Lara Gayle Chepenik, MD, PhD

Time is a vanishing resource that shapes our collaboration with 

 These colleagues evaluate more patients in less time, because the number of emergency department (ED) visits has increased an average of 20% from the early 1990s to the most recent decade, and the number of EDs has decreased by more than 10% in the same period.

 Our emergency medicine colleagues have also noticed that psychiatric cases constitute a growing portion of their caseload.

 This suggests that psychiatrists who consult in an ED have to do more with less among personnel who are already strained.

Collaboration may be further strained if ED staff are unfamiliar with certain critical preconditions for meaningful psychiatric consultation, such as safety. It might appear reasonable to perform quick consultations in ED waiting rooms for psychiatric patients asking only for medication refills because this potentially saves time and space. However, a waiting room fails to ensure a safe setting, putting consultant, hospital, and patient at unnecessary risk.

Because triage nurses typically perform only limited evaluations of patients, consulting psychiatrists must decide whether to write prescriptions based solely on the recommendations of these nurses. The inherent risk in doing so is that when a physician prescribes a medication, he or she creates a full, legal physician-patient relationship without benefit of a thorough assessment.

Alternatively, consulting psychiatrists could try to conduct interviews in the waiting room. Setting aside the impracticality of such interviews, what if the patient is suicidal, violent, or both-and armed? It will be cold comfort to those injured that the patient was reported to be merely seeking a refill of his olanzapine prescription.

Consultation for behavior management highlights the importance of a safe setting. Just as surgery might be consulted to place a line, or orthopedics to place a cast, psychiatry might be consulted to help manage an acutely agitated patient. Although these consultations seem to be similar requests for circumscribed assistance, the urgency of such requests requires preestablished procedures. The ED should be staffed with personnel trained in restraint procedures and there should be a convenient, reliable mechanism for requesting their assistance. It is also critical that ED staff, especially rotating or floating staff, know to summon such personnel in order to avoid risking injury to patients and staff while waiting for a psychiatrist.

Psychiatrists can play an important role in coaching their emergency medicine colleagues on the implicit dangers of dealing with unfamiliar patients and in promoting procedures to establish safe practices. An appropriate setting for psychiatric consultation should include designated nurses and removal of weapons, sharp tools, and drugs from patients and visitors. The setting needs to be secure against a patient’s sudden violence or attempts to depart. Placing all patients in hospital gowns is an effective means to remove potentially dangerous items from patients and to reduce risk of elopement. If this is not hospital practice, the administration should designate staff responsible for searching patients and provide adequate support equipment (eg, metal detectors, secure storage for patient belongings).

Visitors should secure their belongings while visiting psychiatric patients because they may bring in dangerous items or substances of abuse. Although these transgressions are usually inadvertent, visitors have been known to attempt to bring patients banned items, such as “a last fix” before going clean. A locked area, monitored rooms, and personnel trained to manage dangerously agitated patients make up the preferred setting for emergency psychiatric consultation. If limited space prohibits such a designated facility, strategically stationed guards and sitters help considerably. Physical restraints may also become necessary.

Physical restraint alone is sometimes sufficient to manage behavioral dysregulation. In addition, it provides the treatment team time to evaluate the patient’s medical history, drug allergies, and presenting circumstances so that they will be prepared if pharmacological management becomes necessary.

Pharmacological management of acute agitation has been extensively reviewed elsewhere.

 Briefly, benzodiazepines constitute the recommended treatment of alcohol/sedative withdrawal. Neuroleptics, most commonly haloperidol, or neuroleptic/benzodiazepine combinations constitute the recommended treatment of intoxication, delirium, or psychosis.

Unfortunately, pressures in the ED can promote impatience with agitated patients who typically consume that valuable resource-time. This may lead to overmedication and increased medication adverse effects. Psychiatrists can help their ED colleagues by guiding drug therapy and providing education about a medication’s adverse effects and its onset of action. The psychiatrist can also suggest alternatives should the first medication fail to manage the patient’s agitation.

Clear policies for medical examination, established in advance and with agreement among triage, emergency medicine, and psychiatry, promote collegial interactions.

