Hello there, and welcome to session 1043 on ER Psychiatry 101, Standards, Solutions, and Safety, coming to you from members of the American Association for Emergency Psychiatry, otherwise known as AAEP. Before we begin and introduce a little bit about our speakers, our plan for the talk, and the type of conclusions we're going to try to share with you, I wanted to share a quick quote that I think pertains to the interaction between emergency departments and the field of mental health. Learning how to think really means learning how to exercise control over how and what you think. It means being conscious and aware enough to choose what you pay attention to and to choose how you construct meaning from that experience. Now, that is really meant to kind of point out the fact that we are dealing with very complicated scenarios that have nuances, and part of our challenge in both fields of emergency medicine and psychiatry is to find the best ways to get to that nuance while still offering very concrete, critical evidence that people can use to make patients' lives better. So, these are our three disclosures from Dr. Nordstrom, Dr. Zunn, and myself. Here's what we're going to be talking about today. We're going to look at the rationale of why we believe using education for emergency psychiatry should be prevalent across all training milieus, whether it's for a psychiatric physician or physician training in emergency medicine. We're going to break it up into three main sections. Dr. Zunn is going to focus on some of our evidence-based recommendations for medical clearance. I will then step in and look at some methods and strategies that work on engagement and interaction with our patients. And then, lastly, Dr. Nordstrom is going to close us out with some important commentary on evidence-based practices for handling risk and agitation. And then, at the end, we're going to also kind of give you some more information on what we do as an organization and some of the educational opportunities that we have if you found any of this to be of use. Now, all three of us are coming to you from a very, very wonderful organization known as AAEP, the American Association for Emergency Psychiatry. We are actually an APA affiliate group. We are a very diverse membership with a lot of different people from all over the world, people that are in training, people that are in senior leadership, people from all different scopes of practice, so it's not purely a physician-led organization. We have a lot of room with advocacy and collaborations. We also look at a lot of different innovative developments and working with some of our external shareholders, such as law enforcement. And we're coming to you also in leadership roles, myself as the current president of AAEP and Dr. Nordstrom and Dr. Zun, both as past presidents of AAEP. Some further commentary is that we are a multidisciplinary organization that serves as the voice of emergency mental health, and our membership, as mentioned, includes a wide variety of directorship and leadership of different emergency rooms, site crisis services, and other ambulatory care centers. And I left our website there, and we'll talk a bit more about that at the end of our talk. And lastly, I just want to point out that we are champions for the advancement of evidence-based, compassionate care for behavioral emergencies through research, education, and interdisciplinary collaboration. We're a fun group to be a part of. We get a lot of work done, and I think at the end, I will close with some comments on an upcoming conference that some of you may have interest in if some of these particular educational points really hit home with. So as we move into the body of our presentation, once again, our title was Standards, Solutions, and Safety. And that was a purposeful choice for a title because each one of us are going to take a different piece of that pie. So Dr. Zun will be looking very much at the standards that you have, particularly at the very initial encounter, because we all know that how you frame an encounter in the beginning will play a role for how the encounter plays out in the end. I will look at some solutions to deal with engagement, which is often a very complicated part of the interaction. And then lastly, Dr. Nordstrom will focus on safety, perhaps the most important part, as we look towards patient safety, not just during the time of assessment, but also during the time of disposition. So with no further delays, I will hand it over to Dr. Zun, who will start us off with standards in medical clearance. Thank you, Tony, for that wonderful introduction. And I'm Les Zun, and just a little bit more embellishment, I'm the Medical Director for the Lake County Health Department. We have a rather large behavioral health component to the services we provide. I'm Professor of Emergency Medicine with a secondary appointment in psychiatry at Chicago Medical School. I've been involved with AEP for many, many years, and really would encourage you all to join and get involved. So I'm going to talk about evidence-based medical clearance. So I think we need to first set up the learning objectives. So I'm going to talk about the triage process for psych patients, or the mistriage of psych patients. We're going to talk about medical clearance. I'm going to talk about testing, and I know testing is controversial. We may agree or disagree. And then I'm going to briefly introduce a couple of protocols that are used, and then kind of summarize the findings. So this is the five-tiered system that is primarily used throughout the United States for patients who come to emergency departments versus, now, again, I'm not talking about psych EDs, I'm just talking about general medical emergency departments. And the problem with this is that the tool is really not designed for psychiatric patients. In fact, they make Level 2. So Level 1 comes in right away. Level 5 can wait. That's like a prescription refill. But Level 1 is like your traumas and your chest pains. Now, it's interesting in this triage system, Level 2 is suicidal or homicidal. So I'm a little concerned about that and think that that may need to be rethought. There are some protocols out there that actually do direct triage to psych EDs or to PESs. There are two studies. We're going to talk about another one in a minute. But the first one uses the TAPS device, which is the protocol on the right-hand side. I think you can see it here with my arrow. There are six components of the TAPS. It was used in the study of about 1,200 patients. 70% had negative TAPS. So they were sent basically to the psych ED or the PES. In the second study, they used a little different tool. They looked at a much smaller number, 174. And again, here is the tool that they used here or the screening device. And unfortunately, they had some problems. They had about 30% that were non-compliant, meaning that paramedics did not follow the protocol. And there are five protocol failures where they went to a PES and then had to get sent back. So what I want you to take a look at is this study. And this study really just looked at patients that were involuntary, involuntary holds that got screened and went to a PES. This was actually in Alameda County. And so they had this criteria. It was fairly complicated, including extremes of age and medical problems that needed to go to ED versus the PES. And those included if they used substances but not intoxicated, they could go. If they had normal vital signs but no acute medical problems, they could go minor abrasions and they couldn't look ill. And so they didn't really look at protocol violations and non-compliance. But what they said is of the involuntary holds, about 41%, and this was a large N, could go directly from the field that were involuntary holds to a PES. So I think we need to think a little bit more about moving in that direction. It's going to take a lot of work from those emergency docs out there to rethink this. So I'm going to go through two cases to illustrate the discussion about the medical evaluation. The first is a 64-year-old female brought to the hospital for manic behavior. She has multiple medical problems, but no prior psych history. So we need to think about, you know, what information to get from her? What do we need to look for on the physical exam? And does she need testing? And if so, what testing would