Psychiatric Emergencies: Who Gets Hospitalized and Who Gets Discharged -Good afternoon, my name is Nicole Lederman and I’m a second year Psychiatry Resident at the Univ of New Mexico -Thank you to the CIT team for giving me the opportunity to present to you all today -As second year residents on call in psychiatric emergency services we make the decision of which patients come into the hospital for treatment -My goal this aft to introduce you all to that process Nicole Lederman, MD University of New Mexico Department of Psychiatry

Learning Objectives: Overview of Psychiatric Emergency Services Identification of individuals who are appropriate for admission to acute inpatient psychiatric unit Overview of common presentations and interventions in psychiatric emergency room When should a patient be brought to the hospital -That being said learning objectives are described as follows

UNM Psychiatric Emergency Services This is our facility as it appears from the outside coming in right adjacent to our inpatient unit at the Mental Health Center Of note our facility geographically and physically distinct and separated from the main/medical Emergency Dept which directs patients towards inpatient treatment for medical conditions

Faces of PES Administration/Clerks Security Mental Health Techs Nurses (Staff and Charge) Physicians (Resident and Attending) Psychiatric Nurse Provider These are the individuals who are responsible for maintaining the flow of patients through psychiatric emergency services and work closely together as a team

Patients present to Psychiatric Emergency Depts for a variety of different reasons This chart is taken from a paper entitled Service Expectations and Clinical Characteristics of Patients Receiving Psychiatric Emergency Services Displayed in this table are a series of responses from a sample of 82 patients who presented to a psychiatric emergency service at Butler Hospital in Providence, Rhode Island As you can see among the many reasons individuals may seek emergency psychiatric care the top few being a concern for depression or suicidality, substance abuse, detoxification, other and seeking admission to facilities Other reasons being frustration with care at other facilities, problems with anger, having a so-called “mental breakdown”, “anxiety”, referral by a psychiatrist, and a desire to be evaluated or to get medication

Events Belongings Secured Vital Signs and initial triage Nurse Evaluation Physician Evaluation When a patient presents to PES either by transfer from the main ED, by walking in, by Certificate for Evaluation or by Law Enforcement every patient goes this process of having their belongings secured, having their vital signs taken and being initially triaged by nursing staff, making the determination as to whether or not a patient is safe to wait in the lobby or needs to be brought back into a room, after which point provider evaluates pt and determines appropriate level of intervention… does the patient need admission, can the patient be discharged with outpatient follow up, or does the patient necessitate medication for stabilization and further observation?

Risk Factors for Suicide and Homicide Fixed and Demographic: male, Caucasian, Native American, adolescent/elderly, separated, homosexual/bisexual, psychiatric dx, previous SA and attempt w/in 12 mo, FH or close associate suicide, h/o physical/sexual abuse, chronic medical co-morbidities, pain, aggressiveness, h/o violence, borderline intellectual functioning Short Term: recent loss/trauma, psych d/c within 12 months, 1st dx psych illness, worsening of depressive sx, inc use of substances Current: Hopelessness, insomnia, agitation/anxiety, living alone, help rejecting, firearms/ other means Protective: Future oriented, pregnancy/kids, social/family support, lack of previous suicide attempts, absence of SI/HI, willingness to engage in tx, therapeutic alliance, lack of access Determination of Acute Risk and Chronic Risk Listed here are numerous risk factors that are taken into consideration when making decision as to whether or not a patient is safe to be discharged home No specific formula Items we do take into consideration Overall if Fixed/Short Term/Current RF outweigh protective RF more likely to admit or obs Important to note that acute risk and chronic risk are different in that given presence of fixed/demographic rf chronic risk may be always elevated, however imp to weigh acute risk which in addition looks at short term and current rf

Who Gets Admitted? Immediate danger to self or others Suicidality Homicidality Mania Active Psychosis Grave Passive Neglect Poor Insight and Judgment Perceived Benefit from Treatment Least Restrictive Means While I did mention there is no specific formula for admission and that each patient needs to be evaluated on a case by case basis There are a number of items listed above that necessitate admission to inpt psychiatric facility including Determination that pt is an immediate danger to self or others that may present as Suicidality or wanting to end life. Passive suicidality (thoughts) vs. active suicidality (intent, plan) Homicidality or wanting to harm others Mania – clinical condition indicative that the patient has Bipolar Disorder and which may present as an excessively elevated or irritable mood lasting at least 1 wk where pt presents with dec need for sleep, sense of grandiosity, excessive risk taking behaviors among other diagnostic considerations Active psychosis in which pt is unable to distinguish Reality, stemming from either a primary mental/medical illness or substance Concern for grave passive neglect or inability to care for oneself Will the pt benefit from admission Is this least restrictive manner of tx

Goals of Hospitalization Safety Stabilization Evaluation Medication Management Psychotherapy

Psychiatry and the Law Certificate for Evaluation Voluntary Admission Involuntary Hold Court Commitment When generating treatment plans for patients it is important to determine the patient’s legal status A provider may issue a cert of evaluation which indicates that provider is concerned about the patient’s safety or level of dangerousness and necessitates that they be picked up by law enforcement and taken to psychiatric facility for appropriate evaluation Does not mean automatic admit 7DH invol hold on a pt which is time period that hospital has to guarantee a court date for the pt in which their case is presenting to a commissioner who will at that point decide if pt will need commitment to the hospital. Provider places a hold on a pt, they file for time period of commitment to hospital which may range usually anywhere from 7-30days

Who Gets Discharged? Medically unstable  medical ED Passive suicidal ideation without intent or plan Rapid outpatient follow up Drug Rehab Searching for new provider/medication refills Chronic psychosis Vitals, infection, trouble breathing Most relevant to law enforcement are pts that appear to be actively intoxicated which if they come in to PES are almost always tranfserred to the medical ED often times because we don’t have the capabilities to appropriately monitor these patients

Common Interventions Medication – acute stabilization Supportive Psychotherapy Crisis Counseling Metabolize to Freedom Observation Admission to Inpatient Unit

Outpatient Services Detox/inpatient rehab Tests Medication prescriptions Referral to outpatient providers Family therapy

When should a patient be brought to PES? Is the patient an acute danger to himself or others? Does the patient have a severe mental illness that is not being treated? Is there evidence of intoxication? Medical ED Is there an intervention that is less restrictive that would provide equal benefit to patient?

Interventions in the Field Inquire about outpatient follow up and medication adherence History of violence – ?incarceration? Identification of coping strategies and social support Gathering of collateral information and phone numbers for PES providers Validation, support, non-judgmental approach

Common Presentations 32 yo F h/o AUD biba to UNM ED with BAL >200 reporting suicidal ideations 10 yo M h/o DD, ADHD banging head against wall and threatening to hurt his siblings 55 yo M h/o polysubstance use found walking on tramway barefoot, Urinary Tox Screen positive for opiates, benzodiazepines and methamphetamine 30 yo F h/o unspecified psychosis found outside convenience store passed out later requiring 4 point restraints, spitting, punching and cursing at staff

Common Presentations Cont… 75 yo F h/o Dementia with Behavioral Disturbances with dysuria and inc in aggression 40 yo M h/o Bipolar Disorder kicked off the Greyhound with erratic behaviors, singing to himself 60 yo M history of Diabetes and Hypertension living alone with elevated blood pressures and blood sugars wandering on the streets, urinating on himself 50 year old female with history of Bipolar Disorder Type II, Borderline Personality Disorder and multiple suicide attempts by overdose reporting ingesting a handfull of pills in the setting of partner conflict