Management of Behavioral Health Emergencies in the ED

Management of Behavioral Health Emergencies in the ED

PLEASE NOTE: The presenter(s)
do not have financial arrangements or affiliations with any commercial company, which provides products or services directly related to the subject matter of this presentation at this continuing education activity. Thank You

Cleveland Clinic

Goal: To ensure prompt & effective management of patients presenting
with acute behavioral health issues.

Policy: The ED has become the entry point for patients who access the healthcare system. Additionally, patients presenting to the Emergency Department with behavioral health issues will be medically screened & cared for in a calm, compassionate & respectful manner.

Patient Rights: Patient Rights
Patients have the right to be cared for with respect and dignity. EMTALA – patients have the right to medical screening regardless of their ability to pay

Objective 1: Identify and discuss behavioral health diagnosis presenting in the ED Special Populations: Patient with Perinatal Depression & Anxiety Patient with Suicidal Ideation Patient with Substance Use Disorders/Acute Withdrawal

Objective 2: Identify patients at risk for increased agitation and potential aggressive behaviors

Objective 3: Understand Psychiatric/ Behavioral Health Emergencies

Complete CBL: activity prior to class
Objective 4: Review of current W&I Policy and Procedures Suicide Management of Behavioral Health Patient in ED Code Grey Complete CBL: activity prior to class

Objective 5: Recognize the importance of symptom management for the psychiatric patient “De-escalation is a critical strategy in preventing the agitated patient from being violent.” ENA White Paper, 2013

Objective 6: Provide the staff with increased tools to maintain safe & appropriate care Crisis Prevention & De- escalation

“The ED nurse often is the last chance for these wounded, outcast patients to receive care that gives them the dignity and respect they need and we all deserve as human beings.” McCoy, 2010

Stigma, Shame & Fear Lack of access / knowledge
Media focus on catastrophic events Glorification of motherhood and early motherhood Common symptoms are very frightening to women (OCD, depressive scary thoughts) General stigma of mental illness as something we do to ourselves and can get ourselves out of Some cultural beliefs: “I don’t’ believe in it” Hudak and Wisner (2012) American Journal of Psychiatry 169(4): ; Sockol (2012)—Not yet published

Emergency Department The ED is the first point of entry to care
Persons with severe mental illness utilize the ED in greater numbers Current Challenges Decline of inpatient psychiatric beds Decline of availability of community mental health services Health Care Reform- Previously uninsured are now seeking psychiatric care Cut to federal spending and lack of insurance– ED does not turn the patient away.

Statistics ED visits involving a mental health or substance abuse diagnosis top 12 million a year This translates to one out of every eight ED visits According to the Agency for Healthcare Research and Quality (2010)

Non-psychiatric nurses
Nurses without psychiatric experience historically feel unprepared to provide adequate care for patients with mental illness Nurses associated mental health problems with difficult behavior. Lack of understanding of mental illness. Health Care Providers may be comfortable caring for patient with mental health problems, even though they advocate and have a real desire to help the patient. Health care providers caring for people with mental health problems could feel a lack of feeling safe because of unpredictable behavior or unable to control a situation for which the provider feels responsible for. This threatened their physical and emotional well-being, creating anxiety. It is important to remember that 1% of patient with mental illness are considered violent in nature. Other nurses feel that they have not received enough education regarding mental health to care for these patients. Remember only negative interaction

Define Behavioral Emergency
Behavioral emergencies include any patient-initiated threat of harm to self, health care personnel, or others in the patient's sphere of influence. It is defined as an emergent situation in which the patient is in need of assessment and treatment in a safe and therapeutic setting, maybe a a danger to themselves and others, will exhibits acute onset of psychosis, exhibits severe thought disorganization, extreme anxiety and agitation rendering the patient unable to manage and unable to cooperate in their treatment.

Acute Psychiatric Emergency
Any patient with a suspected mental illness that is: Highly agitated or aggressive Suicidal or homicidal Non-responsive to de-escalation These patients may be: Manic Psychotic Intoxicated Delirious

Common Psychiatric Disorders
Psychotic Disorders (Schizophrenia) Mood Disorders (Major Depressive Disorder and Bipolar Disorder) Perinatal Depression Anxiety Disorders Delirium/Dementia Personality Disorders Symptoms can range from mild to severe

Underlying behaviors that can lead to violence in the Emergency Department
Anxiety Depression/suicidal ideation Substance misuse/intoxication Change in mental status; delirium Psychosis Agitation

Anxiety A nervous disorder characterized by a state of excessive unease or apprehension. Characterized by somatic, emotional, cognitive and behavioral components.

