Psychiatric Services in an Emergency Department

1. Psychiatric Services in an Emergency Department Prepared by: Kathleen Crapanzano, MD DHH, OMH Medical Director Presented by: Patricia Gonzales, LCSW Acting Assistant Deputy Secretary, OMH Acting CEO, Southeast Louisiana Hospital

2. Screening Assessment The initial Medical Exam in the ED should include: • Vital Signs • A cognitive examination that screens for significant cognitive or neuropsychiatric impairment • A screening neurologic examination that is adequate to rule out significant acute pathology • A medical history and review of systems • A pregnancy test in all fertile women • A urine toxicology evaluation • Blood levels of psychiatric medications that have established therapeutic or toxic ranges • Other tests and examinations as appropriate and indicated Continuous monitoring is required if there is a risk of harm to self or others.

3. Mental Health Assessment Consult the available qualified mental health professional to perform a mental health assessment, that will include: • A patient interview • A review of medical records available to the ED • History gathering from collateral sources, if possible • Contact with current mental health providers, when possible • Identification of social, environmental, and cultural factors that may be contributing to the emergency • A risk assessment assessing risk factors for suicide or harm to others • An assessment of substance use, abuse, and misuse

4. Disposition • Another level of service other than inpatient treatment is appropriate. • Further psychiatric assessment and treatment is needed – the patient will be referred to the psychiatric beds of the emergency room (M-HERE). • Every patient under the age of 18 will have an assessment by a mental health provider trained in the assessment and treatment of children in a crisis setting Based on this assessment, the patient and qualified mental health professional, in consultation with psychiatrist, will then make a decision regarding treatment:

5. Psychiatric Beds in the ED GOAL: Disposition of each patient to an appropriate setting within 24 hours. UTILIZATION: • Observation and intensive emergency intervention is indicated for patients with the following • Suicidal crisis related to an acute event and/or a pattern of unstable mood or behavior that is longstanding • Substance induced or related emergency that is of relatively short duration • Conditions that are likely to significantly improve within a short period of time • Staging Area • These psychiatric beds will be used as a staging area prior to admission for evaluation of all persons who present to the ER with BH concerns who are not easily triaged out of the ER Written models should be utilized to specify which patients are appropriate or not appropriate for such treatment

6. Psychiatric Evaluation A full Psychiatric Assessment is required when a patient is received in Psychiatric ED setting. It includes: • Patient interview • Review of available past records • History gathering from collateral sources • Contact with the current mental health provider whenever possible • A psychiatric diagnostic assessment which addresses any medical conditions that may cause similar symptoms or complicate the patient’s condition

7. Psychiatric Evaluation (con’t) • Identification of social, environmental, and cultural factors that may be contributing to the urgent need for care • An assessment of the patient’s ability and willingness to cooperate with treatment • A history of previous treatment and the responses to that treatment that includes a record of past psychiatric medications, dose, response, side effects, and compliance, and an up-to-date record of all medications currently prescribed, and the name of the prescribers.

8. Psychiatric Evaluation (con’t) • A general medical history that addresses medical illnesses that may affect the patient’s general current condition (including a review of systems focused on conditions that may present with psychiatric symptoms or that may cause cognitive impairment) • An assessment of substance use, abuse, and misuse • A treatment plan that addresses at least immediate treatment in the service, the goals of such treatment, plans for aftercare, ways of addressing barriers to care Physician will write appropriate orders related to treatment plan.

9. Considerations for Setting Up Psychiatric Services in an ED • Medication use – Pharmacologic needs include: • Immediate access to medications commonly used in psychiatric disorders and behavioral emergencies • Availability of qualified staff to administer those medications and monitor the patient’s response. • Emergency medications • Seclusion and Restraint - There must be a policy for use of S/R that addresses: • Justification and authorization for use • Assessment and monitoring • Provisions of patient needs (food, water, and toilet) • Staff training in prevention, de-escalation, and proper use.

10. Considerations for Setting Up Psychiatric Services in an ED – Con’t • Medical Records – Policies and procedures for medical record documentation need to be developed: • Assessment by a LIP with recommendations for treatment and disposition. • Provision of a discharge plan to the patient and to each agency. • Security of the records

11. Considerations for Setting Up Psychiatric Services in an ED – Con’t • Aftercare – aftercare services should include: • A list of resources available in the region for inpatient care, outpatient mental health services and substance abuse facilities and providers. • A discharge process that ensures continuity of care for patients with ongoing problems. • Procedure for ensuring the availability of specific appointments for continued outpatient mental health treatment within one week of discharge from the ED. • Subsequent contact for the purpose of ascertaining the patient’s status will be a routine part of care.

12. Informed consent Confidentiality/Privacy Mental Health Rights Communication Grievance/complaint Abuse/neglect Considerations for Setting Up Psychiatric Services in an ED – Con’t • Patient Rights– Policies/protocols must be developed related to:

13. Considerations for Setting Up Psychiatric Services in an ED – Con’t • Space and Equipment – Special consideration must be given to the physical environment: • Provision must be made that there are no dangerous materials accessible to patients who may be dangerous to themselves or others to patient. • Space should be continuously supervised and monitored by staff • Controlled access to the space and a process for reducing the risk of elopement. • Privacy provided for sexes for sleeping accommodations • Quiet areas that are accessible to all patients

14. Considerations for Setting Up Psychiatric Services in an ED – Con’t • Staffing – Staffing requires employees that are attuned to the needs of patients with mental illness: • Recruit and train staff to handle behavioral emergencies • Security staff should be appropriately trained. • Adequate staff to allow reassessment and documentation at least every 8 hours and to provide active therapeutic interventions. • Social worker that completes an assessment and a discharge plan for every patient

15. Staffing – Con’t • At least one staff member trained and competent in substance abuse assessment and treatment • A licensed mental health professional assigned to the patient on each shift. • An RN that is always in the psychiatric area of ED overseeing operations • Written procedure for ensuring the ongoing assessment of mental health staff competence.

16. Reference: Report and recommendations regarding psychiatric emergency and crisis services – A review and model program descriptions APA Task Force on Psychiatric Emergency Services August 2002