Presenter : R2 鐘壬鴻

碰到類似狀況要注意什麼事
情 ??
身為急診醫師需要做到什麼事
情 ??
Introduction and Epidemiolo
gy
Why this is an issue ..
 Psychiatric and behavioral emergenci
es

Wide range of psychosocial pathology

Anxiety Depression Suicidal

Substance use disorders
Agitation ideation

Neurocognitive
disorders

Psychoses Personality disorder

Psychiatric and behavioral emergenci
es

Wide range of complaints

Medical Psychiatric Combined

 Statically speaking…
World Health Organization – Globally
1 in 4 people suffer from mental illness or neurologic disorde
rs Depression – No.1 cause

The National Institute of Mental Health - United S

tates
1 in 5 Americans suffers from a mental, behavioral, or emotion
al disorder
1 in 25 suffer from a severe mental illness
 Statically speaking…
The Centers for Disease Control and Prevention
24% increase in the rate of suicide in the United States
from 1999 to 2014
 Psychiatric patients :
Higher incidence of medical conditions Greater risk of
injury

At least one chronic medical condition : 50 ~ 90%

Shortened life expectancy : 8 to 30 years

60% : Physical illness

Goals of Clinical Evaluatio
n
The importance/purpose of medical clearance a
nd stability
 The evaluative process for identifying
Medical clea
rance primary or comorbid medical conditions

① Organic issues may be reversible

Why it is ② Failure to identify can have
important ? devastating outcomes
 How serious is this problem ?
7% to 10% of patients admitted to psychiatric wards have
an organic condition that should have been identified
Higher at the extremes of life

Meningitis Toxicologic
- Acetaminophen toxicity
- Neuroleptic malignant syndrome
Delirium
Missed life-
threatening organic Trauma Metabolic
pathology - Hepatic encephalopathy
- Myxedema coma
Sepsis
- DKA
No psychiatric h Altered mental status /
x New-onset psychosis
Presumed to have an underlying medical disorder or an
“organic” cause until proven otherwise

Identify any medical or surgical emergencies

Evaluation should include appropriate

reassessment and observation periods

Assuming a psychiatric condition for first-time episodes

(Psychiatric condition is a diagnosis of exclusion)
Known psychiatri Psychiatric / Behavioral
c history complaint
Completing a medical evaluation of patients
with psychiatric or behavioral complaints
!! This initial medical evaluation may be the only one that the patient will receive
!!

No interdisciplinary consensus

Historical and physical examination elements, ancillary testing, and treatment

 Medical stability

Such conditions are not responsible

for the patient’s psychiatric or
behavioral issues or are incidental
Patients with
complaints
chronic
medical conditions

Medical illness has been treated

Patient’s condition has stabilized
End goal of medical Distinguish between
clearance/stability Organic / Psychiatri
c condition

Comorbid medical diseases may be causing or exacerbating

psychiatric symptoms

34% to 50% of patients who present with psychiatric emergencies

ED Medical Stability or Cle
arance Evaluation
ED arrival/Triage  History  Review of sys
tems  Physical examination  Laboratory an
d ancillary testing  Reassessment
 Threaten harm to others
Altered mental status
Severe agitation

• Paramedics or police provide advance notice to the

ED

• Prepared to search the patient for weapons

• Secure an appropriate ED room
• Search the patient for weapons

• Secure an appropriate ED room

• Provide verbal de-escalation

• Restraints / Medication as needed

• Place the patient in a room where there are no objects,

liquids, or devices

• Undress the patient and provide a hospital gown

 Identify high-risk situations
Suicidal or homicidal ideation, psychotic or violent
behaviors, and risk for elopement

Protective custody/Precautionary hold

Flag patients at risk of eloping or those who cannot
be released until assessment is complete

Different color gowns, special area assignments, and

special flagging of the chart
 More stable patients

Triage is accomplished in the usual manner as for

medical patients
 History
• Detailed description of recent symptoms

• Severity of symptoms

• Changes in behavior

• Provoking and palliative features

• Similar previous occurrences

• Timing and duration of symptoms

 History
Challenges
 Patients may not be cooperative

 Patients may offer tangential responses

 Patients may provide diagnostic terms for their

disorder that are technically inaccurate

It is best to ask the patient to describe symptoms

Ask openly about substance use disorders

 History
Collateral information
Try to obtain collateral information from as many
ancillary sources as possible