Anxiety Psychological and physiological state characterized by somatic, emotional, cognitive and behavioral components. Anxiety is considered a normal reaction to stress and may help a person deal with a difficult situation by prompting one to cope with the stressor. Anxiety can exacerbate feelings of fear, worry, uneasiness and dread. Helping our patients manage their anxiety and identifying coping strategies to combat stress is key in maintaining control. Unmanaged anxiety may lead to acting out behaviors.

Multiple Types of Anxiety Disorders
Panic disorder Obsessive-compulsive disorder Generalized anxiety disorder Social anxiety disorder/social phobia Post-traumatic stress disorder

“Assume that all patients are anxious all the time”
Chris Bernardo RN Talk about this : do you feel that this true (? Bringing in own experiences)

Therapeutic Intervention
Stand 3-5 feet distance Offer time/therapeutic presence Help Problem Solve Validate feelings Decrease Stimuli in area Sensory interventions: Distraction techniques Warm Blanket/Warm Packs Obtain/offer PRN Medications Prevention is the key

Major Depressive Disorder
Depression is a mood disorder that is characterized by persistent feeling of sadness and loss of interest. Clinical Manifestation: Persistent sadness, hopelessness, guilt, loss of interest in normally pleasurable activities Neurovegetative symptoms Changes in sleep, appetite, energy, concentration, motivation Suicidal ideation MDD can be a progressive illness; if left untreated can lead to SI or “loss” of ability to perceive situations in rational, objective way

Major Depressive Disorder
Presentation: Usually cooperative in the ER Tend to not ask for what they need/want believe they are a burden feel they can’t trust others to care for them May or may not have intent to hurt self Impaired judgment, lack of motivation, difficulty making decisions May be trying to please others vs. caring for themselves Negative thinking, poor self esteem The most common diagnosis associated with suicide

Postpartum Depression
Occurs in 15% of women within the first 12 months following childbirth. Symptoms frequently begin during pregnancy. Characteristic symptoms: Sadness Irritability Mood Swings Inability to Concentrate Sleep/Appetite Disturbances Low Self –Esteem Loss of Pleasure in Activities Inability to Adjust to Role of Motherhood Suicidal Ideation Occurs in 15% of women, typically manifests within first 3 months following delivery, but symptom onset can frequently be in pregnancy Pp blues vs. deression

Risk Factors for Postpartum Depression
Prior history of PPD Depression or anxiety during pregnancy Any history of depression Family history of depression or mood disorder Diminished social support Current or historical stressful life events (poverty, trauma, unwanted pregnancy) Adolescence with psychosocial stress

Risks of Postpartum Depression
Increased risks of suicide Increased risk of miscarriage or preterm birth in pregnancy Poor fetal growth & impaired fetal development Impaired infant development: higher incidence of excessive crying, colic, sleep problems, & temperamental difficulties Increased risk of disrupted maternal/infant attachment Less likelihood to initiate or maintain breastfeeding Increased non-routine pediatrician visits Long term increased risk in children includes poor cognitive functioning, behavioral inhibition, & emotional maladjustment Pearlstein et al (2009) American Journal of Obstetrics & Gynecology: April:

Characterized by cycles of manic and depressive states
Bipolar Disorder Characterized by cycles of manic and depressive states Characteristic MANIC symptoms: Inflated self-esteem/grandiosity Decreased need for sleep Increased talkativeness or pressure to keep talking Flight of ideas or describes racing thoughts Distractibility Psychomotor agitation Excessive involvement in pleasurable activities

*4% of women with postpartum psychosis commit infanticide*
Prevalence 1-2 per 1000 childbirths Rate is 100 times higher in women with a history of bipolar disorder or previous history of postpartum psychosis “Cognitive disorganization psychosis” (Wisner et al 1994) Cognitive impairment Bizarre behavior Thought disorganization Lack of insight Delusions of reference Delusions of persecution Greater levels of HI and behavior Can also present with visual, tactile, olfactory hallucinations and appear delirious *4% of women with postpartum psychosis commit infanticide*

