Psychiatric Emergency Crisis · symptoms dissipate with return of their blood alcohol level to normal • Psychiatric symptoms attributed to toxins, in association with a positive

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© 2017 Otsuka Pharmaceutical Development and Commercialization, Inc., Rockville, MD

Otsuka Pharmaceutical Development & Commercialization, Inc. Lundbeck, LLC.

January 2017 MRC2.CORP.D.00192

Psychiatric Emergency and CrisisAhmed Nizar, MD

PsychiatristSt. Joseph’s Hospital Health Center

Syracuse, NY

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This program was developed with the support of Otsuka Pharmaceutical Development &

Commercialization, Inc. and Lundbeck, LLC. The speaker is either an employee or

paid contractor of Otsuka Pharmaceutical Development & Commercialization, Inc.

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© PsychU. All rights reserved.


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Ahmed Nizar, MD

Position: Dr. Nizar is board-certified in psychiatry and neurology, and serves as Medical Director of the Comprehensive Psychiatric Emergency Program at St. Joseph’s Hospital Health Center in Syracuse, NY.

Education: Dr. Nizar received his MD from St. George’s University School of Medicine in Grenada and completed his psychiatric residency at SUNY Downstate Medical Center in Brooklyn, NY.

Speaker Profile



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• Acute disturbance of thought, mood, behavior, or social relationship that requires an immediate intervention as defined by the patient, family, or community

• A set of circumstances in which:– The behavior or condition of an individual is perceived by

someone, often not the identified individual, as having the potential to rapidly eventuate in a catastrophic outcome

– The resources available to understand and deal with the situation are not available at the time and place of the occurrence

Allen MH, et al Report and Recommendation Regarding Psychiatric Emergency and Crisis Services: A Review and Model Program Descriptions. August 2002. Available at: http://www.emergencypsychiatry.org/data/tfr200201.pdf. Accessed December 2016.

Psychiatric Emergency: Definitions



• Deinstitutionalization in the United States (US) since the 1960s has resulted in a decrease in availability of inpatient services1

– Inpatient beds decreased from 400,000 in 1970 to 43,000 in 20101,2

– In 2010, only 28% of the number of beds considered necessary for minimally adequate inpatient psychiatric services were available across the 50 US states2

• Fewer options for patients experiencing acute psychiatric exacerbations because of a shift toward prevention and maintenance in community outpatient clinics1

– Psychiatric visits to the emergency department almost doubled from 2001 to 2007 (6.3% to 12.5% of 95 million visits to the emergency department)

• A 2007 study of data from the Healthcare Cost and Utilization Project reported that 1 in 8 visits to the emergency room were related to a mental health or substance abuse condition3,4

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1. Halmer TC, et al. Emerg Med Clin North Am. 2015;33(4):875-91.2. No Room at the Inn. Treatment Advocacy Center. 2012. Available at:

http://www.treatmentadvocacycenter.org/storage/documents/no_room_at_the_inn-2012.pdf. Accessed January, 2017.3. Jensen and Clough. Nurs Clin N Am. 51 (2016) 185–197.4. Owens PL, et al. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs Website. Agency for Healthcare Research and Quality (US);

2006-2010. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb92.pdf. Accessed December, 2016.

The Number of Patients Requiring Psychiatric Emergency Services Is Increasing



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1. Gerson S, Bassuk E. Am J Psychiatry. 1980;137(1):1-11.2. Zeller SL. Primary Psychiatry. June 2010. Available at: http://primarypsychiatry.com/treatment-of-psychiatric-patients-in-emergency-settings/.

Accessed December 2016.3. Allen MH, et al Report and Recommendation Regarding Psychiatric Emergency and Crisis Services: A Review and Model Program Descriptions.

August 2002. Available at: http://www.emergencypsychiatry.org/data/tfr200201.pdf. Accessed December 2016.