that be? The other case I want to bring up is a 36-year-old male with schizophrenia brought in by the family because guess what? He stopped taking his medicine and he's getting a little violent at home. Surprise, surprise. I don't think this is too odd for patients that we commonly see. What other information do we need about this patient? What do we need to look for in the physical exam? Same kind of thing. And what tests are indicated? If tests are indicated at all. So really the primary purpose of a medical evaluation, whether it be in a PES or an ED or wherever it may be, a medical ED, we really need to figure out is the cause of their symptoms today from a medical problem, psychiatric, or could it be drug intoxication or withdrawal? So we'll talk a little bit more about that, but what I'm trying to get across here is there's a number of medical things that need to be thought about and evaluated before we decide what the best place to send them. And the other part of this is I love this little Venn diagram in the middle because to me, this is what I see in most of the patients that come to the EDs is, well, they got a little psych problem. They got a little medical problem. They have, they're, they're doing drugs. And my job is to figure out which one is it today, or is it a little bit of each today or who needs to evaluate the patient? So as we think through this medical clearance process, probably the most important thing that we want to make sure we identify, and it's in red here, delirium. Why is delirium so important not to miss? Delirium is important not to miss because it has a high mortality rate if missed, and it has a very high miss rate in emergency departments. So I kind of commented on the primary purpose, but I also want to talk about the secondary purpose as well. So basically we need to know, is the medical problem causing, like we just went through, or exacerbating their psychiatric condition, or if they've been medically evaluated and they're going to go to a psychiatric facility, transfer there, have we identified the medical or surgical conditions that need, might be incidental, but need to be addressed? Are they diabetic? Do they need insulin? Are they asthmatic or COPD? They're in the albuterol. And from my perspective, some psychiatric facilities are able to treat these medical problems and monitor them. Some are not. So we need to know what problems they have before we decide to transfer them and make sure that transferring facility has those resources. So as we go through the process, we need to think about really how to evaluate them. Do they have, and we do that with a history, a physical exam, mental status evaluation, and maybe testing, and we'll talk more about it. And so which ones do we automatically think about probably have a medical eulogy, or at least that should be forefront in our mind. That's those that are 45 years or older that have new onset. Now, if they have a psychiatric condition throughout their life, it doesn't matter how old they are at that point in time, but new onset or something like that, I'm always concerned about. Have they been exposed to toxins or drugs? Is this from substance intoxication or withdrawal? In which case we need to maybe have them sober up and see what comes out while they're in the ED. Do they have a prior history, either medical or psychiatric, that may go along with today's presentation? And I'm always looking for abnormal vital signs as my red flag, that this is a medical problem, and as well as some, you know, abnormal physical findings. Do they have a cognitive deficit? Well, but here the cognitive deficit, really the question is, is it a new cognitive deficit or is it a worsening cognitive deficit? If they have the same old one, I'm not so concerned about. And focal neurologic findings. So do they have something new, maybe a new stroke, something else that might go along with it. And sometimes it's not so easy to make this determination or differentiation. And sometimes we need to observe them over time, maybe admission, maybe observation. So is, so as we think about this incidental medical problems, we really need to say, well, do they have, you know, what medical problems do I need to be looking for? What's common? Well, you know, in this one study, they looked at 300 patients and you know, like two thirds had a medical problem and most common was hypertension, asthma, and diabetes. So this is always something we need to think about. And we need to do the proper assessment while they're in that emergency facility. And we need to think about whether that, as I noted a little earlier, whether that facility can actually treat them or not. So one example that I want to give is that I live in Chicago and the Illinois psychiatric hospitals, there's a system of them, take many inpatients and they have very limited medical capabilities. They can't give albuterol NEMS. They can't do frequent glucose checks. So they can't give oxygen. They don't like to take care of catheters. So these are the things we need to know about before we send a patient to one of these facilities. So what is the most important? What tells us, what gives us that best information? Well, in this study, a retrospective study by O'Shaker, he looked at 352 patients and about 20% of them had a medical problem. And of those medical problems, the diagnosis of whether this is psychiatric or medical was made almost all the time with just a history. Physical exam contributed in about half, vital signs in about 20% and lab testing. We'll talk more about lab testing about 20% as well. So they also asked the patient about whether they did drugs or alcohol. And then they screened them. They did an alcohol level on a tox screen. And what they found in this study was the sensitivity was 92% for drugs. And the specificity was 91%. Similar numbers with alcohol, although for alcohol specificity, a little bit lower. So sometimes some folks say they don't do it when they do it, but still, these are high numbers. Now I'll agree that there's other studies that say patients aren't as reliable in self-reported history, but I think this is where we need to rethink some of this process about does everybody need a drug screen? When we go to looking at documentation, and I find this very interesting. This was a study, a Canadian study where they looked at emergency physicians and they looked at their documentation of a physical exam on psychiatric patients. Oh my God, they only documented vital signs in 52%, pulse ox in 28%, glucose in 5%, respiratory system in half, about the same cardiovascular. Ah, but they did much better with a behavioral exam, 76%, but they missed in 24%. So not great documentation. I don't think that the Canadians are any different than the Americans. So let's talk about what's needed in a mental status exam. So I understand that, you know, psychiatrists frequently do a formal mental status exam, but for me in the emergency department, I need to be very focused. And so usually I can get appearance, behavior and attitude, mood and affect just by looking and talking to the patient. And as we know, sometimes disorders of thought, suicide and homicidality, we need to ask. Insight and judgment, we need to get an idea about why. Well, if I'm going to send that patient home, I got to make sure that they know why they need to be taking their meds. And sometimes I know that they're hallucinating because they're grabbing at things or talking to somebody else, but sometimes it's not so apparent, not so overt. And I also need to know if they have new cognitive impairment that may be something I need to work up and be concerned about. So these are specific ones that I need to look at. So do we need to get testing on everyone? Well, here was an interesting study where they kind of compared emergency physicians to psychiatrists and actually done by Dr. Broderick, an old resident of mine. And the routine testing was required in 35%, but only 16% in ED protocol, but the psychiatrist required in an 80, 84% of the time. And they asked for urine drug screens and alcohol and CBCs. And most believed, especially the emergency docs, that they weren't necessary. And just an aside, if they, if emergency docs were trained in emergency medicine, they were even less likely to think that the testing was important. So then the next question is, well, is it the same for kids? Do we