Psychotic Disorders: Schizophrenia
Characteristic symptoms: Delusions Hallucinations Disorganized speech (derailment or incoherence) Grossly disorganized or catatonic behavior Negative symptoms (affect flattening, alogia, or avolition

Psychotic Disorder: Schizophrenia
Presentation: Paranoid, hyper-vigilant, responding to voices, religious references, delusions Paranoia may extend to include staff May believe others are reading their thoughts or secretly plotting against them Socially withdrawn, focused on delusions Not typically violent/aggressive to others If having command hallucinations, could be self-harming or suicidal May be uncooperative with an aggressive approach/demeanor

Perinatal Substance Abuse
Every nurse’s nightmare

Perinatal Substance Abuse
4.4% of all pregnant women abuse illicit drugs 1 7.4% of pregnant women ages 18-25yo abuse illicit drugs1 Delivering mothers misusing or dependent on opiates has increased 5-fold between 2000 and 20092 1.4% of pregnant women binge drink (ave 6 drinks, 3x/mo) 3 1.) Substance Abuse and Mental Health Services Administration, Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-41, HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011. 2.) Patrick,SW, Schumacher,RE, Benneyworth, BD, Krans, EE, McAllister, JM, Davis, MM. Neonatal Abstinence Syndrome and Associated Health Care Expenditures, United States, , JAMA. 2012; 307(18): 3.) CDC, Alcohol Use and Binge Drinking Among Women of Childbearing Age—U.S.,

Perinatal Substance Abuse: why is substance abuse a behavioral health emergency?
INTOXICATION Respiratory depression with overdose of opiates or opiates with benzos/ETOH Disinhibition Mood Lability Increase risk of aggression, suicidality, risk-taking behavior Psychosis (cocaine, THC) WITHDRAWAL ETOH and benzo withdrawal can be life threatening; overactivity of the CNS Opioid withdrawal is NOT life-threatening, though it feels that way to patients Nalaxone to tx OD opiates; benzos to treat ETOH withdrawal, tapers from benzos, no treatment for cocaine-induced psychosis. Has to just go through their system.

Perinatal Substance Abuse: intoxication emergencies—aka OVERDOSE
Respiratory depression in opioids: NALAXONE (NARCAN) Accidental deaths by overdose of illicit and prescription opioids began to be characterized as an epidemic in RI in Jan average 4 deaths per week. Statewide initiative to distribute Nalaxone (Narcan) in emergency rooms, front line police doses of nalaxone distributed a month from Jan to July. (courtsey of the Office of the RI State Medical Examiner data.) As providers, it’s essential that we educate on mixing opioids, ETOH and benzos

Perinatal Substance Abuse: withdrawal emergencies: ALCOHOL slide courtesy of Laura Hollar-Wilt, MD

Perinatal Substance Abuse: withdrawal emergencies: ALCOHOL slide courtesy of Laura Hollar-Wilt, MD
CIWA: protocol/scale to assess and treat ETOH withdrawal. Agitation Tremor Anxiety Auditory Disturbances Clouding of Sensorium Headache Nausea/Vomiting Paroxysmal Sweats Tactile and Visual Disturbances Scores of less than 8 indicate minimal to mild withdrawal. Scores of 8 to 15 indicate moderate withdrawal (marked autonomic arousal); and scores of 15 or more indicate severe withdrawal.

Nursing Documentation
If your patient is having withdrawal symptoms Documentation for the CIWA Scale when appropriate is done in HOC

Perinatal Substance Abuse: opioid withdrawal in pregnancy
Behaviorally agitated, irritable, aggressive and emotionally disregulated patients when in withdrawal. Withdrawal sxs include: vomiting, diarrhea, agitation, insomnia, sweating, abdominal cramps, etc Treat their withdrawal = decrease in behavioral dysregulation ACOG, ASAM recommends women NOT to taper off of opioids if physically dependent in pregnancy Rementeria & Nunag, 1973; Zuspan et al., 1975 Jones et al., 2008 Conversion to opioid replacement therapy: methadone or buprenorphrine

Perinatal Substance Abuse: opioid withdrawal in pregnancy
COWS: Clinical Opiate Withdrawal Scale (based on the CIWA) 5-12 = mild 13-24 = moderate 25-35 = moderately severe more than 36 = severe withdrawal What to do with each category (how to dose, etc) depends on the specific protocol determined for the service.

