DEVELOPMENT OF EMERGENCY CARE PSYCHIATRIC CLINICAL FRAMEWORK
By default, the emergency department (ED) has become the "portal to the community" and the entry point where most patients are introduced to the health care system. It is also a logical place to expedite needed reform to ensure universal access to essential health care services. Historically, ED nurses have felt unprepared to provide adequate care for patients with mental illnesses, and are well aware of the increasing challenges the disparities in our health care system have brought for persons with substance use and psychiatric/mental health disorders. The Emergency Nurses Association (ENA) believes health care providers have a unique opportunity to make unprecedented change in the care of patients with mental illness in the ED.
On July 28, 2008, ENA convened a stakeholders meeting in Washington, D.C. with the primary goal of developing a consensus document on the care of patients with mental illnesses in the ED. Additional stated objectives of this stakeholders meeting included (1) developing and promoting guidelines for practice, including strategies regarding boarding patients with mental illnesses in the ED, and (2) developing measures to ensure that patients with mental illnesses receive quality care. During that meeting, it was decided that a "clinical framework" needed to be a separate document from the consensus principles statement under review and that a work group would be formed to develop the framework.
ENA hosted a work group conference call on November 25, 2008. The goal was to develop a consensus statement that would aid our health care workers but, more important, provide the quality care that all our patients deserve. The following organizations participated in this project:
American Academy of Emergency Medicine
American College of Emergency Physicians
American Nurses Association
American Psychiatric Nurses Association
Emergency Nurses Association International Society of Psychiatric-Mental Health Nurses
National Association of State Mental Health Program Directors
Two other organizations indicated that they wished to participate in the discussion, but were unable to attend the conference call: the American Association of Emergency Psychiatry and the American Psychiatric Association.
During the November call, the work group reviewed a document containing the clinical statements extrapolated from the discussion held at the consensus stakeholder meeting on ED Care of Patients with Mental Illnesses. The members of the work group worked toward achieving consensus on (1) principles of practice and care and (2) clinical evaluation guidelines for care of emergency patients with mental illnesses and/or substance abuse. By the end of the call, the work group had completed a draft consensus statement consisting of an introductory statement of the problem, defined principles for the practice and emergency care and clinical evaluation guidelines for the assessment and treatment of emergency patients with mental illnesses and/or substance abuse, and an addendum of defined terms and cited references.
The draft was subsequently reviewed by the participants on December 17 during a web-based conference call to confirm the document captured the essence of the discussion and to provide any editorial changes. The document is to serve as a resource and call to action for emergency care leaders – in collaboration with mental health partners and community leaders – and provides guidance for the clinical evaluation and treatment of emergency patients with mental illness and/or substance abuse.
The attendees agreed to run the attached final framework – dated February 1, 2009 – through the approval process of their various organizations. A conference call will be held in the beginning of April 2009 to receive status reports on how the Emergency Care Psychiatric Clinical Framework is faring through organizational approval, to address any concerns that have surfaced, and to discuss the next steps relative to an official release. The consensus principles statement is still in development and will be sent to all stakeholders who participated in the July 2008 meeting at a later date.
Kathleen A Ream
Director, Government Affairs Emergency Nurses Association Phone: 703-241-3947
EMERGENCY CARE PSYCHIATRIC CLINICAL FRAMEWORK
In order to provide competent and accountable emergency psychiatric care, hospitals need to provide a consistent practice model for patient care regardless of facility or time of day. Our collective goal for the provision of psychiatric and substance use disorder treatment in the emergency department, is to provide care that meets the Institute of Medicine's Six Quality Aims of safe, effective, timely, efficient, equitable, and patient-centered care:1
The following principles provide the framework for competent and accountable emergency psychiatric clinical care.
PRINCIPLES OF PRACTICE AND CARE
- Implement evidence-based clinical guidelines for emergency patients with mental illnesses and/or substance use disorders.
- Use a standardized ED triage scale and acuity categorization2 to ensure the timely and appropriate evaluation and treatment of emergency patients with mental illnesses and/or substance use disorders.3
- Expect emergency care professionals providing evaluation and care to emergency patients with mental illnesses and/or substance use disorders to possess the core competencies necessary to perform the clinical evaluation functions as outlined in the Clinical Evaluation Guidelines section of this document.
- Support and participate in research, when possible, to further the development and dissemination of best practices models and algorithms for care.
- Encourage and support efforts to organize and regionalize psychiatric care including adherence to state and community guidelines for emergency medical services. Collaboration will be needed among emergency care, mental health, and law enforcement services in the development of regional transport guidelines.