Consultation for behavior management highlights the importance of a safe setting: psychiatrists can play an important role in coaching emergency medicine colleagues on the dangers of dealing with unfamiliar patients and promoting procedures to establish safe practice.

A locked area, monitored rooms, and personnel trained to manage dangerously agitated patients is the preferred setting for emergency psychiatric consultation.

Physical restraint is sometimes sufficient to manage behavioral dysregulation. It provides the treatment team time to evaluate the patient’s medical history, drug allergies, and presenting circumstances so that they will be prepared if pharmacological management becomes necessary.

Legal mechanisms to establish capacity vary by locale; therefore, advance planning with hospital attorneys and education of colleagues are instrumental to success.

Medical clearance can be a minefield of disagreements between emergency medicine and psychiatry, leading to less-than-collegial interactions that can derail disposition efforts. The Emergency Medical Treatment & Labor Act (EMTALA; 

) mandates medical screening examinations for all patients who present to the EDs of hospitals that accept Medicare. However, EMTALA does not specify the minimal medical examination, which may create opportunity for disagreement between hospital personnel. Patients themselves may believe a physical examination is unnecessary if they are requesting minimal services, such as referral to outpatient treatment or medication refills.

Clear policies for medical examination, which are established in advance and on which triage, emergency medicine, and psychiatry agree, should help maintain collegial interactions. To paraphrase Robert Frost’s “

,” good clinical policies make good collaborators. Specify in advance routine examination protocols based on simple patient parameters (for instance, anyone 65 or older might warrant a urinalysis, complete blood cell count, and chest films, in addition to a basic history taking and physical examination). Evidence of substance abuse could require a breath test for alcohol or a urine test for other substances.

The resources available to the psychiatric consultation and inpatient services also guide medical evaluations. Some psychiatric facilities lack resources for medical consultation or provision for timely laboratory results. Medical expertise may be nonexistent for psychiatric services that primarily depend on social workers for an initial examination. Educating our emergency medicine colleagues about these limitations and talking through worst-case scenarios for patients’ conditions permit ED clinicians to better gauge what constitutes an appropriate medical evaluation.

Patient intoxication also poses a rich area for conflict over medical clearance. Intoxicated patients can be disruptive and may require a great deal of time. They require observation by skilled personnel because they may be at risk for respiratory depression, seizures, or other complicated symptoms of withdrawal.

A clear diagnosis of intoxication is also needed. Sometimes, individuals who are delirious may be inappropriately thought to be intoxicated. This can happen when a police report or ambulance run-sheet labels the patient as such and ED staff fail to use breath, blood, or urine tests to confirm the diagnosis.

In some facilities, intoxicated patients are placed in a separate part of the ED, removed from clinical observation. However, caution is appropriate when planning for the intoxicated patient. “Better admit a patient to the hospital dead drunk than turn him away to be discharged from the jail dead sober a little later.”

 Determination of blood alcohol level, laboratory determination of substances of abuse, and a physical examination help ensure correct diagnosis.

Psychiatric consultants are understandably frustrated at requests to evaluate an intoxicated patient who is incoherent. In this setting, examinations are limited by an absence of mind-reading acumen in the consultant and by dramatic changes in the patient’s clinical presentation between intoxication and sobriety. Thoughtful consultants can review past history and attempt to contact previous treatment providers, family, or friends before doing the evaluation. This can accelerate admission to an appropriate substance abuse treatment facility or facilitate a ride home. Almost any effort that safely moves patients along from an ED is usually appreciated.

Situations in which a patient is disorganized secondary to a nonpsychiatric organic process, such as dementia, pose a particular challenge. In these circumstances, it is not always clear whether internal medicine, psychiatry, or their geriatric subspecialties best serve the patient. Emergency medicine will pursue overt causes of delirium or vascular disease, but psychiatry may be consulted to evaluate more serious behavioral dysregulation.

If emergency medicine fails to identify an acute organic process that justifies medical admission, it may take an interdisciplinary team to arrange an appropriate disposition. Family members, hospital care coordinators (or social workers), and physicians from emergency medicine and psychiatry may be able to coordinate resources to allow safe discharge home (perhaps with visiting nurses or aides). Otherwise, the patient may have to be admitted to the psychiatric ward.