Treatment Model2,3

Comprehensive services that both triage AND provide comprehensive assessment and a broader range of services

Triage Model (Historical Model)1,2

Rapid evaluation, containment, and referral

Replaced by

Psychiatric Emergency Service Models



*In that order.

Riba MB, et al (eds). Clinical Manual of Emergency Psychiatry. Second Edition. American Psychiatric Association Publishing; 2016.

Psychiatric emergency objectives include:

Assure safety for all

Rule out acute medical causes of presentation

Address concerns of patient in calm environment

If not helped, use de-escalation, medications, and seclusion and restraints*

Develop a comprehensive treatment plan

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Psychiatric Emergency Objectives

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Emergency psychiatric symptoms:- Medical condition- Substance abuse (and withdrawal)- Psychiatric Illness

Patient’s premorbid functioning

Alcohol/substance abuse

Recent injury

Presence of any neurologic symptoms including confusion, slurred speech, focal deficits,

ataxia, headache, and incontinence

Medical history and medication

use

Review of systems should emphasize

organ system malfunction

associated with behavioral changes including endocrine,

hepatic, renal, pulmonary, and

neurologic systems

Previous psychiatric

history

Reischel UA, Shih RD. Hospital Physicians. 1999;35(10):1-10.

Assessing Emergency Psychiatric Symptoms



• Move the patient to a large quiet and open area with minimal items which can be used as weapons1

• Speak in a calm clear voice1Verbal

• Offer oral medications first: allows patient choice and gives perception of control1

• If oral options are not effective or feasible, intramuscular medications, including anxiolytics, sedatives, and antipsychotics can be used1,2

• Sublingual and inhaled medications can be used as well1,3

Medication

• Less intrusive• Padded rooms allow a safer environment with minimal patient

injuriesSeclusion

Restraint• Most intrusive: patients are physically strapped to a bed1

• Continual monitoring by trained medical staff and frequent assessment by physician is critical1

• Always used as a last resort1

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1. Riba MB, et al (eds). Clinical Manual of Emergency Psychiatry. Second Edition. American Psychiatric Association Publishing; 2016. 2. Nuss P, et al. Ther Clin Risk Manag. 2007;3(1):3-11. 3. Lesem MD, et al. Br J Psychiatry. 2011;198:51-58.

Treatment Options



• History of illegal drug use is important to note, as drug intoxication is often misdiagnosed as an acute psychiatric illness – Patients with psychotic illness have a high incidence of coexisting

substance abuse

• Because substance abuse may potentiate mental symptoms, elevated alcohol levels and positive urine drug screens may affect emergency department decisions regarding patient disposition– Patients intoxicated with alcohol often require higher levels of behavior

management while undergoing evaluation in the emergency department• Such intoxicated patients have lower admission rates because their psychiatric

symptoms dissipate with return of their blood alcohol level to normal

• Psychiatric symptoms attributed to toxins, in association with a positive urine drug screen, may result in admission for substance abuse/substance induced mood disturbance, rather than for functional mood disorder

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Reischel UA, Shih RD. Hospital Physicians. 1999;35(10):1-10.

Substance Abuse Considerations



Cause Clinical presentation

Acute cocaine / stimulant intoxication

Tachycardia, dilated pupils, irritability with or without psychosis, which can present as almost entirely similar to schizophrenia-like symptoms. Cocaine effects usually time limited, as opposed to PCP or amphetamine psychosis, which can persist longer

Benzodiazepine / barbiturate withdrawal

Similar to alcohol withdrawal, but may not show vital sign changes, and may present solely as a delirium with or without tremor. High risk of seizure

Delirium Waxing and waning level of consciousness, fluctuation in vital signs, confusion. Can be irritable or passive and detached. More common in the elderly or medically frail patient

Delirium tremens All signs of delirium, with or without tremors, with or without hallucinations; intense fluctuation in vital signs. Last drink of alcohol 24–72 hours prior

Hypoglycemia Altered mental status with sweating, tachycardia, and weakness

Postictal states Altered level of consciousness, confusion, ataxia. May have Todd paralysis or other residual neurological signs, such as slurred speech. May have evidence of tongue biting or incontinence from prior seizure

