benzodiazepines (BZDs) and antipsychotics are the two main groups of drugs used to treat agitated patients (APs). First-generation (FGAs) and second-generation (SGAs) access points (APs) are available. These drugs may be taken orally, sublingually (SL), quickly dissolving, intramuscularly (IM), or intravenously. Diagnostic findings and the degree of agitation will guide the choice of medicine or drug combination and the method of administration.
Quick neuroleptization and potentially even rapid tranquilization, in which huge cumulative doses of medicines are administered in a short period of time to cause drowsiness, are no longer supported by current research. In order to achieve a state of calm, it is advised that the medicine be administered based on a thorough understanding of its pharmacokinetics. If the patient is compliant and there are no medical contraindications, oral drugs should be administered prior to IM injections if feasible. Faster-acting methods like SL or IM are needed for the more anxious patients. Working diagnosis is the most significant factor in medicine selection. First-line treatment for psychosis of psychiatric etiology is APs, with or without BZDs. Haloperidol and risperidone, two of the most potent APs (FGA and SGA), often need a BZD for sedation. BZDs should be used to treat agitation caused by alcohol consumption. In the emergency department, lorazepam is a popular BZD because of its low toxicity and several routes of administration. BZDs should be avoided in the delirious patient, and high-potency APs should be preferred to limit the probable anticholinergic side effects. Of course, addressing the underlying reason is vital. In Canada, loxapine, a mid-potency FGA that may be administered intravenously, and a less expensive choice than the SGAs are all important differences between the American standards and Canadian methods. Combining haloperidol with lorazepam intramuscularly (IM) is still an excellent choice for the most disturbed individuals. 14
Residents must be competent to manage acute agitation in the emergency department and write treatment orders that may need continuous pharmacological and mechanical restraint in order to advance with their evaluation. Each hospital’s least-restraint rules are unique, and staff and patients alike should be familiar with the guidelines set out by their respective facilities. Medication is used to control behavior since treatment capability is not routinely evaluated in the ED. At times, the agitated patient may not react promptly to interventions in the Emergency Department. If more aid is needed, a Code White should be activated at any moment. Documentation of the occurrence and a mechanism for evaluation should begin promptly in the event of an attack. Residents may count on the assistance of their training programs, departments, and the hospital in question.
Even in the emergency department, risk assessment is critical to a thorough psychiatric evaluation. The majority of psychiatric referrals in the ER are for a risk assessment of suicide. Even though it’s impossible to accurately predict suicide risk, the emergency psychiatrist can assess a patient’s degree of danger and decide whether or not they should be admitted on a voluntary or involuntary basis. There is a wide variety of diagnoses and clinical manifestations to consider when determining a person’s risk of suicide. In order to identify the degree of danger, whether the patient presents as persistently suicidal or self-harming but with no evident purpose, the resident trainee will require exposure to several evaluations. Depending on the level of danger, the documentation will need to represent that perception, and the strategy will follow appropriately. If a suicide occurs after a visit to the emergency department (ED), the sole record of the visit will be the paperwork from the ED appointment. 15
Patients with suicidal thoughts will be referred if the emergency physician is worried about the result of a suicide attempt or in a condition of suicidal ideation. Patients who take their own lives have a known mental condition, and the psychiatrist may be the best person to evaluate what illness is causing the patient’s symptoms and what treatment choices are available to them. Interventions should focus on reducing the risk factors that can be changed, while also addressing the underlying condition. There will also be psychotherapeutic procedures used in the ED to treat lower-risk patients. For the persistently suicidal patient, dialectical behavior therapy recommends psychoeducation on mindfulness, emotional regulation, and distress tolerance. 17 When the immediate crisis has passed, it is excellent and therapeutic for the patient to have the option of an emergency hold to review the patient’s suicide risk.
All emergency evaluations must include questions regarding suicide that residents feel comfortable asking. It’s important to include facts regarding present suicide thoughts and purpose, as well as earlier suicidal thoughts, plans & attempts, and accompanying symptoms of anxiety, despair & impulsivity in histories and documentation. Additionally, it is crucial to consider the usage of drugs, the availability of resources, and the existence of psychological stresses. In addition, any protective factors that are present or missing should be examined and noted.
ED visits are often triggered by substance-related issues, which account for around 20% of all cases.