need to do a different evaluation with kids? Well, these two studies in fact show that routine testing is not helpful in the pediatric population. And matter of fact, in these two studies, they recommend that routine urine drug screens in fact are not useful. Now, this is an interesting study where they said, okay, so I talked earlier about the amount of medical problems. Well, let's take a look at the amount of substance use in psychiatric patients. Now, this was not an ED study. This was, you know, looking at chronic patients. And it was very interesting that 44% were current substance users, 29% had a history of substance use, and about 27% had a little or no substance use history. So we're going to talk more about the appropriateness for labs in that setting, but let's go a little bit more global. So here was a study looking at 100 consecutive patients between the ages 16 and 65. Those with a fever got a CT and LP, by the way, there were three. And in this, these are new onset, new onset, 63 of the 100 had an organic etiology for their symptoms. Found in history in 27%, physical exam in six, et cetera, et cetera. But it was very interesting because of the three that had fever. Two of the three actually had meningitis and they had herpes meningitis. So let's talk about whether they need, everybody needs a drug and alcohol levels. And here, what I try to say is really the only indication to do a drug screen and alcohol level in the emergency department is altered mental status without an etiology. Intoxication is a clinical diagnosis. So remember that just getting a drug screen doesn't tell you whether they're intoxicated or not. And the same with alcohol levels, just because an alcohol level may be X or Y doesn't mean that it's impairing them. So it's, I don't think it's very helpful. Matter of fact, I think these two may make the evaluation much more difficult. So when we talk about the assessment of intoxication, really what we need to talk about is are they awake and alert? Do they have an appropriate cognitive function? Do they have appropriate heel, shin and gait? And do they have nice stagnant? So those are the questions I think are much better at getting at whether the drugs or alcohol are impairing them or interfering with the evaluation that we're doing. So what are the experts say? Well, depends who you talk to. The American College of Emergency Physicians says routine urine drug tests and alert awake cooperative patients does not affect the ED management and need not be performed. And they also go on to say that the patient's cognitive abilities rather than their specific blood alcohol should be the basis on which clinicians begin their psychiatric assessment. And psychiatrists, on the other hand, from the APA say that, well, they may need to request or initiate further general medical evaluation to address diagnostic concerns that emerge from the psychiatric evaluation. In fact, they say that emergency docs and psychiatrists have different viewpoints. We need to do a better job. We need to work together. This diverging opinion is not good, not good for either specialty. So how do we reconcile all this question about testing? So most would agree, and I'll admit there's some debate, that we really should rely on clinical indications based on a medical assessment. That routine lab testings are not valuable. Should there be new onset? Yes, we should do a battery of tests. But chronic patients with the same presentation, really not helpful. Is advanced testing needed? Well, it depends. Again, coming up with deciding if it's clinically indicated, EKG, CT head, chest x-ray, et cetera. But what we really need to look for are those red flags of medical etiology, like I discussed before. If it's new onset, if they have altered mental status without a known etiology. Now, and sometimes I will agree that we need to accommodate the psychiatric facility. And if a psychiatric facility says, I need a CBC like in Illinois, because we get it once a week, and I'm concerned this patient has a history of anemia, and I want to make sure that I'm not dealing with anemia again. And in which case, yeah, it probably makes some sense to get some lab testing. So I'm going to talk about the clearance process a little bit more, and we'll talk about that. So this is the SMART clearance form. And on the right, goes through the topics, medical conditions, abnormal vital signs. So these would screen out to be properly medical evaluated and might need testing. And in fact, Tony's using this in Wisconsin, and the ones that need testing are those with new onset, have medical conditions that need appropriate screening, have an abnormal physical exam, have risky presentations, like maybe there was some trauma involved, they're caught in a car accident, or maybe we need therapeutic blood levels. Now, as we continue to talk about this issue about medical clearance, this is just one study that talked about this term medically clear. And the problem with medically clear is, I don't know what it means. I don't think it is definitive. And in fact, this Dr. Titnelli, who's well known in emergency medicine, says that we really shouldn't use that term, because we didn't cure their diabetes and hypertension. But matter of fact, we should probably use the term medically stable, or write a note on the chart. Here's the history and physical we did, here's the mental status exam neuro, here's what the labs demonstrated if we did do labs, and what they need in follow up, kind of what is important for someone who's going to care for that patient. So I want to go back to the two cases that we have. The first is a 64 year old female brought to the hospital for manic behavior. She has multiple medical problems, but no psych history. What prior psych site, she has no prior psych history, she has diabetes, hypertension, CVA. She doesn't use drugs. She has a history of tachycardia and hypertension. She has right sided weakness. She has heightened level of consciousness. So yeah, tests are indicated here. CBC, electrolytes, alcohol level, thyroid function, EKG, CT head, chest x-ray, etc. What's the diagnosis? Hyperthyroidism. Makes a lot of sense in this case. Now, before I go on to the second case, I wanted to bring up the use of another medical clearance protocol, because in fact, this is the one that was used on this patient that follows. That's case two that we're going to talk about. So does the patient have a new psychiatric condition? This is that 36 year old with chronic schizophrenia. So no. Does he have a history of active medical problems? No. We checked his vital signs and they're normal. We did a physical exam, nothing new. We did his mental status and he's pretty much at baseline. So using this protocol, which is one that we used in Illinois, if all these one through five are no, then one would say you don't need to be doing testing. So in fact, this is what we determined in case two, that based on that protocol, he didn't need any testing. And we use that sheet as a means to document it. And we then sent him to a psychiatric facility. So in conclusion, I wanted to go over this consensus guidelines that was published by Dr. Wilson and others. And just as a way to summarize it, the medical evaluation process. So recommendation one, to identify potential causative factors for their behavior, like we talked about the medical evaluation, that we need further value onset. And if we use criteria like our protocols, like the SMART protocol, advanced age, new cognitive deficit, something that's positive on review systems, substance intoxication or withdrawal. And we need to use the appropriate term as we talked about for medical clearance. We need to do vital signs, do a physical exam, assess mentation, do directed labs if necessary, work collaboratively, cooperatively with the psychiatric facility, collaborate with or review the vital signs, the history and physical exam. And the research on this isn't great. We need to do more about what's an appropriate medical evaluation. Thank you, Dr. Zun. That is a very helpful and a very important first part to this entire puzzle. As I spend the next 15 to 20 minutes focusing upon engagement issues, we cannot downplay how important that topic of medical clearance is or medical stabilization to use a more appropriate term. If not done correctly, it can throw off all the rest of this particular