Provide a baseline for the patient’s symptoms and

confirm the story

Chart reviews can provide additional collateral

 History
Hidden medical problems
《 Prospective Evaluation of Emergency Department Medical
Clearance 》

• 63% of patients with new psychiatric symptoms had

significant medical pathology
• 42% could be diagnosed from history alone

Identify current infections & Consider delirium

 History
Hidden medical problems
 Review of system
More structured manner than the rest of the interview

Unfortunately, many avoid asking detailed questions

- Concerns that the patient will endorse everything asked

How to obtain
 Specific targeted yes or no questions
 Focus on elements most likely to point to organic problems
(recent fevers, productive cough, rashes, headaches, trauma)
 Physical examination
Cornerstone of medical stability/clearance
 Obtain a full set of vital signs
 Address any abnormalities
 Recheck before discharge
One study from 2008
Failure to document a complete set of vital signs in up to 50% of patients
 Perform a head to toe examination
Order and amount of attention individualized

Limited histories
Comprehensive physical examination
Standardized trauma assessment
Self-inflicted
injuries
 Physical examination
Cornerstone of medical stability/clearance
 Physical examination
Psychiatrist may expect more..
Mental Status Examination
Mini-Mental Brief Mental Quick Confusion
Status Status Scale
Examination Examination

Attention Language Memory Affect

Visual-spatial
Orientation ability Conceptualization

A significant portion of the examination can be done by observing from the doorway
 Lab tests
Routine laboratory testing is typically low yield
• Individualized assessments

• Most inpatient psychiatric facilities

- Require extensive ancillary testing
- Will list specific test abnormalities
 Determining the patient’s suitability for admission

Most psychiatric facilities lack laboratories and imaging suites

 Reassessment & Anticipation of
decompensation
Patients can decompensate in the in-hospitable ED
environment

Withdrawal or overdose symptoms may develop

One study
1/3 cases of severe intoxication
12.5% of patients with withdrawal or delirium tremens
2.5% of patients with a medication overdose
 Not identified on initial assessment

Coexisting medical disorder will require attention

(e.g., a diabetic requiring insulin or a patient with hypertension requiring twice-daily
dosing of home medications)

Coexisting medical disorder may reveal itself

Special considerations
1. Pitfalls & Techniques in actual practice
2. Special patient groups
Pitfalls & Techniques in
Special patient groups
actual practice
 Deficiencies in the initi  High ED users
al assessment  Involuntary patients
 Interviewing techniques  Exclusion criteria for
 Violent restraints psychiatric admission
 Assessing the degree of a
gitation
Pitfalls & Techniques in
Special patient groups
actual practice
 Deficiencies in the initi  High ED users
al assessment  Involuntary patients
 Interviewing techniques  Exclusion criteria for
 Violent restraints psychiatric admission
 Assessing the degree of a
gitation
Deficiencies in the initial assessme
nt
 Deficiencies in the initial assessme
nt
《 Unrecognized medical emergencies admitted to psychiatric units 》
Over 1/3 of medical clearance assessments lacked a history

《 Medical clearance: fact or fiction in the hospital emergency room 》

8% of patients had no documented physical exam
Many did not include critical components
56 % missing mental examinations

《 Epic fail! Poor Neuropsychiatric documentation practices in emergency

psychiatric patients 》
50 % cranial nerve testing absent
72% motor exam testing absent
88% sensory exam testing absent
75% gait testing absent
Interviewing techniques
 Violent restraints
Team of five staff members Shows of force with multiple team

 1 team leader & 1 person for each limb

members poised to act can at times
be sufficient

Patient and any family members present

provided with explanations of the procedure and
 reasons for it

Place the patient on a bed or stretcher Secure all Be careful to avoid injury to the
patient and personnel assisting in
four limbs with leather restraints
 the process

 Elevate the patient’s head To minimize risk of aspiration

If refused, administer medications

 Offer medications involuntarily
 Violent restraints
Reassessment & Removal

 Familiarize with hospital policies and laws

- Frequency of reassessment
- Elements that must be documented
 The first face-to-face assessment : 1 hour after application

 Once the patient is calm and cooperative

Remove the restraints in a stepwise fashion (one at a time)
Assessing the degree of agitation