18 It is possible for a person to have both a substance addiction problem and a mental health issue at the same time. Over a third of patients with mental illness are found to suffer from co-occurring drug abuse disorders, according to research. 19
In addition to the most prevalent intoxicants, such as alcohol, stimulants, opioids, and hallucinogens, the list of chemicals is constantly expanding and evolving. Bath salts, a novel central nervous system stimulant, and herbal marijuana equivalents such as Spice and K2.20,21 have received media attention, making them more accessible to the general population. There is a possibility that these novel substances will not be detected by existing toxicology screenings. It is imperative that education in this field continues even beyond residency because of the ever-expanding array of drugs available for use and abuse.
Whether a patient is suffering from a mental disorder and drug abuse, it is important to analyze the patient’s history to see if there is a link between the two. The Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised, and the Clinical Opiate Withdrawal Scale are two examples of standardized measures that may be used to assess the severity of withdrawal and track its development. EDs often defer to the psychiatric team the choice to do toxicological tests. Unknown chemicals consumed, clinical presentation inconsistent with the stated substances, or substance-related mental disease may warrant a toxicology screening.
Mental health professionals should be consulted for risk assessment, diagnosis, and treatment while a patient is sober. Residents can’t adequately evaluate drunk patients due to the strains on EDs, therefore patients are typically sent to a detox facility before they’ve completed their entire detox. There are guidelines for holding an inebriated patient without the necessity to get involuntary certification from the Canadian Medical Protective Association. 24
Addiction options, such as detox centers, 12-step programs, and rehabilitation programs may also be referred to or suggested by residents. This difficult patient type will need close collaboration between emergency psychiatric specialists and their medical and addictions counterparts.
The assessment of patients in the ED is made more difficult by their medical comorbidity, which is rather prevalent. It’s not uncommon for psychiatric patients to have a higher chance of developing a medical condition than the general population. For example, patients may not have a primary care physician; they may have poor lifestyles due to poverty or the symptoms of their illnesses; psychotropic medications may have significant medical side effects; and physicians may attribute symptoms to the psychiatric illness without adequately screening for medical co-morbidities. 25,26
Medical stability (a better phrase than medical clearance) has a considerable body of literature, although no one definition exists.
27 Due to this ongoing disagreement, it is difficult to educate trainees about the medically complicated patients in the ED. When it comes to medical stability, there are several factors that come into play, including the institution, medical support and time of day. In the event of a medical emergency, trainees should be familiar with the policies of the hospital where they are working, in particular the approach to consultation.
Trainees will need varying levels of assistance for the medically challenging patient in the ED, regardless of location. Assessing medical stability requires in-depth conversation with the prescribing physician. If the rationale for recommending a patient is unclear or there is a disputed problem amongst agencies, interprofessional discussions may be difficult to navigate. It is possible that residents may want support in learning how to effectively negotiate treatment for patients with delirium or dementia who have strained relationships with several specialties.
If you’re dealing with an urgent psychiatric situation, you may need to tackle only one problem or begin therapy for a whole condition. It’s important for both the resident and the psychiatrist to feel at ease with the various alternatives. It’s possible that treatment may only be needed once, or that it will signal the need for continuous psychiatric care in the future. The patient’s capacity must be evaluated before therapy can begin. In the event of an emergency, a biopsychosocial approach is the best course of action.
In an emergency situation, pharmacotherapy may be used to alleviate unpleasant symptoms so that patients can engage more actively in their own treatment. BZDs and APs are often used in emergency psychiatry to treat agitation, anxiety, and sleeplessness in patients. Residents must have both intellectual and practical understanding of the drugs they are prescribing in the ED. Medications should be prescribed with caution when discharged from the hospital, especially if follow-up is unclear.
Active listening and approaches from motivational interviewing and short psychodynamic models may be used to initiate psychological treatments during the interview.
28,29 It is critical that patients and their loved ones understand the diagnosis and the treatment options available to them. Clinical results will improve if residents are educated on the components of successful psychoeducation—definition of the illness, building an alliance, and conveying the necessity of treatment compliance. 30 These abilities are often and urgently required in difficult situations.
In an emergency situation, crisis intervention abilities are essential. People who work in emergency psychiatry need to learn how to build relationships with patients, recognize the triggers of crises, and help them cope with uncomfortable feelings by coming up with creative solutions to the problem. 31 Each phase requires specialized training in order to make crisis intervention more than just a catch phrase in a treatment plan..
Last but not least, a wide range of societal ills are directly linked to mental emergencies or at the very least contribute to their aggravation. There should be members of an emergency psychiatric team with a better understanding of local resources. Residents may benefit from the interdisciplinary team’s knowledge and experience while they are on call or working on their own during an emergency.
