Disturbed or Psychiatric Patients in the ED

Context

Emergency Department attendance from patients in mental health crisis continue to rise. National hospital episode statistics 2017-18 data showed an increase in mental health attendances by 133% between 2009/10 and 2017/18. [1]

Those who have had a previous attempted suicide have an increased risk, 30-40 fold more, than the general population of completed suicide. [2]

The Royal College of Psychiatry (RCP) has produced guidance relevant to ED staff which include the assessment of self-harm and safety for trainees. [3]

NICE has updated the guidance on self-harm assessment, management and preventing recurrence. [4]

Doctors need to familiarise themselves with safety guidance to ensure personal safety. An accurate initial assessment may include a psychiatric history and mental state examination, including risk assessment of the patient.

Disturbances in mental state may be due to organic or non-organic causes and the features which help distinguish between these groups will be discussed.

Definition

Specific terms are used to describe alterations in perception and mental state.

A group of mental disorders that feature loss of contact with reality	Psychosis
An irrationally held belief that cannot be altered by rational argument	Delusion
Acute disorder of mental processes accompanying organic disease	Delirium
A false perception in the absence of external stimuli	Hallucination
An acquired global impairment of intellect, memory and personality without impairment of consciousness	Dementia

Consideration should be given to the potential causes for an alteration in mental state.

This list illustrates a few of the potential organic causes of an altered mental state. [5]

• Structural abnormalities space-occupying lesions
• Biochemical changes electrolyte imbalances
• Physiological changes hypotension
• Multi-factorial conditions sepsis

Psychiatric conditions may in part be due to genetic, biochemical and structural abnormalities.

Risk Factors

The Health and Safety at Work Regulations from 1992 state that all employers need to assess risks, identify precautions and provide training to minimise risks at work. [6]

The RCP has produced a document for trainees on minimising risk and safety issues.

How do you reduce risk when assessing a disturbed patient in the ED?

The factors to consider are:

Personal privacy issues

Avoid giving out addresses or personal details of staff.

Consider whether addresses are obtainable from other sources, e.g. GMC database of registered professionals.

Personal appearance

Avoid loose clothing that could be used to harm. In addition, avoid wearing provocative or offensive items.

Personal behaviour

Maintain professional behaviour. Be positive and courteous.

Isolation

Check the known risks of patients prior to assessment.

Ensure other staff are aware of your location when conducting an assessment and ensure you know how to raise the alarm should you feel threatened.

Emergency situations

In an emergency situation, leave the room if possible. Raise the alarm to alert other staff members.

Recommended Physical Factors for an Interview Room

The RCP and National Institute for Clinical Excellence (NICE) guidelines recommended physical factors should be taken into account when providing an interview room for psychiatric assessment [3, 7].

No ligature points, nothing that can be used as a missile, and two doors (that open both ways). Specific NICE Recommendations (Grade D) for EDs

2015 NICE guideline

Specific NICE Recommendations (Grade D) for EDs

Specific NICE recommendations [7,8] have been put in place to ensure the safety of both the staff and other patients in emergency departments:

Table 1: NICE recommendations for EDs

Systems should be in place for placing alerts on those known to pose a threat of violence

Interview rooms should be of the standard set by the RCP [3]

Chaperones should be present during an assessment and regular checks provided by other staff, for example every five minutes

Psychiatric assessment should be available in the emergency department within one hour

Mental health nurses should be employed within the emergency department

Lorazepam is recommended as 1st line for rapid tranquilisation

Lorazepam Intramuscular is the first line choice for rapid tranquilisation, however, can be considered in combination with haloperidol if required (and no associated cardiac risks). [7]

Confidentiality

Patients should be able to disclose information in a safe and private environment.

Relatives, friends and third parties, e.g. police should not be informed of what occurs within the consultation.

There are specific instances where confidentiality can be breached and these are referred to in the General Medical Councils (GMC) guidance for doctors. [9]

Before breaching confidentiality, the patients consent should first be sought. If consent is refused you should discuss the matter further with your Trust legal department and your medical defence union.

Breaching confidentiality

Examples of instances where confidentiality may be breached include disclosures:

• Required by law, e.g. notification of a communicable disease
• Relating to the courts or litigation, e.g. specific requests from a judge for relevant information
• Relating to statutory regulatory bodies, e.g. DVLA, where a patient poses a threat to the public
• In the public interest, e.g. patient has disclosed involvement in serious criminal activity such as terrorism
• To protect the patient or others, e.g. patient expresses homicidal intent towards a specific person

Self-harm

The mental health triage scale can be used at the initial assessment of the patient presenting to the ED.