- Ensure that patients requiring inpatient treatment are not boarded in the emergency department.
CLINICAL EVALUATION GUIDELINES
- 1. Perform a psychiatrically relevant and focused medical assessment when indicated by triage or medical evaluation – a process by which a medical etiology for the patient's symptoms is excluded and other illnesses and/or injuries in need of acute care are detected and treated.4 Assessment findings which may indicate a patient has a medical illness for which a symptom-based evaluation is suggested include:4
- Abnormal vital signs
- Abnormal physical exam relevant to clinical presentation
- Altered cognition relevant to the clinical presentation
- Engage in a collaborative psychiatric assessment with each patient individually beginning with a mental status examination that includes appearance, speech, mood, cognitive function, perception, sensorium, insight, and judgment.
- Include the following objectives in an emergency psychiatric evaluation:5
- Assess and have processes in place to enhance the environmental safety of the patient and others.
- Establish a provisional diagnosis (or diagnoses) of the mental disorder most likely to be responsible for the current emergency, including identification of any general medical condition(s) or substance use that is causing or contributing to the patient's mental condition.
- Review current medications (prescribed and non-prescribed) and known indications.
- Review relevant laboratory or radiologic study reports.
- Identify family or other involved persons who can provide information that will help the mental health provider determine the accuracy of reported history, particularly if the patient is cognitively impaired, agitated, or psychotic and has difficulty communicating a history of events.
- Identify any current treatment providers who can supply information relevant to the evaluation. Community mental health providers should be encouraged to contact and provide clinically relevant information when referring their patients to an emergency care facility.
- Identify social, environmental, and cultural factors relevant to immediate treatment decisions.
- Determine whether the patient is able and willing to form a therapeutic partnership alliance that will support further assessment and treatment.
- Identify what precautions are needed if there is a substantial risk of harm to self or others, and whether involuntary treatment is necessary. Treatment should be delivered in the least restrictive manner to ensure positive clinical outcomes.6
- Determine whether the patient requires treatment in a hospital or other supervised setting and what follow-up will be required if the patient is not placed in a supervised setting.
- Address family members' or caretaker's ability to care for the patient and their understanding of the patient's needs, if the patient is to be discharged to the care of family members or other caretaking persons.
- Develop collaborative relationships and policies to facilitate the admission of patients to the most appropriate mental health facility with the least delay after evaluation and disposition by the emergency health care professional.
- Develop a specific plan for follow-up, including immediate treatment and disposition.
- Ensure that patients requiring inpatient treatment are not boarded in the emergency department.7
1. Institute of Medicine. (IOM, 2001). Crossing the Quality Chasm, IOH Report. National Academies Press.
2. Emergency Nurses Association, American College of Emergency Physicians, (ENA/ACEP, 2004). Standardized ED Triage Scale and Acuity Scale and Acuity Categorization: Joint ENA/ACEP Statement. Available at: http://ena.org/about/position(jointstatements/Standardized_ED_Triage_Scale_and_Acuity_Categorization_ENA_&_ACEP.pdf
3. Illinois Hospital Association Behavioral Health Steering Committee (IHA, 2007). Best Practices for the Treatment of Patients with Mental and Substance Use Illnesses in the Emergency Department. Springfield, IL. Available at http://www.aha.org/aha/content/2007/pdf/2007oct-ihabehavreport.pdf
4. American College of Emergency Physicians, (ACEP, 2005). Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. Ann Emerg Med, 2005 Jan; 47( I): 79-99. Available at http://www.acep.org/workarea/showcontent.aspx?id=8826
5. American Psychiatric Association, (APA, 2006), Work Group on Psychiatric Evaluation (2"d Ed). Psychiatric Evaluation of Adults. Available at http://www.psychiatryonline.com/content.aspx?alD= 137164
6. International Society of Psychiatric Mental Health Nurses, (ISPN, 1999). The Use of Restraint and Seclusion Position Statement. Available at http://www.ispn-psych.org/docs/99Restraint-Seclusion.pdf
7. American College of Emergency Physicians, (ACEP, 2008). ACEP Task Force Reporting on Boarding: Emergency Department Crowding, High Impact Solutions. Available at http://www.acep.org/workarea/showcontent.aspx?id=37960.
