Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department
From the American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency DepartmentAnnals of emergency medicine (Impact Factor: 4.68). 02/2006; 47(1):79-99. DOI: 10.1016/j.annemergmed.2005.10.002
Chapter: The Emergency Department Setting[Show abstract] [Hide abstract]
ABSTRACT: Consultants may be called to an emergency department for a variety of reasons. Most requests are like those from a general hospital ward. However, two issues are notable: a broader definition of psychiatric emergencies and greater concern about patient rights. These issues stem from an emergency department’s lack of a buffer from its surrounding community: patients come as they are, whether pushed, or just so inclined. There is little or no time for patients and emergency department staff to come to any understanding. In this absence of a traditional physician-patient relationship, consultants may be forced to change their usual approach. Psychiatric emergencies now include patients who are depressed, disorganized, odd, or acting badly for no obvious gain. Psychiatric emergencies traditionally meant patients going berserk: yelling, screaming, likely to hurt themselves or others. The newer, broader definition follows in part from a better appreciation of the morbidity of untreated psychiatric illness. And it follows in part from a fear of liability for homicidal public violence, perhaps as part of a suicide attempt. Ever since the Columbine High School massacre, Americans have become leery of any adolescent talk or behavior suggesting depression or self-destructive urges. Widely publicized workplace shootings and maternal infanticides have further increased public fears of mental illness. Concern for the patient’s right to accept or refuse medical treatment is a frequent trigger for emergent consultations. Old attitudes were simpler: “If you want treatment, walk in: if you don’t want treatment, walk out.” Such attitudes are very fitting for a country of frontiersmen. However, there are few frontiersman left, and more urbane citizens worry that the complexities of medical treatment will elude anyone whose cognitive capabilities are impaired, by mental or by medical illness. Psychiatric consultants now find themselves cast as arbiters of medical choice.
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ABSTRACT: Patients presenting after reported overdose are typically precluded from admission to emergency department observation units (EDOU). The purpose of this study was to describe the initial experience with an EDOU overdose protocol. Retrospective chart review of all individuals presenting to a tertiary care hospital with a chief complaint of overdose or intoxication for the period 7/1/2004 through 12/24/2004. Inclusion criteria for EDOU placement included asymptomatic patients aged >or= 15 years presenting after known or suspected potentially toxic exposure. Exclusion criteria included isolated ethanol intoxication, presence of persistent self-injurious or violent behaviors, chronic intoxication, ingestion of sustained release preparation, and presence of previously defined high-risk criteria. Retrospective chart review demonstrated that 163 patients presented to the ED after ingestion during this time period, of which 15 were excluded secondary to age. Six patients were admitted to the EDOU. No patient eloped or attempted further self-harm while in the EDOU. No clinical decompensation occurred. Another 27 patients were retrospectively identified as EDOU candidates, eight of whom were admitted to the MICU. Although initial numbers are too small for meaningful analysis, the results suggest that prolonged observation of this problematic patient subset within an EDOU is feasible.
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ABSTRACT: There is limited research to acquaint clinicians and payers about antipsychotic use in psychiatric patients visiting United States (US) emergency departments (EDs). The study objective is to describe the epidemiology and compare characteristics of ED visits by adults > or = 18 years with psychiatric diagnoses and different types of antipsychotic. Data for 2000-2004 adult ED visits were obtained from the National Hospital Ambulatory Medical Care Survey. Sample-weighted national estimates of (1) typical, (2) atypical, or (3) typical-atypical combination antipsychotic-associated psychiatric ED visits with 95% confidence intervals (CIs) were produced. Characteristics of the three psychiatric ED visit groups with antipsychotic mention, (prescribed, supplied, administered, ordered or continued) were analyzed retrospectively. Significant characteristics for atypical versus typical antipsychotic mention at visits were determined using multivariate logistic regression. Adults made an estimated 26 million ED visits over the 5-year study period that resulted in a psychiatric diagnosis. Of 2 million (or 8%) of these psychiatric ED visits, 38, 55, and 8% mentioned typical, atypical, and combination antipsychotics respectively. From 2000 to 2004 there was an 8-, 3.5-, and 1.5-fold increase in ED visits with combination, atypical, and typical antipsychotics, respectively. The majority of antipsychotic-associated psychiatric ED visits were made by young adults less than 40 years old, Caucasians, needing urgent treatment, and reimbursed by public insurance. More combination-, and typical versus atypical antipsychotic-associated ED visits included a mention of medications for extrapyramidal symptoms (40%, 14% vs. 4%; p < 0.0001) and antianxiety medications (50%, 48% vs. 27%; p < 0.0001). More combination and atypical than typical antipsychotic-related ED visits had anticonvulsant (42%, 35% vs. 12%; p < 0.0001) and antidepressant mentions (31%, 42% vs. 11%; p < 0.0001). A diagnosis of depression (OR 3.2, 95% CI: 1.9-5.3; p < 0.001) or bipolar-disorder (OR 2.5, 95% CI: 1.3-5.0; p = 0.008), and the number of medications received (OR 1.4, 95% CI: 1.0-1.8; p = 0.034) significantly increased the likelihood of atypical versus typical antipsychotic mention at psychiatric ED visits. Despite limitations of analyses with cross-sectional visit data, an increasing number of combination- and atypical antipsychotic-associated US adult ED visits depict the burden on the healthcare system. The associated characteristics of these visits deserve the attention of providers, and payers for cost-effective patient management.
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