patient's episode. And we owe it to them to be at our best in all particular stages of this patient encounter. So with that in mind, let's talk about solutions for engagement. So kind of building off this idea that we've now had a subject matter expert in emergency medicine and psychiatric emergency medicine speak to you on how to handle the medical clearance point, I'd like to pretend now that we have moved past that. You're past the point or you're in the midst of creating the medical stabilization. It's a quick reminder to all of us that even though this is something we do every single day, for our patients, they are working with a variety of emotions that are actually going to work against engagement. Grief, anger, sadness, despair, paranoia, mania, all of these different things are going to be something we have to work around and or through to work with engagement and do so in a therapeutic fashion. So we're not just getting past the barrier, but doing it in a way that actually brings the patient over to our cause so we can get the best diagnostic information and treat in the safest way. So real briefly here, we're going to talk about how this affects patients, even just as importantly, how this affects staff and how if we look at some of these principles of engagement, we can actually end up providing support and treatment, which is a nice step up from what we had been doing in the past. In this, I'll also briefly touch on trauma informed care and psychological first aid and then we'll hopefully dovetail very nicely into how some of these principles will actually be picked up by Dr. Nordstrom as she looks at issues of risk, safety, and principles of de-escalation. So why do we even need to do this? Why are we talking about this in an ER psych 101 type of course? Well, most of the time that you're working with these patients in these scenarios, you've got limited space, time, and staff. We do have shorter hospital stays across the country, so we're getting out patients that are of a higher acuity. For a lot of our patients, there may be either a organic rationale for a fear of authority or even a traumatic historical reason for a fear of authority figures. Sometimes we are inheriting the patient after they've already had a difficult scenario with another external stakeholder and for some of our patients, their actual brain matter has been affected by their illness, which makes it difficult to engage and difficult to foster that rapport. There's also active psychiatric symptoms, continued stigma, which I think Dr. Zahn touched on very nicely earlier. There's still refusal of health systems to recognize psychiatric care as equivalent to other things such as neuro and obstetrics, and kind of an overall issue and belief that everything is psychiatric. In other words, this isn't a medical emergency. Why would I spend any time developing rapport and therapeutic interactions? So just remember all of this as we proceed through the next couple slides. Anybody when having one of these particular days is going to have a lot of things going through their mind, and it's on us to recognize that. We've got to think neuroanatomically. When you're in crisis, your frontal temporal system has likely taken a nap, and this is functioning from a much more primal system. As such, one of the nicest things we can bring to people is our frontal lobes, our kind of capacity for processing and walking through topics when they're having such a difficult day. Now I'd like to credit this next two particular slides to a previous mentor of mine, Dr. John Berlin, also a past president of AAEP, who really showed me this in a presentation once and it's stuck with me ever since. I think it's a principle that any scope of practice can use. It just seems somewhat antithetical in the field of medicine, which is the idea of seek first to understand, then to be understood. Now, what do I mean by this? Well, in most of medicine, we are often trained as physicians and as leaders to go in there and start giving our thoughts and our diagnostics and our impressions, and that is all fine. That is what you're trained for, and you're specialists in that. However, when somebody is in crisis, particularly a psychiatric crisis, you may need to slow that a bit. It is not always in your best interest to come at people with what you think they need, and we'll talk about this a bit more with psychological first aid, or PFA. What you really want to spend your first five to ten minutes is what do they need? You may already know and have an idea of the type of information you need, and you're in an emergency department and you're thinking about throughput and wanting to move things quickly, but in reality, taking a couple moments, slowing down, and trying to see what they need first. Can we talk? What do you want? What are the things I can give you versus the things I cannot give you? There has to be therapeutic limit setting as well. Then, once you've had a chance to hear what they need, which are often very basic needs that you can accomplish in a short period of time, then you want to share with them the things that you bring to the table. Once you've identified your own automatic feelings and kind of gotten your feet under you, then you can start talking to the patient about, hello, I'm Dr. Thrasher. I'd like to help you through some of this. Let me give you some thoughts on what we can do, but I would never start with that. I would start with, it looks like you're having an incredibly difficult day. How can I help? Then, be quiet and listen. Even if you think you know what's going to be said, spending those early moments, those first impressions, trying to see what they need first, even though you may already think that you know the answers, goes a long way in establishing rapport, and I think, as Dr. Nordstrom will echo later, also aids in de-escalation, if so applicable. A couple concepts I list here that we're going to talk about later are psychological first aid and trauma-informed care, because both of those tie very nicely in the seek-first-to-understand-and-then-to-be-understood dynamic. Now, to that point, psychological first aid, or PFA. The nice thing about PFA is it really assists both the patients and the consumers and the providers. It's very much a dual agency that can be synergistic. It was developed in response to focus on debriefing issues, so for those of you that have been in the EMS field before, or law enforcement or fire, you're probably familiar with CISM and CISD, different modalities, but PFA has really looked at trauma research, and particularly that focusing not just on risk, but also on resilience. It's very culturally diverse. It works in a variety of populations across age spans, and the big take-home is there at the bottom. When we are using PFA, we're trying to not just reduce the initial distress that you're having, but also build that resilience and foster whatever adaptive functioning you have. In other words, it's not just, well, here I am, let's see what I can do to you. It's here, how can I help you and help the inherent things that you have inside of you lead to more adaptive functioning and coping? It's very strengthening. It's very positive in all aspects of mental health. So you're looking to make a human connection. You want to do it with compassion and without being intrusive, as we already mentioned. One of the best things you can do is let people tell you what they need, not what you think they need. You connect them with resources, support what they've been doing. For a lot of people, that's what I spend those first two to three minutes doing, is acknowledging all the good things they've done to get here so far. You'd be surprised how often emergency room visits start with the opposite, which is, why didn't you do this? Why did you wait so long to come in? Why was the medication not taken? It helps to start up front with some of the positive aspects. And once again, for those of you with some psychological background, think of Maslow's hierarchy. For a lot of people, we want them to start talking about the things at the tip of that hierarchy, how you're thinking, how you're feeling, what your plans are. But in reality, we got to cover the basement first. You got to get to that first floor. You have to make sure they are fed, they are feeling comfortable, and they are feeling safe. And by doing those