Perinatal Substance Abuse: W&I Initiative: to treat opioid-dependent pregnant women when hospitalized for another medical issue with methadone and then transfer to an outpatient methadone clinic. NEW ORDER SET MEDICATIONS: methadone 15mg, tab, BID (not to be dispensed until pt accepted for outpatient treatment at CODAC), Acetaminophen 650mg PO, q6 PRN pain, Lorazepam 1mg, PO, once PRN insomnia or anxiety FETAL EVALUATION: NST daily LABS: urine drug screen-8 + oxycodone screen, Hepatitis C testing CONSULTS: social service, MFM, neonatal RELATIONSHIP WITH CODAC-PROVIDENCE FOR A SMOOTH TRANSITION TO OUTPATIENT CARE. PT MUST AGREE TO OUTPATIENT CARE BEFOREHAND AND CODAC MUST AGREE THAT PT IS APPROPRIATE SMOOTHER TRANSITION IN CARING FOR THEIR OPIOD WITHDRAWAL AND IN SETTING THEM UP WITH OUTPATIENT CARE IDEALLY INCREASES A WOMAN’S CHANCE IN OBTAINING ABSTINENCE—AND MAKES A SMOOTHER STAY INPATIENT.

Perinatal Substance Abuse W&I Initiative: to treat opioid-dependent pregnant women when hospitalized for another medical issue with methadone and then transfer to an outpatient methadone clinic. What does this initiative mean for triage?? If a pregnant patient is being admitted for another medical condition and is dependent on illicit opioids that pt is eligible for this initiative. Call SW to begin the process of discussing with pt whether pt wants outpatient methadone tx at CODAC. Pt MUST agree to outpt tx before she will be converted onto methadone.

If your patient is having opiate withdrawal symptoms Documentation for the COWS Scale when appropriate is done in HOC

Suicide 2011- 39,518 suicides reported
10th leading cause of death for Americans 2nd leading cause of death for college students Approximately 12 suicide attempts for every completed suicide Highest suicide rates in: Middle age Men (women attempt more) White/Native American + Alaskan natives Western US Using firearms $3 billion in medical care; $5 billion in lost wages and indirect costs American Foundation for Suicide Prevention

Risk Factors for Suicidality
S Sex (male) A Age (>40) D Depression P Previous attempt E Excessive alcohol/ substance R Rational thought loss S Social supports lacking O Organized plan N No spouse/partner S Sickness (medical illness) Robin Williams

Risks for completed suicide:
Male, age > 40, white, atheist, living alone, prior attempts, history of depression/mood disorder or schizophrenia, substance abuse, co-morbid anxiety disorder, divorced, unemployed, access to lethal means Risks for attempted suicide: Female, younger, black, widowed, divorced or single, terminal or chronic illness Protective factors: Pregnancy, marriage, religion/spirituality, life satisfaction, social support, future orientation, children or pets at home In a recent study our of great Britain suicide was the leading cause of maternal mortality. I can get you the reference. Also, women who kill selves during postpartum period do so with lethal means (like men) American Foundation for Suicide Prevention

Suicide Assessment Any thoughts to hurt yourself? Any thoughts of suicide? Do you wish you were dead or were not here anymore? History of prior suicide attempts? Lethality? Hopelessness? Any thoughts of future plans? Plan? Access to lethal means (not just guns…) Intent? If not reassuring – please order a SITTER prior to psychiatric consultation 75% of those that complete suicide give clear warning of intent

All patients that present with or disclose Suicidal Thoughts at any point during their hospital stay must be documented in the EMR per ED Policy Assessment can be found in the Patient’s RED CROSS section of the EMR

If you are in crisis, call 1-800-273-TALK (8255)
National Suicide Prevention Lifeline