Queensland ambulance service

Clinical Practice Procedures : Assessment/Sedation Assessment Tool
Assessing the degree of agitation
Pitfalls & Techniques in
Special patient groups
actual practice
 Deficiencies in the initi  High ED users
al assessment  Involuntary patients
 Interviewing techniques  Exclusion criteria for
 Violent restraints psychiatric admission
 Assessing the degree of a
gitation
Pitfalls & Techniques in
Special patient groups
actual practice
 Deficiencies in the initi  High ED users
al assessment  Involuntary patients
 Interviewing techniques  Exclusion criteria for
 Violent restraints psychiatric admission
 Assessing the degree of a
gitation
 High ED users (aka Frequent flyers)
Severe
Often accused of psychosocial
stressors
malingering
Poor social Chronic
support conditions

Challenging to deal with

Elicit strong, negative

feelings Broken family
Background of
trauma
 Family

Unable to take care of mentally ill ED

individuals

Unable to ensure safety nets

The go-to for Crises
Communities & Decompensations
 “Bedless” psychiatry Outpatient & Emergency care

Many challenges

Many have called for a return of long-term care

Although psychiatric asylums are not the answers

They did fulfill a stabilizing function for a very difficult and fragile population
 1960s 1970~2010 2010~
The advent of Continuous decrease in Demand outweigh supply
deinstitutionalization beds
 1960s
The advent of
deinstitutionalization

Dearth of inpatient psychiatric beds

 Outpatient and community outreach services

 More hospital admissions
 Shorter hospital stays
 Significant gaps in care

Many patients previously been housed in Nowhere to live

long-term state hospitals or facilities
Nowhere to go
 1960s 1970~2010 2010~
The advent of Continuous decrease in Demand outweigh supply
deinstitutionalization beds
 1970~2010
Continuous decrease in
beds

From 1970 to 2006

Inpatient psychiatric beds decreased from
400,000  50,000

From 2005 to 2010

Number of state psychiatric beds continued to
decrease by another 14%
 1960s 1970~2010 2010~
The advent of Continuous decrease in Demand outweigh supply
deinstitutionalization beds
 2010~
Demand outweigh supply

2016 : Becker Hospital Review

Demand Supply
Beds in the United Beds actually
States 123,300 available
37,679

With less than 30% of the needed inpatient beds available

 2010~
Demand outweigh supply

Substance use disorders/addiction, depression, anxiety,

and psychoses in the general population have exploded

Last beacon of hope

Safety net for the community’s most vulnerable

Estimated 1 in 8 ED visits involving mental and substance abuse disorders

How do we deal with this problem

Sometimes derive emotional benefit

from the ED visits

Reports of patients who call their

previous inpatient units on a regular
basis to update on their progress

Some strategies can help deal more effectively with

this group
 Providing housing reduces ED seeking
behavior
Unresolved
symptoms
Supported housing may
help more than medical
interventions

Low
Urgent social
treatment
needs
adherence
 Robust health system reduces ED seeki
ng behavior

Trouble Ignore/Lack Programs that address

navigating the primary care these factors can reduce
health system resource
ED recidivism
 Importance of patient education

Chronic Profound impacts on cognition

substance use

Undisclosed or unexplored history of
head trauma
Victimization rates elevated in this
group
Combination
Mental illness
of both

Decreased ability to recall and

comprehend instructions
Importance of patient education
 Simplify instructions

Make sure the patient understands the

 explanation

Provide a limited, singular-focused plan, without

multiple steps or complicated follow-up provisions

Simple planning applies to verbal, written, or even
E-health/mobile-based interventions

High users often have unmet medical n
eeds

Must deal with the patient’s attitudes and behavioral difficulties

Intense patients can provoke negative feelings
Adhere to existing protocols
Discuss difficult cases with colleagues
Beware of unconscious biases

Negative bias is an unconscious, automatic reaction to a patient’s preexisting attributes

(gender, race, obesity status, ED recidivism, socioeconomic status, or sexual orientation)
Involuntary patients

Involuntary
transport to ED

Involuntary
commitment /
hospitalization
 Involuntary patients
Involuntary
transport to ED
Harm to
Harm to self
others

