1. 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

2. 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

3. 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

4. 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

5. 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

6. 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?

7. 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

8. 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

9. Goals of Hospitalization
Safety
Stabilization
Evaluation
Medication Management
Psychotherapy

10. 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

11. 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

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

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

14. 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?

15. 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

16. 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

17. 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