Homicidality & Risk of Violence
3.7% percent of general population commits a violent act Increased risk in lower SES, lower education, less social stability, areas with high unemployment CDC: Homicide 15th leading cause of death Rates of violence in mentally ill patients peak at the time of hospitalization Stable mental illness does not increase the risk of violence High rates of mental illness among incarcerated patients Not a predictor of violence but more likely attributed to lack of access to mental health care in community Rueve ME & Welton RS (2008) Psychiatry 5(5): 34-48

Assessing Homicidality
Assess for thoughts of physical harm and homicide to others RF: History of violence Poor impulse control Inability to delay gratification Impairment/loss of reality testing Substance use History of antisocial personality disorder Rueve ME & Welton RS (2008) Psychiatry 5(5): 34-48

Tarasoff: Duty to Warn Tarasoff v. the Regents of the University of California (1976) Mental health professionals have a duty to protect individuals that are being threatened by a patient Notify police Warn the potential victim "The public policy favoring protection of the confidential character of patient-psychotherapist communications must yield to the extent to which disclosure is essential to avert danger to others. The protective privilege ends where the public peril begins.” (Judge Matthew O. Tobriner, Majority Opinion)

Changes in Mental Status
Delirium= disturbance in consciousness with reduced ability to focus, sustain, or shift attention Develops over a short period of time and tends to fluctuate during the course of the day Can include reversal of sleep-wake cycle, psychomotor activity changes, neurobehavioral symptoms Hyperactive delirium = hyperarousal, hypervigilance, pronounced agitation Hypoactive delirium = hypoalert, lethargic (often not recognized)

Acute Delirium – Differential Diagnosis
I Infection W Withdrawal A Acute metabolic T Toxic C Cerebrovascular H Hemodynamic D Deficiencies E Endocrine/electrical A Autoimmune T Trauma/Tumor H Hypoxemia Fricchione GL et al (2008) Am J Psychiatry 165(7):

R/O Medical Issues Performed by ED attending or resident per EMTALA guidelines: Assess for and rule out medical causes for agitation/change in mental status Hypoglycemia Hypoxia Drug overdoses/poisoning Infection Intracranial processes All of these healthcare diagnosis be mistaken for a mental illness. Intervention: Assess mental status: Do you know where you are? Blood sugar O2 sat B/P, Pulse Temp Perrla

Don’t Forget Rule Out “Reversibles”
“GOT IVS” LUCOSE NFECTION GOT IVS XYGEN ASCULAR RAUMA EMPERATURE EIZURE

Capacity vs. Competence
Capacity: reflects moment-to-moment decision making capacity. Can vary based on specific situation, and fluctuates moment-to-moment depending on level of impairment. Level of capacity needed can vary on a “sliding scale” based on the complexity of the decision and the potential for risk in the outcome Competence: a legal determination, made by a judge, regarding one’s ability to make decisions for herself. Is a permanent, legally binding decision Appelbaum PS (2007) NEJM 357:

Assessment of Capacity
Can the patient make a decision without coercion/indecision? Can they communicate a choice? Can the patient understand their disorder, including the progress of disease, treatment options, benefits, risks, alternatives? Does the patient have logical reasons for their decision? Can they reason about treatment options? Does the patient understand the consequences of their actions? Appelbaum PS (2007) NEJM 357:

When you suspect patient lacks capacity…
Assess mental status and ability to understand illness/procedure Ensure no intoxication, withdrawal or acute illness that compromises mentation If NO CAPACITY: Seek substituted consent Next of kin, HCPOA, etc “Any physician who is aware of the relevant criteria should be able to assess a patient’s [capacity]…treating physicians may have the advantage of greater familiarity with the patient and with available treatment options.” (Appelbaum 2007) Appelbaum PS (2007) NEJM 357:

WHY IS SYMPTOM MANAGEMENT IMPORTANT?
Anxiety drives many problematic behavioral symptoms Anxiety > Agitation > Aggression Symptom management reduces anxiety, acting out, need for restraints and enhances cooperation of patient and family Avoid the attitudes and behaviors that increase patient anxiety and frustration …don’t REACT

Symptom Management Prevention of symptoms by use of early intervention, building trust, conveying nonjudgmental attitude, establishing therapeutic rapport and alliance with patient Management of symptoms saves time, energy and resources; reduces chaos, noise > improves patient outcomes and satisfaction Ultimate goal is to keep patients and staff safe by enlisting cooperation of patient to stay in self - control

Women and Infants Assessment Protocols

Non-Urgent Interventions: Presents with:
Social services consultation if appropriate Outpatient referral if appropriate Presents with: Depression of anxiety and able to contract for safety Medication management Outpatient consultation Why do we place the patient in Room 13?