This was developed for use with the NICE guidelines on self-harm. [4]

It can be helpful in assessing risk of further self-harm or risk to others and highlights those patients requiring a higher level of supervision prior to full assessment. [10]

In accordance with the latest guidance from NICE, risk assessment tools are not recommended to be used to predict risk of future harm, which patients would benefit from treatment and for global risk stratification. [4]

The Folstein Mini-mental State Examination

Before taking a history it is important to assess whether the patient is capable of giving accurate information. It may become obvious after the first few orientation questions that the patient cannot provide a reliable history and a collateral history should be sought from relatives, care staff, GPs, hospital notes and clinic letters.

Performing a mini-mental state assessment can be particularly beneficial in the ED setting.

The full Folstein mini-mental state assessment consists of 30 questions and can be time consuming.

Alternatively, much more suitable to perform in the ED is the abbreviated mental test, a validated alternative assessment. [11]

What score on the abbreviated mental test indicates cognitive impairment?

A score of six or less.

 

Abbreviated Mental State Test Assessment

What questions are asked when carrying out the abbreviated mental test?

The following questions should be asked:

1. What is your age?
2. What is your date of birth?
3. What year is it?
4. What time of day is it?
5. What address/place are we in?
6. Register a three line address and recall at the end of the test
7. Who is the King or Queen?
8. What year was World War 1?
9. Count backwards from 20 to 1
10. Identify two people (names/jobs)

The patient should score one mark for each answer that is completely correct. For question 8, the first or last year of World War 1 is taken to be correct. For question 9, patients can score one mark if they make no mistakes or if they correct themselves spontaneously.

A history should be sought from patients presenting with psychiatric conditions, disturbed patients or those with altered mental state. The history and examination will enable a differential diagnosis to be formulated and appropriately direct investigations and management.

The following components should be covered in the psychiatric history:

• Identifiers Name, age, occupation, location of consultant, Mental Health Act (MHA) status
• Presenting complaint A brief description, ideally in the patient’s own words, of why they are attending the department
• History of presenting complaint (HPC) Time of onset, course, progression, associations, severity, predisposing factors
• Past psychiatric history (PPH), past medical history (PMH), past surgical history (PSH) All previous admissions to psychiatric units and MHA category for admission, current and previous psychiatric contacts, medical conditions, previous surgical interventions
• Drug history (DH) Current medications, dosages, routes and frequencies, known allergies, reactions and intolerances
• Social history (SH) Employment status, living arrangements, smoking, drug and alcohol history, normal functional capacity, e.g. mobility and independence
• Family history (FH) Any conditions in immediate family
• Personal history (PH) Childhood development, family tree, parental issues, schooling, employment, relationships, children, social circumstances, financial issues, forensic issues

The mental state examination (MSE) is required in addition to any relevant physical examination.

What are the key components of the MSE?

The key components of the MSE and the factors to consider for each component are shown below:

Table 1: Key components of the MSE

Component	Factors to consider
Appearance	Dress unkempt, self-harm, physical disorder, inappropriate dress, previous deliberate self-harm
Behaviour	Co-operation, aggression, disinhibition, distress, preoccupations
Speech	Amount, spontaneity, volume, flow
Mood and affect	Subjective versus objective, posture, facial expression
Suicidality	Plans and intent
Thought form	Tangentiality, circumstantiality, associations, neologisms, flight
Thought content	Worries, obsessions, delusions
Abnormal perception	Hallucination and sensory modalities
Cognition	Orientation, attention, memory, intelligence
Insight	Patient’s understanding and expectations of their condition

Patients present to the ED for a variety of reasons; some may have a background of mental health issues.

For those who present acutely it is important to assess the patients physical state as well as their mental state.

For those having taken an overdose, TOXBASE and the British National Formulary (BNF) can be used to obtain information on the risk of physical harm and the medical management of the patient.