very simple humanity things, I think you'll find that people tend to respond better to you and also eventually take your medical advice much more sincerely. Now, things to avoid with PFA. I've seen very well-meaning individuals that want to assume that they've been through it too. Can I share my experience with you? And sometimes that works, but a lot of times it doesn't. And it's nothing personal. It doesn't mean that your experience is not important. It means that when people are in crisis, they're in their crisis. And unfortunately, when people are having horrible times, they don't often like to hear that they're one of many. They like to know that their particular situation is different, and it is special to them in both good and bad fashions. Don't assume that everybody's traumatized. This is another big mistake, is if you look at the data on trauma and resilience, many people are exposed to horrific things and never develop PTSD. So what we want to do is we want to educate. We want to give resources and warning signs to keep an eye on. But by no means should we lead with, well, now you're going to have PTSD. Let me sign you up for therapy. And to that point, a big point of PFA is not making things diagnostic and part of pathology. That really gets patients very, very concerned. And once you mention a diagnosis, you then kind of close the conversation to only that diagnosis, which doesn't assist with rapport building. It doesn't assist with de-escalation. It doesn't assist with getting the best information from an interview. Now, who supports the PFA? Just so you know, it's not just me giving you my personal thoughts. Just about every large organization out there. The big ones being the Red Cross, International Olympic Committee, SAMHSA, WHO, NIMH, et cetera, et cetera. This has really replaced debriefing as a formality in most places with some exceptions of law enforcement and fire. Now, trauma-informed care is another one that we should really just touch briefly upon. And this is an important one, not just for your patients, but for your staff. It's a good reminder that at least 50%, most numbers would say higher, of people that present to a public mental health system, such as an emergency department, such as a psychiatric emergency room, probably have had significant trauma in their past. And this goes for your staff as well. So a lot of times when I'm working with complicated cases, the patient themselves may actually do very well, but the staff that works with them are severely affected by the trauma the patient had because it reminds them of something in their own past. So you want to really make sure that when you're doing a trauma-informed care model, you are not repeating the same questions. You are not making them go over sensitive information more than once. Inherent in this is something I think we all know, which is you try to minimize restraints and hands-on behaviors, because when you've been traumatized and you're having a horrible day, the last thing you want to do is have to do that unless it's absolutely the least restrictive intervention at that particular point in time. So for the patient, try to find templates in your EHR so you're not repeating questioning. Do a nice fluid interview. Don't feel that you have to make somebody tell you everything right up front. Spend 10 minutes, move on another patient, come back, spend another 15 minutes. Give kind of the rhythm of the intervention and the rhythm of the interview to the patient, so to speak. Understand that every interview has some degree of compromise and negotiation. Those aren't bad terms. This isn't a zero-sum game, and if you're trying to make it zero-sum, then you're probably going to head down the road of mandating and controlling, which will probably undo all the good work we've been talking about. And for staff, I think one of the best things you can do is educate and support. Support them after difficult restraint episodes or difficult hands-on components and teach them different things. You'd be surprised how quickly staff really take to important information you can do on therapeutic ways to interrupt a patient, how to say no with compassion or empathy, or one of my personal favorites, service recovery. Teaching them proper ways to kind of express an apology to a patient that they're not feeling well-treated, it doesn't mean that you yourself actually did a wrong. That is a really professional way of handling things that is very useful in an emergency department setting. Now, we couldn't talk about this without talking a little tiny bit about the law and ethics. So for these last five minutes, I want to touch on this. When focusing on this particular area of engagement, there's some unique things that pop up between emergency presentations, crisis presentations, and psychiatric illness. First off, in most states, you're going to see a much higher percentage of involuntary cases, which already is putting you on a very difficult footing as a physician, or vice versa, which is the assumption that they should all be involuntary, and when somebody's dealing with a voluntary person, they're having a hard time handling some of that ambiguity and complex high-risk discharges that may occur from that as well. So patients are being primed not to be interactive, and they honestly, if they're under an involuntary hold, have a right to not be as interactive. They may see that as legally protective, and most state statutes allow for that. They're feeling stressed just from having their rights taken away, and a lot of our patients have been traumatized in the courts. So while this particular court proceeding we may see as therapeutic and helpful to help decrease the suffering from their mental illness, it may not be perceived that way by our patients. So be very cautious as you approach these cases, particularly from some of these ethical conundrums. So to do that, brief review on psychiatric ethics. One slide. These are your four big principles, right? We want to do what's good, beneficence, respect the person, autonomy, try to avoid doing any harm to the patients, non-malfeasance, and then have some equity and access and provision of care, such as justice. Now the hard part is there are some things that are at odds here. Those four things don't work together synergistically, unfortunately. When you have autonomy and beneficence, you have these two quotes kind of affecting each other. I want to help you, and that may mean making certain decisions in more of a paternalistic time frame. However, I also respect you and want you to live your life. How do you make those two work together? How do you make those two work together when I mentioned the interesting concept that we often see in psychotic illnesses of anosnosia? How about other systemic tensions? There's a big one between non-malfeasance and justice. For non-malfeasance, how are we placing patients in an involuntary pathway? Are we treating the patient or are we treating ourselves? Are we treating the patient or are we treating our systemic anxiety and some misplaced sense of liability? Versus justice, are we truly using this as a least restrictive pathway or are we doing it to try to get people care? Are we doing it because we perceive it to be a mitigation of risk, which to be fair, is very rarely the case. So a column I did for the Psychiatric Times back in January that I just want to comment on for these last three slides, really focus on when you're doing an interview that focuses on engagement, these are some concepts to consider. First off, you got to keep your medical knowledge up, reference Dr. Zun's earlier commentary. You have to be good at risk management, and I think what's hardest with engagement is number three, being good at multitasking and time management. Unlike other areas of practice, we don't get to delay these. We can't do number one now and do number two and three later. All three have to be done in that moment, and that places a rush on you which can accidentally affect your engagement with the patients. So let's look at some other concrete thoughts. First off, when you're going to establish that rapport, you really want to focus on your initial interaction, which I think we've talked about a bit with TIC and PFA. Don't be afraid to utilize service recovery, which once again is not apologizing for you, it's apologizing for how the person feels