Big Book of Emergency Department Psychiatry

PrefaceFRONT LINE PERSPECTIVESEmergency Psychiatry: An Emergency Psychiatrist's PerspectiveIntroduction: The Psychiatric Emergency RoomMy Past Shaped My PracticeVariety of ED Settings and StaffHow to Keep a Positive Perspective and Have Fun at WorkSecondary Motivation and MalingeringConfusing and Mixed Incentive StructuresEducation Systems and Their "Psychiatric Emergency"Home EnvironmentNursing FacilitiesSubstance MisuseNeurodiverse PatientsConclusionEmergency Psychiatry: An Emergency Psychiatric Social Worker's PerspectiveIntroductionSocial Work as a ProfessionPsychiatric Assessment in the Emergency RoomAssessing for Risk of Self-HarmSocial Media and MinorsAssessing and Working with the Agitated PatientThe ER Treatment Team and Working with the Agitated PatientWorking with Children and Adolescents in the Emergency RoomAdolescent Case Review: ParanoiaAdolescent Case Review: Suicidal IdeationWorking with the Family of the Suicidal or Self-Injuring ChildThe Emergency Room Psychiatric Social Worker's Role in Substance Use AssessmentSynthetic Marijuana CrisisConversing about Substance Use with PatientsMental Health System Issues: The Impact on Psychiatric Social Workers and PatientsMental Healthcare Access Issues: The Impact on Emergency RoomsConclusionResourcesEmergency Psychiatry: An Emergency Physician's PerspectiveIntroductionThe ABCs: Airway, Breathing, and CirculationEmergent Psychiatric PresentationsThe Acutely Agitated PatientThe Suicidal PatientAfter the ABCs Is the DMedical ClearanceSubstance UsePovertyWhat We NeedConclusionReferencesResourceEmergency Psychiatry: An Emergency Nurse's PerspectiveIntroductionCaring for PeoplePsychiatric Nursing KnowledgeMisdiagnosis due to Medical Mimicry: A Case StudyCase Study Discussion: MisdiagnosisPatient and Staff SafetyPills and Vodka: An Unfortunate OccurrencePurses and Knifes: Not What the Doctor OrderedPatient Coping MechanismsStaff SplittingYou Are a Great Nurse, Unlike Your Rude Colleague: A Case StudyCase Study Discussion: Staff SplittingCommunication with the Emergency PhysicianConclusionSTRUCTURAL APPROACHES TO PATIENT CENTERED CAREContemporary Psychiatric Care in the Emergency Department: Care Options, Treatment Teams, and Documentation RecommendationsIntroductionOperational Processes: BenefitsAdministrative BenefitsStaffing BenefitsDirect Care Staff BenefitsPatient and Advocate BenefitsRegulatory and Quality Oversight BenefitsLength of Stay BenefitsAppropriate Level of CareLeast Restrictive Level of Care: Is the Use of Physical and Chemical Restraints Necessary?Reduction in Restraint and Seclusion UseEmergency Department Workplace Safety ConcernsImproving Workplace SafetyCrisis Response TeamsSafety CommitteesSign-Out ReportsPatient and Staff SatisfactionPatient Satisfaction SurveyPatient ConfidentialityMeasuring Success: How Do You Know If the Team is Making a Difference?Interdepartmental Memorandum of Understanding or Service AgreementService Agreement: What Does This Entail?Suggested Model for StaffingEmergency Department PhysicianEmergency Department NurseEmergency Department Social Services and Discharge Planning TeamPsychiatristMental Health TherapistsThe Security TeamRecommended Patient Liberties for Attire and Personal Belongings in the EDSuggestions for Daily FrameworkMorning RoundsTemplate for ED Psychiatry Pre-RoundingTemplate for Treatment Update NoteEmergency Department Nursing Rounding Note TemplateReviewing the Patient List and Assigning CliniciansTemplate