INTRODUCTION TO EMERGENCY PSYCHIATRY

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INTRODUCTION TO EMERGENCY PSYCHIATRY
Brian E. Wood, D.O. Associate Professor and
Chair Department of Neuropsychiatry and
Behavioral Sciences Edward Via Virginia College
of Osteopathic Medicine Assistant. Professor of
Clinical Psychiatric Medicine. University of
Virginia School of Medicine
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Definition
A psychiatric emergency is a disturbance in
thoughts, feelings, or actions that requires
immediate treatment. (Kaplan and Sadock, 1996)
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Properties

• Can happen at any time either outside or during a
  treatment episode.
• Can happen anywhere
• Not confined to the Emergency Room
• May happen on other services or involve other
  disciplines.

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The Patient in the Emergency Setting
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Central Principles

• Assessment of Acuity
• Assessment of Risk
• Risk to self
• Risk to others
• Disposition to address risk factors
• Documentation.

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Acuity

• Acuity is often in the eye of the beholder
• Acute conditions or symptoms may exist within the
  context of chronic illnesses.
• Often acuity needs to be assessed within the
  context of available support mechanisms.
• May also be resolved with appropriate support
  mechanisms.

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Risk

• Should be viewed as existing along a continuum.
• There is no black or white
• Risk varies with time.
• Prediction of likely behavior may be made
  utilizing risk assessment

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Disposition

• Application of problem solving strategies.
• Should address identified areas of acuity and
  risk.
• Should encompass the least restrictive
  caredoctrine.
• Care should be provided in the least restrictive
  setting possible while still providing protection
  for the patient.

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Documentation

• Purpose
• To summarize the assessment and care of the
  emergency patient
• To provide a roadmap which can be continued by
  follow up care providers.
• Should follow a logical progression of thought
  (problem solving strategy) and logical
  conclusions based on assessment.
• Should not include conclusions that can not be
  substantiated. (ie. Diagnoses, etc.)

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The Care provider in the Emergency Setting
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Risks

• Violence in the emergency setting
• Generally more risk than in non-emergent
  settings.
• Secondary gain issues
• Legal exposure

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Protection in the emergency setting

• Knowledge of historical risk factors etc. prior
  to seeing the patient.
• Careful review of the record is time well spent.
• Be alert to risks of impending violence.
• Careful attention to therapeutic alliance issues.
• Attention to safety of physical surroundings.
• Include others if needed ( ex. Police, etc.)
• Confidentiality ends where there is risk of
  injury

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Protection in the emergency Setting

• Be aware of secondary gain issues
• May help in prediction of behavior including
  violence.
• Document, document, document
• Does not refer to volume of documentation but
  rather quality of documentation.

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Summary

• Psychiatric emergencies can occur anywhere at any
  time.
• Important issues include protection of the
  patient as well as of the practitioner and staff.
• Central principles guiding assessment and
  treatment in the emergency setting include
  assessment of risk and acuity, plan and
  disposition, and appropriate documentation.
• Central principles guiding protection of
  practitioners in the emergency setting include
  appropriate knowledge, remaining alert, including
  others, and documentation.