and acknowledging that I'm sorry that you were feeling that way or feeling like the system or even me in particular, I'm not helping you, but I would really like to help you and like you to understand that I'm trying to help you. So what else can I do? It's a really nice way to compromise and engage in their feelings as opposed to the way that you think they should be feeling. Too often a patient's anger can then kind of anchor us in a position of defensiveness, which is then not productive to the rest of the interview. And there's a lot of psychodynamics here. You've got to understand your own counter-transference towards certain patients, defense mechanisms of the patient so that you don't feel offended when you start to see some less mature defense mechanisms coming your way, which are very common during crisis episodes. And something that's so important is a well-done interview is treatment. I agree we don't bill for it. I agree it has not been captured very well yet in the literature, but the very idea of proper interviewing and doing so, taking into account all these different techniques, it's not just good for de-escalation and diagnostics. It's good for treatment. People feel better when engaged by this. And that's why you find so many patients that do better with certain physicians versus others. If you could look at some of the common characteristics those physicians have that they employ during their interviews, I would not be surprised to see a lot of crossover with the previous slides. So with that being said, I really appreciate your attention to my thoughts on engagement with the patient, finding ways to respect and to balance all these different tensions, particularly when under a very condensed timeframe. With that in mind, I would like to turn it over to our next subject matter expert, Dr. Kim Nordstrom. Good day. I'm Kim Nordstrom. I am an emergency psychiatrist and an associate professor at University of Colorado, Denver. Thank you, Tony, for those remarks. In fact, my section really follows his so nicely because I'm talking more about that assessment and then into treatment. And I have to do all of that in 20 minutes or less. Let's see. Let's see what I could do here. Key pieces in emergency treatment. Well, the one thing that you have to understand is that treatment begins immediately. So as Dr. Thrasher was saying in his, when the patient first walks in, it's not all about our speaking. It's about our seeing, our acknowledging what's happening. And we may use verbal de-escalation immediately. We may just give some supportive therapy. This is even before we're starting anything in the assessment realm. And treatment's necessary to fully assess a person in a crisis situation. So we may go back and forth between treating and assessing throughout the patient stay, you know, and this could be in the inpatient setting, outpatient setting, or in our setting, which is the emergency setting. Using medication, it definitely has its place, but it's only one tool in the toolbox. And that's really what makes us stand out, is that we have so many other tools. In treatment, the focus is, of course, it's the underlying issue. There may be agitation that happens during the course, and then any secondary symptoms. So I was asked to speak about safety and emergency treatment, and I thought, oh my goodness, what am I going to talk about? There's so much to talk about. I could easily do this in an eight-hour presentation. And so we treat all the same things in the emergency setting that are being treated in the outpatient setting. It's just that the patient is currently in crisis. So for an example, psychosis, there's not just one treatment. First, we have to figure out, is it a known disorder with exacerbation? Is it new-onset psychosis? Is it substance-induced psychosis? Or is it a medically-induced psychosis? So delirium. Of course, all those treatments will be different. And I could say the same for all the other disorders that are common in psychiatry. When I'm asked to do this talk, though, people usually want to hear about agitation and suicidal ideation. How do we treat these patients? Because the one thing that we've studied over time is that when patients come to a psych emergency service, we're usually able to discharge about 76% of them. And they all come in in crisis, and many of them come in involuntarily. If we're able to do that, that means that you can treat suicidal ideation, even in a short-term setting. You can bring someone who is, frankly, agitated, de-escalate them, safety plan, and help them get back into the outpatient setting. I'm going to start out with the suicide. How do you treat suicide in the emergency setting? Well, first off, you have to do a full suicide risk assessment. And I know that hospitals are in love with the Columbia Suicide Severity Rating Scale. They love it. If you have an EHR, many of the hospitals have thrown at least a version of that scale into your EHR. But Columbia is really just the suicide inquiry. It's very important that you do the full risk assessment, which includes current risk factors, as well as protective factors. Now, there are many different tools out there that help you think about the full suicide risk assessment. The SAFE-T tool has been around for quite a long time, and you can still find it on the suicidepreventionlifeline.org website. And it stands for Suicide Assessment Five-Step Evaluation and Treatment. And it takes you through really what we're going to talk about now, identifying risk factors, identifying protective factors, looking at the current or conducting a current suicide inquiry, determining level of risk, level of intervention that's necessary, and then, of course, documenting all of that. A newer tool that has come out, and it's actually, it was made for emergency physicians with a joint work group between the American College of Emergency Physicians and the Suicide Prevention Resource Center. This tool can be found on the ASEP website. And even though it was made for emergency physicians, it's a great tool and can be used by anyone. And basically, it follows this mnemonic of eye care, identify suicide risk, communicate, assess for life threats, risk assessment, reduce the risk, and extend care beyond the ED. Each part of that mnemonic has drop-down. So I took a quick picture, screenshot of the identify suicide risk. And I did that because I wanted to show you that if you look at the bottom of that, you will see that we have embedded screenings. And then when you get to reduce the risk and extend care beyond the ED, there's also other types of embedded forms that can be very useful for safety planning and things like that. So these are two really good tools. And in fact, this particular citation at the bottom here, Lifeline placed the suicide, the Columbia Suicide Rating Scale into a larger risk assessment. And this has a very nice PDF, and it's right there at Suicide Prevention Lifeline. So getting beyond the Columbia. So the Columbia or any of these tools, they're great for reminding you of important pieces that you need to follow through on and to assess during your assessment. So they're forms where you check a box. That in itself is not sufficient. So when you're asking about suicidal ideation, you have to go deeper. You have to say, they say, well, yeah, I'm suicidal. I'll shoot myself. Oh, okay. Do you have a gun at home? Would it be easy for you to obtain a gun? You have to go deeper to really see how much the patient has thought about it, how easy it is for that patient to actually follow through. Those are all very helpful in determining risk. And understand the patient's past. You know, of course, not all self-harms are actually past suicide attempts. So you may say, you know, I see in the past you cut your risk. Were you trying to kill yourself at the time? Oh no? Then what were you doing? It sounds like it benefited you in some way. Can you explain that to me? It's all about understanding the current patient in front of you to help determine that person's risk. So risk factors. There are two different large groups in terms of risk factors. You have your static risk factors, and those are basically your demographics. And those are very, very helpful when we're talking about global risk, right? So we have a divorced 60-year-old male. And globally, that person is at higher risk than maybe, you know, a 