Agency for Health Care Research and Quality, (AHRQ, 2006). Emergency Department Performance Measures and Benchmarking Summit Consensus Statement. Available at http://www.qualityindicators.ahrq.gov/news/EDPerformanceMeasures-ConsensusStatement.pdf
American College of Emergency Physicians, (ACEP, 2008). ACEP Psychiatric and Substance Abuse Survey 2008. Available at http://acep.org/uploadedFiles/ACEP/Advocacy/federal_issues/PsychiatricBoardingSummary.pdf
American Psychiatric Association (APA, 2002). Report and Recommendations Regarding Psychiatric Emergency and Crisis Services. 2002. Available at http://archive.psych.org/edu/other_res/1ib_archives/archives/tfr/tfr200201.pdf
American Psychiatric Nurses Association (APNA, 2007). Seclusion and Restraint Position Statement. Available at http://www.apna.org/files/public/APNA_SR_Position_Statement_Final.pdf
Antai-Otong, D. (2001). Psychiatric Emergencies. PESI Healthcare, LLC. Eau Claire, WS
Emergency Nurses Association, (ENA, 1999). Medical Evaluation of Suspected Intoxicated and Psychiatric Patients. Available at http://ena.org/about/position/position/lntox_and_Psych_Pts_ENA_PS.pdf
Lamb, HR, Weinberger, LE, DeCuir, WJ. (2002). The Police and Mental Health. Psychiatric Services, 53(/0), p/266-1271. Available at: http://psychservices.psychiatryonline.org/cgi/content/full/53/I 0/1266
New Freedom Commission on Mental Health (2004), Subcommittee on Acute Care: Background Paper. DHHS Pub. No. SMA-04-3876. Rockville, MD. Available at http://www.mentalhealthcommission.gov/papers/Acute_Care.pdf
Persis, M. (2007) Psychiatric Emergencies: Caring for People in Crisis. Available at http://www.wildirismedicaleducation.com/courses/198(lndex_nceu.html
Screening for Mental Health (2007). A Resource Guide for Implementing the Joint Commission 2007 Patient Safety Goals on Suicide. Available at http://www.mentalhealthscreening.org/downloads/sites/docs/ndsd/Joint_Commission_ Guide.pdf
Substance Abuse and Mental Health Services Administration (SAMHSA, 2008). Healthy People 2010 Terminology. Available at http://www.oas.samhsa.gov/MentalHealthHP2010/terminology.htm#terminology
Boarding is the term used to describe the process of holding patients in the ED for extended periods of time who have been directed for admission by a physician with admitting privileges. This process then has certain elements of the admission process and ongoing patient care provided by ED staff members. (AHRQ ED Performance Measures and Benchmarking Consensus Statement, 2006)
Emergency health care professional is a licensed health care professional working in an emergency care setting who is providing assessment, planning, diagnosing, and/or interventions to treat an individual with a mental illness.
Focused medical assessment is the process by which a medical etiology for the patient's symptoms is excluded and other illness and/or injury in need of acute care is detected and treated. (ACEP Clinical Policy: Critical Issues in the Diagnosis and Management of the adult Psychiatric Patient in the Emergency Department, 2006)
Mental illness is the term that refers collectively to all diagnosable mental disorders and generally includes disorders related to substance abuse. Mental disorders are health conditions characterized by alterations in thinking, mood, or behavior (or some combination thereof that are all mediated by the brain and associated with distress, or impaired functioning, or both. Mental disorders spawn a host of human problems that may include personal distress, impaired functioning and disability, pain, or death. These disorders can occur in men and women of any age and in all racial and ethnic groups. They can be the result of family history, genetics, or other biological, environmental, social, or behavioral factors that occur alone or in combination. (SAMSHA, 2008)
Psychiatric emergency is an acute disturbance of thought, mood, behavior, or social relationship that requires an immediate intervention as defined by the patient, family, or the community. 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 and the resources available to understand and deal with the situation are not available at the time and place of the occurrence. (APA Report and Recommendations Regarding Psychiatric Emergency and Crisis Services, 2002)
Six Quality Aims as defined by the Institute of Medicine are:
- Safe: Avoiding injuries to patients from the care that is intended to help them.
- Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit thereby avoiding under use and overuse, respectively.
- Patient-centered: Providing care that is respectful of and responsive to individual patients' preferences, needs, and values and ensuring that patient values guide all clinical decisions.
- Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care.
- Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy.
- Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. (Crossing the Quality Chasm/IOM Report. National Academies Press, 2001)
Standardized Triage is a system to assess and categorize acuity which incorporates all aspects of objective and subjective physical and mental patient assessment data and has demonstrated validity and reliability.