Continuity of care and follow-up
As a courtesy and to ensure continuity of care, any psychiatrist who refers a patient to an ED should contact the ED with details about the patient’s status and with recommendations for treatment. Likewise, the treatment provider in the ED who is aware of a patient’s outpatient care should send a report about the ED’s treatment plan to the referring clinician. Patient privacy should be respected when completing these reports, and written consent for communication with providers outside a given medical system should be obtained when possible. However, if the circumstances of the emergency do not permit this, the need to ensure continuity of care in an emergency trumps privacy considerations.8
The outpatient psychiatrist continues to be responsible for the patient’s care if the patient is not referred to an ED. Such a patient should be provided with medications or other interventions needed to prevent relapse of the psychiatric emergency and scheduled for follow-up at an appropriate interval. Most important, the patient should be given a means to obtain emergency psychiatric care in the event of a relapse of the emergency after hours.
Finally, when the crisis has passed, the clinic’s staff may elect to review the way that the crisis was managed, in the interest of quality improvement and to provide support for staff members involved in the crisis.
Telephone management of a patient in crisis can be challenging. As with face-to-face emergencies, the interaction should focus on assessment of risk of intentional or unintention-al danger. Patients do reach out by telephone when they are considering suicide.9 Responses that feature empathy, respect, and collaborative problem solving decrease the risk of suicide following the call.10 Agitated patients will reveal themselves through the content and manner of their communication. The verbal engagement strategies discussed earlier may prove effective in addressing the agitation.
In higher-acuity circumstances (eg, a high-risk patient with active suidical ideation) or if the telephone intervention does not yield improvement of mental status, it is appropriate to involve family members to obtain collateral information or local authorities to bring the patient to the nearest ED for further evaluation and treatment. All patients should be asked where they are and who they are with. Patients may resist these inquiries; therefore, the clinician may have to infer these points using clues in the conversation. Many medical centers have protocols for involving the police in these circumstances and may also have the technical ability to locate the person making the call.
Psychiatric emergencies, defined as acute elevations in an individual’s risk of danger to self or to others, may arise in any treatment context. When a crisis reveals itself, the treating provider is responsible for assessing the concerning behavior. Preincident preparation is the key to accomplishing this task in a safe manner. An empathetic response may be sufficient to defuse the crisis. If this is not enough, a patient referral to the ED for further evaluation and management is essential. Finally, the treating provider should initiate and receive communication from the ED to ensure continuity of care. If these steps are taken, the crisis can be a brief diversion on the patient’s path to mental wellness.