Psychiatric Emergency Service Patients Research Articles

More Than Suicide: Mortality After Emergency Psychiatric Care and Implications for Practice.

Emergency departments (EDs) provide vital mental health services. ED patients with behavioral health presentations, particularly suicidal ideation, are at increased risk of death by suicide, medical illness, trauma, or overdose. Causes of death for patients who receive specialty emergency psychiatric services remain undescribed. We describe the incidence and cause of death after care in a psychiatric emergency service (PES). Mortality data were obtained for all adult patients treated in a safety net ED from April 2016 to June 2020. Causes of death were categorized as medical, external (accidents, overdoses, and homicide), or suicide and compared between PES patients and ED patients who were not treated in the PES. Correlates of mortality were described for PES patients. We analyzed 164,422 encounters including 6063 PES visits. Mortality in the 30 days after discharge was 0.3% among PES patients and 0.6% among medical ED patients. At both 30 and 365 days, PES patients were more likely to die by suicide than medical ED patients, and ED patients were more likely to die by medical causes. Among PES patients who died within 365 days, 46% died by medical causes, 32% by external causes, and 23% by suicide. In multivariable analyses, age was associated with all-cause, medical, and external mortality after a PES visit; opioid and stimulant use disorders were associated with all-cause and external mortality. Most patients who die after receiving emergency psychiatric care die by medical and external causes such as accidents, overdose, and homicide. Patients who are older and have opioid or stimulant use disorders are at higher risk of nonsuicide mortality. We propose interventions to reimagine emergency psychiatric care and address nonsuicide mortality among psychiatric patients treated in emergency and crisis settings.

Evaluation of an Integrated Psychology Service in a Pediatric Emergency Department and Urgent Care.

Children visiting emergency departments (EDs) are disproportionately affected by mental health disorders. Integrated behavioral health models hold promise for improving care among ED patients. We implemented and evaluated a novel behavioral health service integrated psychology trainees in a safety net hospital's pediatric ED and urgent care. Consultations and interventions provided were identified from the service's patient registry. Patients treated by the service were matched based on age, sex, day, and month of presentation to control patients who received a brief assessment by a specialized psychiatric nurse or patients receiving comprehensive management in a psychiatric emergency service. Rates of ED return visits were obtained from local hospital records, and insurance claims were used to identify rates of psychiatric hospitalization and outpatient follow-up care. The most commonly provided interventions among 71 intervention patients were assistance with connection to follow-up behavioral health treatment (65%), relaxation training (41%), and motivational interviewing (31%). These patients were matched with 142 comparison patients. There was no difference among groups in return rates within 90 days among intervention versus nurse assessment or psychiatric emergency service patients (25% vs 23% vs 13%, P = 0.14). Insurance claims data were available for 115 patients (54%): within 90 days, integrated care patients were less likely to have at least 1 outpatient claim (52% vs 78% vs 84%, P < 0.01), and there was no difference in rates of psychiatric hospital admission (18% vs 20% vs 24%, P = 0.83). Although this psychology-led integrated behavioral health service delivered a range of brief psychotherapeutic interventions, its impact on outpatient, inpatient, and emergency care was mixed. This lower follow-up rate among intervention patients may reflect the success of active psychological treatment in the ED, lower acuity among intervention patients, or implications of the study's safety net setting. The authors discuss this model's potential for enhancing mental health care in pediatric EDs.

Psychiatric Emergency Services - Can Duty-Hour Changes Help Residents and Patients?

Limitations on resident duty hours have been widely introduced with the intention of decreasing resident fatigue and improving patient outcomes. While there is evidence of improvement in resident well-being and education following such initiatives, they have inadvertently resulted in increased number of hand-offs between clinicians leading to potential errors in patient care. Current literature emphasizes need for more specialty/setting-specific scheduling, while considering residents' opinions when implementing duty-hour reforms. There are no reports examining the impact of duty-hour changes on residents or patients in psychiatric emergency service (PES) settings. Our purpose was to assess the impact of a recent scheduling change and decrease in overall duty hours, on resident well-being and sense of burnout, while also evaluating changes to patient wait-time and length of stay (LOS) in PES. Residents completed Maslach Burnout Inventory and anonymous surveys focusing on: fatigue, sleep, life outside work for shifts - regular (8am-8pm) and swing shifts (12pm-10pm). Data from the electronic medical records were collected for 6months pre- and post-schedule change (January 2016-February 2017), for LOS and patient wait-time. Residents' preference for shifts was split. However, 86% reported getting enough sleep during swing shifts, while 83% reported lack of sleep during regular shifts. The average patient wait-time and LOS significantly decreased from 169 to 147 and 690 to 515min, respectively. The change to swing shifts significantly impacts LOS and patient wait-time. The short shifts demonstrated an improvement in well-being for residents, but were not the singular factor for overall resident satisfaction.

