INTRODUCTION TO EMERGENCY PSYCHIATRY

Brian E. Wood, D.O.Associate Professor and Chair

Department of Neuropsychiatry and Behavioral SciencesEdward Via Virginia College of Osteopathic MedicineAssistant. Professor of Clinical Psychiatric Medicine.

University of Virginia School of Medicine

Definition

A psychiatric emergency is a disturbance in thoughts, feelings, or

actions that requires immediate treatment.

(Kaplan and Sadock, 1996)

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.

The Patient in the Emergency Setting

Central Principles

• Assessment of Acuity

• Assessment of Risk– Risk to self– Risk to others

• Disposition to address risk factors

• Documentation.

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.

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

Disposition

• Application of problem solving strategies.

• Should address identified areas of acuity and risk.

• Should encompass the “least restrictive care”doctrine.– Care should be provided in the least restrictive

setting possible while still providing protection for the patient.

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.)

The Care provider in the Emergency Setting

Risks

• Violence in the emergency setting– Generally more risk than in non-emergent

settings.

• Secondary gain issues

• Legal exposure

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

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.

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.