for Initial ED Psychiatric Consultation NoteInitial Patient Arrival InformationHistory of Present IllnessPsychiatric HistoryPast Medical HistorySubstance Use HistorySocial HistoryLiving SituationLegal HistoryFinancial HistorySupport SystemMental Status ExamAppearanceBehaviorDemeanor/MannerSpeechMoodAffectPerceptual DisturbancesThought ProcessThought ContentOrientationMemoryConcentrationCognitionInsightJudgmentImpulse ControlRisk AssessmentAssessing Suicide RiskAssessing Homicide RiskAssessing for Grave DisabilityRisk Level ScalingImpressionDiagnosisRecommendations and PlanPsychiatric ReassessmentTo Consult or Not to Consult?: Appropriate Consultations of Psychiatry in the Emergency SettingInnovative Care in the Emergency Department: Dedicated Psychiatric observation AreasRecommendations for the Dedicated Psychiatric Observation AreaUse of Handouts in the EDWelcome LetterDiagnostic-Specific Patient EducationCommunity Resources InformationTherapeutic HandoutsPatient Rights and Advocacy Group InformationConclusionReferencesResourcesRisk Assessments in the Emergency RoomIntroductionClinical Presentation: History and Physical ExaminationPast Psychiatric HistoryOther Elements of HistoryCollateral InformationSynthesis of InformationMr. Turner: Case Example 1Ms. Anderson: Case Example 2Risk Assessment: Key ElementsHistory of Present IllnessPsychiatric HistoryMedical HistoryPast Psychiatric HistorySocial HistorySubstance Use HistoryReferencesThe Myth of Medical ClearanceIntroductionCritical Assessment of Articles in Favor of Laboratory ScreeningArticles in Favor of Selective TestingHistory and Physical ExaminationPediatric PopulationUnimportant PositivesUrine Toxicology ScreenCost and UtilityStandardized Screening ProtocolsConclusionRecommendations for PracticeReferencesResourcesDischarge PlanningIntroductionThe Art of Discharge Planning: Aligning Your Goals with the Patient'sSense of Control, or NotPerception of Loss of ControlProven Techniques—That Work!In the Real WorldYour Steps to WellnessStep 1: The AssessmentStep 2: Individualized TreatmentStep 3: Release/TransferSpecific Information to Gather for the Discharge ProcessSafety PlanningWarning SignsCoping StrategiesFamily, Social, and Professional ContactsKeeping Me SafeSignature SectionChildren and Adolescents: Safety Planning IssuesAdditional Barriers to Discharge PlanningHousingTransportationMedical IssuesDiscussing Discharge MedicationsCommunication: What We Think We're Good At, and Can Always Improve onDischarge InstructionsConclusionReferencesResourcesEthical implications for the Emergency Department PsychiatristIntroductionEthical Choices and the Effect on the PatientEthical Case PresentationsCase 1: The Suicidal PatientThe Suicidal Patient: Ethics Case DiscussionCase 2: The Psychotic PatientThe Psychotic Patient: Ethics Case DiscussionCase 3: The Cognitively Impaired PatientCapacity Evaluation EssentialsThe Cognitively Impaired Patient: Ethics Case DiscussionConclusionReferencesResourceCLINICAL CAREAnxiety and Mood Disorders in an Emergency ContextIntroduction: BackgroundAnxiety DisordersPanic DisorderPost-Traumatic Stress DisorderAcute Stress DisorderSelf-Medication of Anxiety SymptomsMood DisordersDepressionSymptomsAssessing Depression in an Emergency SettingSuicidal Ideation and SuicideSuicidality: The Middle GroundNon-Suicidal Self-Injurious BehaviorParasuicidal GesturesBipolar DisorderManiaMedical Mimicry: Conditions Posing as and Associated with Anxiety or Mood DisordersHypo- and HyperthyroidismTreatment