Urgent Interventions: Presents with: Place in ED Room 13 if available
Social Work Consult Psychiatric consult if appropriate Give security a heads up (may not need to be present) Presents with: Suicidal gestures without plan Alcohol or substance abuse without delirium or altered sensorium Pregnant patient requesting detoxification Why do we place the patient in Room 13?

Emergent Presents with: Interventions:
Acute suicidality plan/intent/means Homicidal/aggressive behavior against others Agitated/Aggressive/Non- re-directable (Manic/Psychotic/Intoxicated) Postpartum Psychosis Acute alteration in mental status Interventions: Page Psychiatry M-F 8am-5pm during day On call 24 hrs/ 7days a week Notify Security Notify ED Attending, NM/ ANM/Nursing Supervisor Declare “code grey?” Social Work and Psychiatry work collaboratively Contact Social Work for the initial assessment of the patient’s acute needs Social Work, in collaboration with on call psychiatry, will make recommendations about further assessment needs and recommendations on disposition

Predictors of Violence- Patient
Predictors that May Lead To Violence Against Staff Not ensuring privacy Staff inexperience New or float staff Provocative or controlling statements Inconsistency Arbitrary application of rules

Behavioral Predictors of Violence
Signs and symptoms Hyperactivity Increasing anxiety or tension Threatening gestures Increased demands Loud voice Verbal abuse Intense eye contact or avoidance of eye contact Violence/Aggression Assessment Checklist (VAAC)

Predictive Phases of Violence22-23
CALM PHASE Normal behavior prior to disturbance PRE-ASSAULT PHASE Individual displays threatening verbal and nonverbal behaviors ASSAULT PHASE Individual displays out of control verbal and physical behavior This slide depicts the phases of violent behavior. Strategic initiatives should be directed at the pre-assault phase, at de-escalation and prevention and the assault phase for containment and response. One can also add a post-assault phase for the purposes of identifying policies and procedures necessary within the institution for documenting, reporting and dealing with the perpetrator and victims after an incident has occurred. Slide 14 Reference: 22. Distasio, C. (2002). Protecting yourself from workplace violence. Nursing, 32(6), 23. Gallant-Roman, M.A. (2008). Strategies and tools to reduce workplace violence. The American Association of Occupational Health Nurses Journal, 56(11),

Non-physical Violence
Cascade of Violence Incivility The intent to harm is ambiguous and subject to varying interpretation Non-physical Violence Intentional behavior Examples: harassment, intimidation, name calling, obscene phone calls, stalking, use of profanity, verbal threats Physical Violence Examples: spitting on person, pushing, grabbing, beating, stabbing, shooting, homicide It is also important to recognize that there is a spiraling effect of violence and it is important to be able to identify and effectively interrupt the sequence before the consequences become life threatening. The tipping point, as shown by this graphic, is when the behavior is no longer ambiguous, and is clearly intentional. Many nurses don’t consider verbal abuse as “violent” behavior. As this slide depicts, besides the obvious emotional toll that verbal abuse can take on employees, verbal abuse is a clear warning sign of escalation of intent to harm physically and should be taken seriously. Verbal abuse is not part of anyone’s job and each employee should have a personal “zero tolerance” policy for this type of violence. Slide 15 Reference: 23. Gallant-Roman, M.A. (2008). Strategies and tools to reduce workplace violence. The American Association of Occupational Health Nurses Journal, 56(11), 24. Andersson, L.M., & Pearson, C.M. (1999). Tit for tat? The spiraling effect of incivility in the workplace. Academy of Management Review, 24(3), 25. Hutton, S. A. (2006). Workplace incivility: State of the science. The Journal of Nursing Administration, 36(1),