Psychosis / mania /primary psychiatric disorder

Not usually associated with disorientation. No waxing and waning level of consciousness, no vital sign changes. Look for other signs of psychiatric illness or history of same

Structural brain abnormality Varies by lesion, but altered mental status with headache, meningeal signs, focal neurological deficit (eg, agitated patient who wants to leave but cannot walk), or progressive neurological deterioration

Toxicologic emergency Varies by substance, but ingestion of toxic substances can lead to mental status changes. Watch for pupillary changes, sweating, vital sign changes, or other signs of medical illness

Riba MB, et al (eds). Clinical Manual of Emergency Psychiatry. First Edition. American Psychiatric Association Publishing; 2010. PCP, phencyclidine.

Common Causes of Agitation in the Emergency Department Setting

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• Ask staff about patient’s behavior while waiting for appointment– If calm and cooperative, clinician may elect to interview following standard

hospital safety protocol– If agitated, additional precautions may be warranted, such as:

• Having staff member present during interview

• Conducting interview in a large, quiet area

• Directly addressing agitation by offering food, water, or oral medication

• Before engaging an agitated patient, the clinician should first determine:– Patient’s basic physical characteristics and presenting complaint – Whether patient is upset about an issue versus psychotic/disorganized– Patient’s behavior (eg yelling, making threats, throwing things) – Indicators of agitation cause (eg obvious illness, intoxication, head trauma)

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Assessing Agitated or Violent Patients



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*Depending on institutional and state regulationsKozub ML, Skidmore R. J Psychosoc Nurs Ment Health Serv. 2001;39(3):32-8.

Interaction and redirectionDirect staff interaction with patient and directing patient’s emotional response to an

acceptable mode of expression

Setting limitsAllows patient to choose a response based on stated consequence of escalation of

behavior versus de-escalation

Time outRemoval of patient from stimulating or reinforcing environment for a short time to allow the

patient to regain control of his or her thoughts and feelings

Physically escorting the patientMental health staff trained in safe physical escort techniques assist the patient to the designated

time out area and help the patient understand the conditions of the process

Therapeutic holdingStaff hold a child who is unable to comply with the conditions of time out in a supportive posture

for a short period while preventing the child from injuring himself or herself

Use of seclusion and/or restraint*Patients who require this have been determined to be unsafe in all the less restrictive levels,

including seclusion or restraint alone, as they are not in control of their behavior

Least to most restrictive

Non-pharmacological Interventions for Managing Agitated Patients



• Minimize crowding and deter worsening of possible paranoid ideations

• Include only enough staff when interviewing to ensure that patient is aware of their presence

1. Talk to patient in large area where there is space

• Let patient know we as a team want to help but are in charge • Speak in clear lower tone to defuse tension and establish rapport

with patient• Be clear, calm, and firm: give clear and firm instructions

2. Take charge

• Offer empathy and help (eg, “I see you are upset, would you be willing to talk to me about your problems?”)

• Open discussion about the patient’s needs

3. Offer choices to patients in interacting with you

4. If patient escalates, leave the room and get help

• Show patient you take him or her seriously and will get help as needed• Show no reaction but offer help and help patient to make choices• If escalation continues, terminate interview and move to next step

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Management of Agitated Patients



1. Respect personal space2. Do not be provocative3. Establish verbal contact4. Be concise5. Identify wants and feelings6. Listen closely to what the patient is saying7. Agree or agree to disagree8. Lay down the law and set clear limits9. Offer choices and optimism10. Debrief the patient and staff

Janet S. Richmond: West J Emerg Med. 2012;13(1):17–25.


*American Association for Emergency Psychiatry Project Best practices in Evaluation and Treatment of Agitation (BETA) De-Escalation Workgroup’s 10 Domains of De-Escalation.