25-year-old woman who's in a, you know, a nice healthy relationship, right? That's global risk, but it doesn't really tell you anything about the patient. So it's important to know that that person may be at a little higher risk, but you really have to go a lot further than that. And that's where we really spend a lot of time with the dynamic or modifiable risk factors. Can you mitigate the risk? And so some of the examples around risk factors that you can mitigate include intoxication, gun ownership, a family dynamic issue, a person who came in totally overwhelmed by some life event, life stressor. These are all things that given a little time, given some education, given some supportive or solution-focused therapy, you can mitigate even in a crisis setting. So for intoxication, it's as simple as giving time to sober, though that does not in itself mean that the person is no longer at risk for suicide. And in fact, they may be at a little less risk when they are sober, but if the thought is this person has an alcohol use disorder and is going to go right back out and drink again, you haven't done too much. So you have to bend safety plan around where the patient is currently at. We also spend a lot of times talking about protective factors. And again, you can see these on a nice form, you can check them off. Yeah, the person's religious. Yeah, that doesn't mean anything. There was a study done back in the 80s and looked at religious beliefs as a protective factor, and I found it to be intriguing. And what they found back then is that a person who has strong Catholic beliefs, and in that case, the person with those beliefs felt that there's purgatory or hell if the person completed suicide, and that in itself was protective. But you had other Christians who were interviewed, and I believe one group were Baptists, and they said, well, you know, God understands, God has grace, and God knows that I'm in such a bad state that suicide was my only option, and so I'll be forgiven. So religion of itself is not protective, or particular types of religion is not protective, it's the actual beliefs of the person sitting in front of you that can be protected. Responsibility to others, it could be children's pets, it could be aging parents, it's any form where the patient truly feels responsible. Engaging in treatment, two ways that that could be protective, a belief that treatment is helpful in the big picture, and the belief that someone actually cares about the person. The belief that death may cause pain to others, and then really understanding the support system. So why do we care about these protective factors? So even in a crisis setting, what we're doing is we're trying to put a spotlight on these protective factors, have the patient think about them, because when they came in, they weren't thinking about protective factors, they weren't thinking about the good in their life, they were overwhelmed, they were so focused on needing to die, and so we're giving some pause, and we're having them think about these things. And then we want to discuss, we want to engage the thoughts around these factors, and then if possible, we want to bring in any natural supports. So interventions, I talked a little bit about this already. Sobering or sleep, if the person's in a withdrawal dysphoria, so think about stimulant withdrawal, they tend to be at a higher risk for suicide. If it was related to a family dynamic issue, having a family meeting, yes, we have family meetings and family therapy, even in the emergency department, and it can be quite successful, especially since everybody's emotions are raw, people tend to just be a lot more honest and put things on the table. So it can be very successful. Shoring up natural supports, like I talked about before, and then of course safety planning, and then if you could bring supports into the safety plan, either have a support come in and have a role in that safety plan, or have the support on the phone, that really helps solidify the safety plan. And then of course, lethal means counseling. As I said earlier, we tend to discharge a lot of patients. We try to keep patients out of the hospital. In fact, we think of the hospital many times as last resort, because for many, going into the hospital itself can be traumatizing. So what is it that I can do that's outside the hospital? Well, can I help increase outpatient services? Can the person have increased contact with their team that's already in play, the maybe care manager, therapist, or physician? Do they need something more intensive, like an intensive outpatient? Do we have short-term crisis services available, like a crisis stabilization unit where they can stay there? Those tend to be more therapy driven, you know, stay there for a day or two. Talk about levels of care. I always start at the bottom. I'm always thinking, how do I get the person back around their natural supports, back in the community, use the resources they currently have, and maybe add to them? And then from there, I go up. You know, like I was saying before, crisis stabilization units, or short-term residential, subacute, high intensity. So if you have acute treatment units available to you. And then again, last resort, I do have to use inpatient. There are some, you know, plenty of patients that I am unable to safely discharge, but I really think of this as a last resort. So that is the fastest, quickest, in a nutshell, review of safety, when we're talking about safety planning, the suicide risk assessment, and how to mitigate risk. I'm going to turn our attention now, again, I only have a few minutes, so I'm having to talk fast, but we're going to turn our attention to agitation. So first off, we have to have a definition in common. I really like this one from Lyndon Mayer. It's old, but I use it a lot because I think it is telling. Many people will say, well, I know agitation when I see it, but they do have difficulty really describing agitation. So the core features of agitation are restlessness with excessive or semi-purposeful motor activity, irritability, heightened responsiveness to internal and external stimuli, and an unstable course. I underlined external here, because this is what we were talking about. You've heard both Dr. Thrasher and I say that, you know, you start treatment or you start this process right when the person comes in, before you even say a word. If I have somebody who's agitated who's first coming into the ED, I'm going to try to minimize external stimuli. What are things I can do? Well, we have terribly bright fluorescent lighting. Can I dim the lighting? If I know a person is already agitated, can I try to get them in a quieter room away from a lot of the beeping and those kinds of noises? Do we really need to have five people rush on the patient as soon as they get there, taking belongings and doing blood pressures here and talking to the patient there? Like, do we need that chaos? Well, that's the worst thing for an agitated patient. And aggression is not a core feature, but it is known to be related. So you stand in front of a door and the person is having fight or flight, they may bowl you over in order to get out. It has nothing to do with you, right? So I see aggression usually as semi-purposeful. Treatment. Think of all those things that are not pharmacological. Start out there. What are things that we can do? Well, de-escalation techniques. I feel like psychiatrists should be black belts in de-escalation. If somebody has dementia, having cues, having cues available for the patient. What do you think the source of the agitation is? Could it be delirium? You have to treat the source because otherwise you'll keep de-escalating the patient, but they'll become agitated again. And then of course, think about pharmacologic treatments for agitation. So I'm going to jump right into de-escalation. These are the 10 commandments of de-escalation. And this citation, as well as the citation on the previous slide, are great. They go into each of these pieces of de-escalation. Some of them are intuitive, some of them less so. So respecting personal space, not standing over the patient. They're already feeling out of control and a doctor or a team, the patient's in the bed, a doctor standing over them only makes that lack of control feeling worse. This is my problematic one. Do not be provocative. I am sarcastic by nature. I