Strategies Manage Environment Manage Self (Self Awareness)
Assertiveness Skills Symptom management reduces anxiety, acting out, need for restraints and enhances cooperation of patient and family Avoid the attitudes and behaviors that increase patient anxiety and frustration …don’t REACT Prevention of symptoms by use of early intervention, building trust, conveying nonjudgmental attitude, establishing therapeutic rapport and alliance with patient Management of symptoms saves time, energy and resources; reduces chaos, noise > improves patient outcomes and satisfaction Ultimate goal is to keep patients and staff safe by enlisting cooperation of patient to stay in self - control

Preventative Strategies
Provide patient centered individualized treatment Validate feelings Provide options Ask the patient if someone else would be more helpful Ask the patient what might help Give space and revisit later Utilize distraction Tolerate affect Reinforce the benefits of healthy choices and remind patient of the natural consequences of their actions Avoid power struggles Invest time Ask the audience what each of these means to them

Effective Techniques-Environment
Manage environment: Decrease stimulation-only utilize minimum amount of people to maintain safety Provide quiet area if possible Provide for dignity and respect by removing witnesses

Effective Techniques-Self
Manage Self: Maintain non-threatening stance Maintain calm neutral rate and tone of voice Use eye contact as appropriate Paranoid patient-avoid eye contact Anxious patient-eye contact to help ground and provide comfort EMPATHIC LISTENING: Empathic listening is an active process to discern what a person is saying. Key elements in empathic listening include: Be nonjudgmental. Give undivided attention. Listen carefully to what the person is really saying (focus on feelings, not just facts). Allow silence for reflection. Use restatement to clarify messages

Self Awareness Understand your: Personal stress Vulnerabilities
Strengths Responses to anger Skills and abilities ** Be open to feedback This is what we must work on-we have several weaknesses in this area. Recognizing personal biases. Recognize strengths in available staff/work as a team. Ask for assistance from other staff if feeling ill-equipped or overwhelmed. Do not take things Personally: Rational Detachment The ability to stay in control of one’s own behavior and not take acting out behavior personally. Key Points: Staff may not be able to control precipitating factors, but they can control their own response to the acting out behaviors which result. A professional attitude must be maintained so that we may control the situation without overreacting or acting inappropriately. Staff need to find positive outlets for the negative energy absorbed from acting out individuals.

Phrases that don’t work
“You need to….” Translates to: You are not listening to me I don’t need to do anything

Phrases that don’t work
“We are trying to help you…. “They are against me” “There is no help” “I don’t want help”

Phrases that do work “Let’s try fixing this together…”
“What can I do to help….” “I honestly don’t know the answer to that right now. I will get you that answer.” “Is there someone you feel comfortable talking with...”

Remember (anticipate)
Maintain open clear path closest to the door Maintain a safe distance of a leg length or more from a potentially violent patient Maintain the patient’s “space” *This differs from person to person

Remember (proactive) Maintain a non-confrontational stance
Arms in front of body, not crossed Eye contact as appropriate to situation Do not face patient head-on Do not turn your back to exit room Paranoid patient-avoid eye contact Anxious patient-eye contact to help ground and provide comfort

EMPATHIC LISTENING Empathic listening is an active process to discern what a person is saying. Key elements in empathic listening include: Be nonjudgmental. Give undivided attention. Listen carefully to what the person is really saying (focus on feelings, not just facts). Allow silence for reflection. Use restatement to clarify messages.

Therapeutic Relationship is Key
Therapeutic Rapport: consistency, reliability, confidentiality, safety, trust, respect Non-judgmental attitude: acceptance, validation, compassion, empathy Alliance: support, meeting of needs, working “with” pt. to achieve goals Establishing a therapeutic relationship does not mean condoning, allowing unhealthy or problem behavior

How do we create one? Nonverbal communication Appropriate humor
Physical needs e.g. pain control, warmth, food Respect: avoid coercion, threats, & ultimatums Clear, reasonable, enforceable limits; give choices Educate vs. lecture; timing is important

Activating Psychiatric Emergency

Social Service Psychiatry
Team Members ED Staff Security Social Service Psychiatry Patient/ Family

Be Proactive …. Not reactive

Team Management of Emergency
Team Leader: Most qualified medical provider Social Service: Provides support for family NM/ ANM/ Nursing Supervisor: Assists provider, role delegation, lead Restraint team Primary ED Nurse: Assists with managing patient Nursing Assistant (or delegate): Clears nearby area to ensure pt./staff safety Security: Ensures patients/family/staff safety, restraint team Collaboration/Care Teams Effective Communication Closed-loop Communication Technique Shared Mental Model Situational Awareness Know the Plan, Share the Plan This is where all our knowledge regarding working collaboratively as a group matters. Utilize the techniques we have learned to ensure the patient and staff’s safety!! Remember: leader can change, delegate when needed, and always know who leader is.