Psychiatric billing codes cover inpatient management of behavioral disturbance from a variety of causes, and this might be the only mechanism to safely manage the patient until he can be placed in an appropriate outpatient facility. As with medical clearance, advance planning and protocols that account for these options can avoid fraying tempers.

Decision-making capacity and involuntary commitment

Consultation around legal matters, such as decision-making capacity and involuntary commitment, rarely leads to serious collegial disputes, but they are potential sources of misunderstanding. Again, advance discussion and education can facilitate disposition planning. For example, in most clinical locales, any physician can make a preliminary determination of capacity. This includes assessment of whether a patient understands his illness and the risks and benefits of treatment options. Psychiatrists and neurologists are frequently consulted for this evaluation. In obvious cases, emergency medicine clinicians do not need to wait for an official consultation.

A capacity evaluation begins with a discussion with the consulting physician to clarify the medical problem that requires treatment, the proposed medical intervention, the risks of refusing this intervention, and any other options. This discussion sometimes encourages consulting physicians to consider alternative interventions acceptable to patients and their families, bypassing the need for formal determination of capacity. It may also be helpful to remind colleagues that patient consent is unnecessary to save life or limb in an emergency.

 However, when formal consultation is needed and the consulting psychiatrist determines that a patient lacks decision-making capacity, there may be several legal mechanisms to admit and treat this patient against his will. These mechanisms vary by locale; therefore, advance planning with hospital attorneys and education of our colleagues can be instrumental to success.

Mechanisms for involuntary commitment to psychiatric treatment facilities also vary by state. States may provide a separate mechanism for substance-related problems, and intoxicated behavior may be expressly excluded from consideration among criteria for involuntary commitment to traditional inpatient psychiatric treatment. Each state provides some mechanism for involuntary commitment based on the presence of danger to self, danger to others, or grave disability.

Physicians unfamiliar with writing and defending involuntary commitments may not realize several subtleties in the required documentation. When danger to self or others is present, there must be evidence that the risk is imminent (eg, smoking is a risk, but hardly an imminent risk). Suicidal comments must be explored to delineate intent as well as ongoing risk. Evidence for homicidal ideation should be restricted to behaviors that arise as a result of a psychiatric illness. Frank criminality should be referred to the police.

The presence of grave disability is best documented by evidence of impaired function. (An example is the patient with diabetes mellitus who cannot appropriately administer insulin because of limited functionality.) Educating concerned parties and formulating questions to better assess the examples of qualifying behaviors may ease frustrations and better inform the consulting psychiatrist’s evaluation.

It is not surprising that one of the most complicated aspects of collaboration with faculty and staff in the ED setting is the professional or social contract. Although the goal of all medical professionals involved should be the optimal treatment of the patients, confusion may arise when it is unclear which treatments are available and who will be providing them. Practices that establish guidelines for consultation and identify a clear hierarchy of personnel responsible for final clinical decisions are likely to smooth these interactions. Establishing these guidelines may also serve to create benchmarks for standardized care for patients, who can present with a complex variety of mental health and social problems.

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 Eastman AB. The Future of Emergency Care in the United States Health System: an Institute of Medicine report. 

 Kellermann AL. Crisis in the emergency department. 

 Larkin GL, Claassen CA, Emond JA, et al. Trends in U.S. emergency department visits for mental health conditions, 1992 to 2001. 

 Marder SR. A review of agitation in mental illness: treatment guidelines and current therapies. 

 Rund DA, Ewing JD, Mitzel K, Votolato N. The use of intramuscular benzodiazepines and antipsychotic agents in the treatment of acute agitation or violence in the emergency department. 

 Zun LS. Evidence-based evaluation of psychiatric patients. 

 Silverman ME, Murray TJ, Bryan CS, eds. 

Tintinalli JE, Stapczynski JS, Ma OJ, et al, eds. 

Tintinalli’s Emergency Medicine: A Comprehen-sive Study Guide.

Articles

It is not surprising that one of the most complicated aspects of collaboration with faculty and staff in the ED setting is the professional or social contract.

Author | Lara Gayle Chepenik, MD, PhD

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Working With Physicians in the Emergency Department