Options for Anxiety and Mood DisordersMedicationsAntidepressantsAnxiolyticsMood StabilizersTherapyRelaxation Skills Training: Quick Interventions for the Emergency SettingCognitive Behavioral Therapy Interventions: Changing the Patient's Frame of MindEncouraging Patient Self-Care: The Positive Outcome on Anxiety and Mood DisordersConclusionReferencesPsychotic Disorders in Emergency DepartmentsIntroductionPsychosis DefinedAuditory HallucinationsVisual and Auditory Hallucinations and Illicit Substance ComorbidityTactile HallucinationsDelusionsThought DisorganizationDisorganized BehaviorsCatatoniaDiagnostic Categories of Psychotic DisordersDelusional DisorderBrief Psychotic DisorderSchizophreniform DisorderSchizophreniaSchizoaffective DisorderDepressive Disorder with PsychosisBipolar Disorder with PsychosisCannabis-Induced PsychosisMedical Mimicry of Psychosis: A Case of Anti-N- Methyl-D-Aspartate Receptor EncephalitisParanoia as a Survival MechanismTreatment Options for Psychosis in the Emergency DepartmentAntipsychotic MedicationsRisperidoneOlanzapineHaloperidolZiprasidoneAripiprazoleQuetiapineClozapineAntipsychotic Medication Side EffectsConclusionKey ED Survival Points for PsychosisReferencesResourcesThe Diagnosis and Management of Substance Use Disorders in the Emergency Psychiatric Setting: A PrimerIntroductionThe Substance Use Epidemic and TreatmentThe Substance Use EpidemicSubstance Use: Treatment and MorbidityAnatomy of Addiction: Pathways in the Brain and Major Brain StructuresNeurotransmitters of Interest in Addiction PathwaysPsychological Craving: Reinforcement and ConditioningResearch: Data SetsThe Motivational Matrix of Stages of ChangeDiagnosis: Criteria and CodesDiagnostic CriteriaAlcohol DisordersAlcohol Disorder Assessment ToolsAUDIT CAUDITAlcohol Effect and MetabolismRisk and Prognostic FactorsBlood Alcohol Level ToxicityAlcohol WithdrawalWithdrawal TreatmentComorbidityMedication for Alcohol Use DisorderWernicke Korsakoff SyndromeWernicke Korsakoff Syndrome TreatmentSedative Hypnotic and Anxiolytic-Related DisordersBenzodiazepinesCannabis-Related DisordersCannabis: Intoxication and WithdrawalCannabis: Social, Legal, and Research IssuesSynthetic CannabisCannabis and Brain ActivityCannabis Use Frequency Studies in AdolescentsTobacco-Related DisordersTobacco: Usage and Mortality RatesNicotine PharmacologyNicotine WithdrawalGold Standard TreatmentNicotine Treatment: Preferred OptionsBupropionVareniclineSecond Line Nicotine Treatment AgentsNicotine Replacement TherapyOpioid-Related DisordersOpioid TypesOpioid Use and Emergency Department VisitsOpioids: A Historical Time LineNational Institutes of Health Consensus Panel on Opioid AddictionEffects of Opioid UseWithdrawalOpioid OverdoseOpioid Overdose Facts for First RespondersManagement of Opioid Use DisorderChoices of Medication to Manage Opioid Use DisordersMethadoneNaltrexoneBuprenorphineStimulant-Related DisordersStimulantsStimulant Intoxication and WithdrawalMethamphetamine: Pharmacology and EffectsMethamphetamine: Addiction and TreatmentEmergency Department Visits and Methamphetamine: 2007-2011The Man Who Ate His Methamphetamine: Case Presentation Teri Miller, Yener Balan, and Tony BergerCocaine Use DisorderCocaine FormulationsMethylenedioxymethamphetamineInhalant-Related DisordersInhalant TypesHallucinogen-Related DisordersCommon HallucinogensLysergic Acid DiethylamidePsilocybinDimethyltryptamineMescalineSalvia DivinorumHallucinogen NeurologyHallucinogen IntoxicationHallucinogen-Persisting