have to leave that outside the door. I have to be very mindful of every word I use and, you know, how I approach the patient. Establish a verbal contact, be concise. If somebody is highly agitated and you say something, they don't tend to, they're not responding. So then you say the same thing again, but in different words, they're hearing two totally different things. All right. You're further giving external stimuli to that agitation. So if you need them to do something, say the same words again, but give them a little time to process. Remember their brain is really firing on all cylinders. For the patient who's a little less agitated and can have a conversation with you, identify wants and feelings, agree or agree to disagree. When they're talking to you, listen closely to what the patient is saying and show that you're listening. You have to lay down limits though, that's necessary. I try early on to offer choices. When somebody is feeling out of control, they feel like all of this is happening to them. So if I can put choices out there. So if we're talking, I say, you know, in times like this, what's helped you in the past? And inevitably they say, I'll prazolam. And, you know, I say, well, you know, I'm not able to give you that, but I can give you this or this. Would either of those work for you? Have you used either of those in the past? And you let them make some decisions and then debrief the patient. Now this does not go against psychological first aid. What they mean here really is about supporting the patient. When somebody has been really out of control, it's extremely scary and you just want to give them support. This is a ridiculously busy slide. I have it on here for one particular reason. I want to show you that in the pharmacologic treatment of agitation, there is not a box at the top that says agitation. And then a box at the bottom that says held all Ativan Benadryl B52. No, what this slide shows is that there are many different reasons for agitation and different treatments based on those reasons. And it's really important that, you know, if you can figure out an etiology right from the beginning, that you give the appropriate proper treatment. To see more about this, you can look at this citation or you can just Google Beta, capital B E T A, agitation, psychopharmacology, and you'll get this article. Everybody always asks when I do any type of treatment, especially around agitation, they want to know about the newer alternative agents. And so just a quick slide on why would you choose one versus another? Well, it's all about where the medicine gets absorbed. So timing, right? Anything that you swallow gets absorbed in the gut. So even though we have orally disintegrating olanzapine and risperidone, they get absorbed in the gut. So they orally dissolve in the mouth, you swallow absorbed in the gut that goes through first pass metabolism. It's no quicker onset than regular PO olanzapine or risperidone. We have sublingual asenapine. So that is faster, right? It gets absorbed right there in the mouth. It doesn't go through first pass, but what's the problem here? Well, you have to have a very educated nurse or whoever's going to be giving the medicine, understand that the person has to fully let it dissolve and absorb in the mouth. If they swallow it, it is less than 2% bioavailable. And you can't eat or drink after the administration of this med. And so it's really hard to break the habit of bringing in a medicine and a glass of water. And so you have to be very mindful if you use that, but it is so much faster. And then there are different ways to get midazolam into the system. So again, sublingual or even intranasal, intranasal is even faster. Midazolam though, it's used more in Europe and in the States where I see it most used is for pediatric dentistry. But it is a lot faster. And then I was very, very excited when inhaled loxapine came to the market. I wrote a bunch of articles on it. I was really waiting for it. IV pharmacokinetics, you get that medicine into the person so quick, but it came in with a really restrictive REMS and it is super expensive. So the REMS has lessened over the years, but it is still pretty price prohibitive. So conclusions on treatment, general. Treatment starts the moment the patient comes into your setting, whatever it is, and be thinking about you are treating when you're using supportive therapy, when you're using solution focused therapy, when you're using any of those 10 commandments of deescalation. Suicide, it begins with a good risk assessment. So you're not going to be able to mitigate risk until you really understand the patient and the patient's protective factor, the patient's risk factors. What can I help modify? Be thinking that, be thinking what is the least restrictive next step in care? And then agitation. Psychiatrists should be black belts in deescalation. There's no one medicine to treat agitation. Thank you for your interest. Thank you, Dr. Nordstrom. And once again, thank you, Dr. Zun. We are very fortunate to have such qualified speakers on this topic. And personally speaking, these are two individuals who have mentored me in a lot of my career work, particularly with the AAEP. So it's always wonderful to share any time with them, particularly on a project of this importance. So in closing, I hope you've gotten taken away from this, that there is so much more to treating patients that are in a crisis, particularly when you have this overlap between the emergency medicine world and the field of psychiatry, that there's a lot more to this with nuance. There's a lot of things to learn. I would argue that every one of our three sections could be four hour talks in of themselves. So there's a lot of good things you can educate your teams on or your own individual skillset, so to speak. And what we tried to focus on were on these particular areas. First off, just treating patients that are in emergent settings is challenging. We need to call that out and own it so that we can do better with our current healthcare delivery system. Secondly, by focusing on these three specific topics, proper medical evaluation, therapeutic engagement, and looking at best practices around safety, you are going to help not just your patient, not just your system, but your team, your staff, and you. And that leads to better employee retention, recruitment, and satisfaction, which is better for the whole system in general, which then once again affects patient care. And then lastly, we understand that these are all much larger topics. I think I heard you, each one of us mentioned that somewhere in our talk, that there's so much more on this we could share. If you or your organization or any of your teams have interest in talking with us further, I've included our contact emails below, so you could reach out to us directly. A couple last things on AAP, since you've been so nice to share your time with us. One of our favorite things that we do every year, started by Dr. Zun some years ago, is known as NUBE, the National Update on Behavioral Emergencies. This is our annual conference. It happens just about every December, and it is pound for pound the best conference that I attend, and I attend a lot of conferences. It's a very high educational impact, with the majority of our talks being 15 to 20 minutes. The idea being that you get a lot of high-yield information. It's also a great place for benchmarking and networking amongst other like-minded individuals, and setting up projects at the national stage. So if you have interest in that, we will have more information out soon, but I wanted at least to give you the dates that will be coming up in early December in Las Vegas, Nevada, with AAP at our annual NUBE conference. Once again, thank you for your time, thank you for your attention, and most importantly, thank you for your service to our patients. This is an immensely important topic that has ramifications outside of purely the world of psychiatry and emergency medicine. If myself, Dr. Zun or Dr. Nordstrom can be of any assistance, please reach out to us directly, and we will make sure to get back to you ASAP. Thank you very much. Have a good day.

ER Psychiatry 101

emergency psychiatry

medical clearance

engagement with patients

handling risk

agitation

Dr. Zun

Dr. Nordstrom

evidence-based recommendations

practical solutions

triage process