Ten Domains of De-escalation*

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• New York State Office of Mental Health’s (OMH) PMCS program: designed to provide inpatient staff with necessary skills to prevent and manage crisis situations

– Main focus: prevention of crisis situations and elimination/reduction of coercive responses to crisis through development of staff competencies in day to day effective interactions

– Tool enhances the safety of both staff and recipients

• Inpatient staff attend two-day program initially and one-day program annually thereafter

– Competency assessments for verbal/non-verbal calming techniques and physical interventions conducted in each class

• A five-day train-the-trainer program is available for both state and non-state providers

– Non-state agencies can select those interventions appropriate for use by their agency’s staff, based on their own policies, objectives, program considerations

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OMH, Office of Mental Health.New York State Office of Mental Health. Preventing and Managing Crisis Situations (PMCS). Available at: https://www.omh.ny.gov/omhweb/dqm/restraint-seclusion/pmcs.pdf. Accessed December 2016.

PMCS Program ComponentsFoundational principles of a crisis prevention, trauma-informed, recovery-focused and person-centered manner of care

Awareness and understanding of aggression and identification of factors influencing aggression

Assessment of the potential for a crisis

Intervention strategies and factors affecting staff performance

Verbal and non-verbal de-escalation techniques

Defensive and restrictive physical interventions

OMH restraint and seclusion policy statutes

Crisis follow-up and methods to improve outcomes

The Preventing and Managing Crisis Situations (PMCS) Program



*Traditional model: patient is evaluated and treated in the ED by both an emergency medicine (EM) physician and then a psychiatry consultant.

Halmer TC, et al. Emerg Med Clin N Am. 2015;33:875-891.

• Three common models of emergency psychiatry delivery in the US– General treatment goals are the same: exclude medical causes for symptoms, stabilize acute crisis,

develop disposition and aftercare planMODEL PROS CONS

Emergency Department Boarding with Psychiatric Consultation*

• Lowest cost and easiest to implement within most existing hospital infrastructures

• Potential delay in diagnosis and intervention• Patients held in environment not conducive to

stabilization• Lack of specialized staff providing psych-

specific nursing care

Designated Psychiatric Area Within the Emergency Department

• Calming environment operated by specialized staff

• Full medical evaluation and quick interventions

• Potential for segregation to contribute to stigma

• Emergency department overflow can compromise the dedicated space and or floatstaff away

Psychiatric Emergency Service

• Stand-alone facility focused on treating acute mental illness

• Staffed 24/7 with specialized on-site or readily available psychiatric staff

• Extended observation capability

• Can have high direct cost to maintain continual specialized staffing

Methods of Emergency Psychiatry Delivery

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• CPEPs must provide1:– Emergency psychiatric evaluations

– Treatment and disposition

– Extended observation beds up to 72 hours

– Mobile crisis outreach services

– Crisis residential beds

• There are 22 licensed CPEPs throughout the state of New York2

– Customized based on location, community served, and physicians1

– Provide wider range of treatment options and alternatives to prolonged inpatient hospitalization1

– Access point to the most acutely and seriously ill patients1

1. Sullivan AM, Rivera J. Psychiatr Q. 2000;71(2):123-38; 2. New York State Office of Mental Health. Mental Health Program Directory. Available at:

http://bi.omh.ny.gov/bridges/directory?region=&prog_selection=02. Accessed December 2016.

New York State Comprehensive Psychiatric Emergency Programs (CPEP)

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http://bi.omh.ny.gov/bridges/directory?region=&prog_selection=02


© 2017 Otsuka Pharmaceutical Development and Commercialization, Inc., Rockville, MD

Otsuka Pharmaceutical Development & Commercialization, Inc. Lundbeck, LLC.

January 2017 MRC2.CORP.D.00192

Psychiatric Emergency and CrisisAhmed Nizar, MD

PsychiatristSt. Joseph’s Hospital Health Center

Syracuse, NY

19

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Psychiatric Emergency Crisis · symptoms dissipate with return of their blood alcohol level to normal • Psychiatric symptoms attributed to toxins, in association with a positive