Perception DisorderConclusionReferencesResourcesEmergency Treatment of Agitation in Delirious and Demented PatientsIntroductionStep 1: Don't Do Anything—Attempt NegotiationStep 2: When Negotiation Has Failed—Simultaneously Assess and ActNon-Pharmacologic InterventionsPharmacologic InterventionsAntipsychoticsBenzodiazepinesThe B52Other Medication ClassesSpecial SituationsStep 3: The Agitated Patient Has Been Calmed, What Now?In ClosingReferencesPersonality Disorders: An Empathic ApproachIntroductionIt's Not You ... It's Me: Impact of Patient Care on the ED Clinician's PsycheWait ... Maybe it is You: The Patient's expectations of Carethis Seems More Complicated: Patient and Clinician Social interactionsWhen Personality Traits Become PathologicalYou Are the Best Doctor Ever!Splitting the TeamMaintaining Consistent BoundariesTreatment OptionsConclusionReferencesResourcesA Primer on Medical ToxicologyIntroductionRisk AssessmentDid a Potentially Toxic Ingestion Occur?What Phase of Poisoning Are We Seeing?Time of IngestionMixed ExposuresToxidromesWhat Is the Care Plan?The Deadly DozenA Few Words About Urine Drugs of Abuse ScreeningImmediate Interventions (Decontamination)Treatments and AntidotesSupportive CareNaloxoneEmergency IntralipidSodium BicarbonateN-acetylcysteineConclusionReferencesSPECIALIZED POPULATION CAREChildren and Adolescents with Psychiatric EmergenciesIntroductionThe Rise of Child and Adolescent Psychiatric Emergency VisitsThe Emergency Department AssessmentInterview ConsiderationsThe EvaluationInterventionsLegal IssuesChild AbuseEmergency Department PresentationsAgitation in the Emergency DepartmentExternalizing Behavioral DisordersHigh-Risk BehaviorsAutismSchool RefusalNon-Suicidal Self-Injurious BehaviorSuicidal Ideation and BehaviorsDepressionAnxietyPsychosisHyperactivityEating DisordersConclusionReferencesResourceCorrectional Emergency PsychiatryOverviewTypes of Correctional FacilitiesCost ImplicationsLegal OverviewCapacityIntake and the New Admissions ProcessEncounters Confidentiality and SafetyConfidentiality ExceptionsDrug UseSuicide Risk in CorrectionsNon-Suicidal Self-InjuryInjuriesMedication IssuesAgitation as a Result of ConfinementCell Extractions and Use of ForceDe-escalationPsychiatrist's Role in the Disciplinary ProceedingHunger StrikesCourt-Ordered EvaluationsTreatment of Corrections OfficersTele-HealthSummaryReferencesResourcesMETHODS FOR OPERATIONAL IMPROVEMENTintroduction to Emergency Psychiatry Operational improvementIntroductionBackgroundLean DefinedCase StudyConclusionReferencesResourcesA Step-by-Step Guide for Improving Emergency PsychiatryStarting Your Lean Journey in emergency Psychiatry improvementVision, Leadership, and Creation of a Process Improvement TeamMetricsOperational MetricsQuality MetricsDiagnosis Specific MetricsDemographic MetricsCost MetricsValue Stream Mapping and the Kaizen EventDefinitionsKaizen Event ScheduleConclusionReferencesResourcesLean Flow and the impact of the Long-Stay PatientIntroductionBackgroundQueues in ED PsychiatryUtilizationimproving Queue PerformanceReduce the Rate of ArrivalsIncrease the Rate of ServiceReduce Variation in ServiceReduce Variation in ArrivalsEffect of the Long-Stay Psychiatric Patient on ED OperationsConclusionReferencesResourcesChange Management and Addressing Barriers to ImprovementIntroductionBarriersHistorical BarriersCultural BarriersBreaking Down Cultural BarriersChange Management PrinciplesConclusionReferencesResources
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