Continued deterioration without

treatment
 Involuntary patients
Involuntary commitment /
hospitalization
 Must be suffering from a severe mental disorder
 Must need treatment on an inpatient basis
 Compulsory/involuntary treatment must be necessary
Must be a prospect of recovery if the patient is treated involuntarily

Intellectual Autism spectrum Substance use

disabilities disorders

May not qualify for involuntary admission

 Harm to
Harm to self
others

Continued deterioration without

treatment
 Harm to self

 Harm to self
 Planned suicide
 Active suicidal attempt
 Reason to believe the patient may harm himself or
herself

Evaluation of self-harm risk is Specialized psychiatric

complex consultation
 Harm to
Harm to self
others

Continued deterioration without

treatment
 Harm to others
 Harm to others
 Risk of harm to others

Frank homicidal ideations are actually fairly rare !!

Irritability and Substance use Access to Personal crises

impulsivity weapons
Recent breakups, divorces, custody battles, and perceived need for revenge
 Harm to
Harm to self
others

Continued deterioration without

treatment
Continued deterioration without treatment
 Self-care doubtful
 Self-preservation doubtful

Often lack open statement of self-harm

!!BUT!!
Self-starvation Eating disorders
Catatonia

Severe Distortion of
psychosis reality

Typically lack capacity to make full medical decisions for

themselves
 An involuntary commitment assumes :

 The patient lacks capacity

to consent to an admission or emergency medications

 Not competency determination

台灣的法規
強制就醫
強制住院
 強制就醫
精神衛生法第 32 條第一項
警察機關或消防機關於執行職務時，發現病人或有第三條第一款所定狀態
之人有傷害他人或自己或有傷害之虞者，應通知當地主管機關，並視需要
要求協助處理或共同處理；除法律另有規定外，應即護送前往就近適當醫
療機構就醫。

第三條第一款
精神疾病：指思考、情緒、知覺、認知、行為等精神狀態表現異常， 致其
適應生活之功能發生障礙，需給予醫療及照顧之疾病；其範圍包
括精神病、精神官能症、酒癮、藥癮及其他經中央主管機關認定之精
神疾病，但不包括反社會人格違常者。
 強制住院
精神衛生法第 41 條
• 嚴重病人傷害他人或自己或有傷害之虞，經專科醫師診斷有全日住院治療
之必要者，其保護人應協助嚴重病人，前往精神醫療機構辦理住院。
• 前項嚴重病人拒絕接受全日住院治療者，直轄市、縣（市）主管機關得指
定精神醫療機構予以緊急安置，並交由二位以上直轄市、縣（市）主管機
關指定之專科醫師進行強制鑑定。但於離島地區，強制鑑定得僅由一位專
科醫師實施。
• 前項強制鑑定結果，仍有全日住院治療必要，經詢問嚴重病人意見，仍拒
絕接受或無法表達時，應即填具強制住院基本資料表及通報表

指病人呈現出與現實脫節之怪異思想及奇特行為，致不能
嚴重病人 處理自己事務，經專科醫師診斷認定者。
Exclusion criteria for psychiatric admission
Process of admission

Determine need Medical clearance/stabilization Finding bed

Process is very complex and elusory !!

Exclusionary criteria

 Add another layer of complexity

 Add to the patient’s overall length of stay
 Trigger the problem of ED boarding
 Exclusionary criteria

 Preexisting medical conditions

(i.e., pregnancy or intellectual delay)
 Inability to manage the patients medical comorbidities
(i.e., patients requiring peritoneal dialysis)
 Specific laboratory or ancillary testing irrespective of clinical need
 Facility issues
(i.e., requiring patients in the same room to be of the same gender)
 Discharge
Housing insecurity
Inability to buy medications

Admission (Psychiatric/Medical)
Bed availability

Observation
Useful for substance intoxication / crises expected
to resolve
Increased length of stay and potential jurisdiction
and liability issues
Take Home Message
 碰到類似狀況要注意什麼事
情 ??
身為急診醫師需要做到什麼事
情 ??
 Restraint & Interviewing
Beware of pitfalls
Medications techniques
Table 286 - 5 Table 286 - 4 Table 286 - 3
Ensure safety
Medical clearance /
stability Hospital policies and
Table 286 - 1 & 286 - 2 laws
Thank you fo
r your atten
tion