Psychiatry Consult Team
Erin Hunt Capece, LICSW Carmen Colomer, MD Thamara Davis, MD Laura Hollar-Wilt, MD Neha Hudepohl, MD H.T. Kao, MD WIH Psych C/L pager: amion.com Psychiatry consult Inpatient/Triage

Medication Management of Agitated Patients
1st choice: antipsychotic plus benzodiazepine Haldol mg (standard dose 5mg) IM q1-4 hours + Ativan 1-2mg IM (preferred agents for pregnant patients) Patient with allergy or contraindication: Zyprexa 5-10mg IM or PO (oral dissolving tablet Zydis) q8 hours Benadryl 25-50mg IM Non-preferred/ for non-pregnant patients Thorazine 25 IM q4 hours (may repeat dose in 1 hour if symptoms persistent)

Special Considerations
If giving Haldol IV the patient MUST have telemetry monitoring for QT prolongation/arrhythmia and must also have q24 hour EKGs Need to have Cogentin (benztropine) available PO and IM in case of acute dystonia Special consideration for patients with known arrhythmias: consider telemetry monitoring do not use IV Haldol consider use of benzodiazepines alone

Transferring to Another Facility for Psychiatric Assessment
Ensure patient stabilization and safety: Medical clearance by ED attending Medications should be administered when appropriate If appropriate, emergency certification should be completed by psychiatry team Emergency certified patients should be placed in room 13 with Constant Observation and security based on determination by patient care team

Transferring to Another Facility for Psychiatric Assessment
EMTALA forms must be completed for non- certified patients Doc to Doc calls for non-psychiatric issues should occur via ED patient care team Patient, with emergent psychiatric condition will be transferred via private ambulance service.(Not LIFEPAC) Notify ambulance service of any special consideration ie. Restraints (both physical and chemical)

Violent or Dysregulated Patients
Transfer to RIH Emergency Department Doctor to Doctor report must be called to “D” Pod Consult Psychiatrist (utilize AMION): Psychiatry In- house- M-F 8am- 5pm On- call after 5pm, weekends, & holidays Emergency Certification (forms kept on unit) to be obtained & completed by psychiatry

Non-dysregulated patients in need of psychiatric assessment
Obtain medical clearance by ED Provider Obtain social service consult Social Service will contact psychiatry following evaluation and consultation with ED provider as necessary depending on patient All decisions regarding psychiatric disposition MUST be made by the psychiatry team

Non-dysregulated patients
in need of admission Obtain medical clearance by ED Provider Notify behavioral health team (Psychiatry & Social Service): Behavioral Health Team will arrange for transfer to psychiatric facility May want to include St. Joes and perhaps TPC crisis stabilization unit.

What do these mean to you?
Debriefing Encouraging staff to reflect A process of sharing and discussing information after an event, is important because it allows staff to reflect on important information and facts which could lead to process improvement It is the process of sharing and discussing information after a event, is important because it allows key players to obtain important information and leads to process improvement. Communicate clear goals for the debrief. These should include providing a setting for each person to communicate their feelings and experiences during and immediately following the incident, venting frustrations, validating one another's experiences and feelings, and gauging the well-being of each person involved.

“Clients have the right to be treated with respect and dignity in a safe, humane, culturally sensitive and developmentally appropriate manner that respects client choice and maximizes self determination.” —American Psychiatric Nurses Association

“What Happens Next….” Preventive Strategies Anticipatory Strategies
Containment Strategies

References American Psychiatric Association, American Psychiatric Nurses Association, & National Association of Psychiatric Health Systems, Learning from each other: Success stories and ideas for reducing restraint/seclusion in behavioral health DSM-IV TR McCoy, E., (2010). Development of Emergency Care Psychiatric Clinical Framework. ENA

Management of Behavioral Health Emergencies in the ED

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