Patients presenting with symptoms suggestive of psychiatric conditions should be thoroughly assessed to ensure organic causes are excluded. This can often be done from the history and examination. [12] Organic conditions can present with symptoms suggestive of psychiatric disease. These symptoms, however, can be attributed to a physical cause rather than a psychiatric cause. [13]

Signs and symptoms

Signs and symptoms of psychiatric conditions suggestive of an organic cause include [14]:

• History of substance misuse
• Over 35 years of age at first presentation
• Fluctuating behaviour
• Predominantly visual hallucinations
• Lethargy
• Abnormal vital signs
• Poor cognitive function

Organic causes [15]

Organic causes that can lead to disturbed behaviour include:

• Traumatic causes head injury: acute and long term
• Infective causes HIV, encephalitis, syphilis, malaria, meningitis, cerebral toxoplasmosis
• Neurological Parkinsons disease, CVA, epilepsy, Huntingdons disease
• Cardiac Mitral valve disease (anxiety)
• Autoimmune Systemic lupus erythematosus (SLE)
• Neoplasia Frontal lobe, temporal lobe, paraneoplastic problems, e.g. hypercalcaemia
• Blood/bone Haemolytic anaemias, e.g. Ribothymidine 5- triphosphate, thrombotic thrombocytopaenic purpura (TTP)
• Endocrine Andrenocortical diseases, thyroid disease, pheochromocytomas
• Degenerative Dementia, visual hallucinations in partially sighted
• Drugs Alcohol, illicit drugs, steroids
• Idiopathic Genetic disorders, e.g. Huntingdons disease, storage disorders, e.g. Wilsons disease
• Obstetric/gynecological Pre-eclampsia, post-partum

Investigations should be guided by the findings of the history and examination.

They should assist in narrowing the differential diagnoses and distinguishing between organic and psychiatric origins.

Several investigations may be required, but only a few will give results within the time frame of the patients stay in the ED what are they?

• Nursing observations
• Blood glucose (BM)
• U&Es
• Thyroid function test (TFT)
• Full blood count (FBC)
• Liver function test (LFT)
• CT Head

Those with an organic cause of altered mental state should be managed appropriately with treatment of the underlying cause.

Delirium, hallucinations and disorientation in these patients can place them at risk of harming themselves and others, as well as causing disruption on the ward.

It is important to optimise the management of these patients by considering environmental factors, e.g. well lit or dimly lit room, nursing on the floor and consideration of pharmacological methods of sedation.

Psychiatric Diagnosis

Once a psychiatric diagnosis has been determined a decision can then be made on the most suitable place for treatment. This is dependent upon many factors.

Those that would warrant admission for treatment include:

• First episode of psychosis
• Suicidal or homicidal
• Gross debilitation from illness
• Lack of capacity to consent or comply with treatment
• Inadequate psychosocial support in the community

 

Patients at Risk of Further Harm

Patients may have co-existing medical and psychiatric conditions which necessitate admission to a general hospital, e.g. those having taken an overdose who require observation.

The Confidential Inquiry into Suicide and Homicide (CISH) has made recommendations on in-patient supervision and the environment required for those who pose a risk of further harm. [16]

Recommendations

Psychiatric and general hospitals, including EDs and observation wards, need to comply with these recommendations.

Key features of these recommendations include wards:

• Having no ligature points
• Eliminating physical obstructions that may impede observation of the high risk patient
• Increasing observations during the evening and night
• Conducting a risk assessment prior to discharge

Engagement with Psychiatric Services

Local arrangements exist between psychiatric and emergency services. These are variable and familiarisation with local protocols is necessary.

In some departments, psychiatric liaison services and outreach teams may be directly accessible and can provide rapid support in the assessment and initial management of the disturbed patient.

In accordance with the latest NICE guidance, psychosocial assessment should be carried out at the earliest possible without delay without waiting for medical treatment to be fully completed. [4]

Risk assessment tools and scales

As discussed earlier, risk assessment tools and scales are not recommended to be used to guide immediate and future treatment as well as risk for current and future harm.

 

There are lots of potential pitfalls in the assessment of disturbed or psychiatric patients in the ED. The most common are:

Making an initial risk assessment

This should form part of the initial assessment of the patient so that appropriate observation and treatment can be put in place. It will also guide the actions required should the patient leave the department before a full assessment has been carried out.

Not getting enough history

Collateral history will often be needed to make a full assessment. This may involve contacting relatives, the GP and psychiatric services as well as reviewing previous attendances and notes.

Failure to consider other diagnosis

The disturbed patient can be disruptive to the department. Staff and other agencies, e.g. the police, may wish for the patient to be discharged quickly.

A thorough assessment and consideration of organic causes will avoid mistakes.

Alcohol intoxication

Alcohol can alter the mental state of the patient and impair rational thought. If possible, the patient should be sober when assessed. A risk assessment must be conducted when sending home a patient who has presented with mental health issues.

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