Unrecognized medical disorders among older patients in psychiatric emergency service

Unrecognized medical disorders among older patients in psychiatric emergency service

Demographic and clinical characteristics of users of psychiatric emergency services on an off-shore island in Taiwan

Objective. This study assessed the socio-demographic and clinical characteristics of psychiatric emergency service (PES) patients treated in a hospital on an off-shore island of Taiwan. Method. Data were gathered on 472 identified psychiatric patients presenting to PES over a 4-year period. Results. The majority of patients were male and were in the 50–59 age group with no previous psychiatric treatment or family history of mental illness. Hospitalization rates were low for both genders, but males spent a longer time in the emergency department. Males were more often seen for violence and homicidal behaviours, while females showed more evidence of suicidal behaviour. Males were more likely to receive medication by injection with or without physical restraint as opposed to oral medication and emotional support. Conclusions. The clinical characteristics of male and female PES patients in this remote island showed differences in length of stay, psychiatric diagnoses, behaviour characteristics, and final disposition. These findings differ from those in studies of PES patients on the main island of Taiwan, the United States and Europe. Future studies of other remote areas may confirm these findings and highlight the need to provide more and particular mental health services to these underserved areas.

Substance misuse among older patients in psychiatric emergency service

Objective To determine the prevalence of substance misuse among older patients presented to a psychiatric emergency service (PES) on involuntary bases. Method At the time of initial presentation to the PES, all patients received a comprehensive assessment that included a urine toxicology screening. The screening consisted of six substances: barbiturate, benzodiazepine, cocaine, opiate, phencyclidine and amphetamine. Charts of elderly patients (aged 65 and above) with positive urine toxicology were reviewed to ensure that the results were not due to (1) home medications and (2) medications given in the PES. Results During the 2-year study period (2006–2007), there were 5914 patients under the age of 65 and 104 patients aged 65 and above. Our findings indicated that 471 (8.0%) and 14 (13.4%) urine toxicology screens were not collected during the PES visits in younger and older patients, respectively ( P=.04). The positive urine toxicology rate was 31.5% (1716/5443) and 26.7% (24/90) for younger and older patients, respectively ( P=.33). Conclusions Substance misuse in the older population presenting with psychiatric emergency is prevalent in the PES. Urine toxicology screens, as well as patient or collateral report of substance usages, should be obtained from this group of patients to ensure quality of care delivered at the PES.

Brief Interventions for Patients Presenting to the Psychiatric Emergency Service (PES) with Major Mental Illnesses and At-risk Drinking

The presentation for care in psychiatric emergency setting provides an opportunity to assist individuals with mental health disorders and problems related to alcohol use. The purpose of this pilot study was to determine whether clinician-administered brief alcohol interventions are effective in reducing alcohol consumption in patients who screen positive for at-risk drinking in the psychiatric emergency setting. A total of 390 PES patients were screened; 87 (schizophrenia/bipolar disorder, n = 34; depression/anxiety, n = 53) met criteria for the study and received a brief alcohol intervention. Both groups dropped their drinking by approximately 7 drinks/week over the 6-months of the study (P < .05). The results of this study suggest that individuals with mental illnesses who drink at risk levels may benefit from a short, targeted brief alcohol intervention directed at changing their alcohol-related behavior and that, delivery of these interventions is feasible in a psychiatric emergency setting.

Assessment of geriatric patients in the psychiatric emergency service.

ical emergencies that are related to psychiatric medications. Possible problems include agranulocytosis secondary to antipsychotics, hypotension or cardiac conduction disturbances that are caused by the use of antipsychotics or antidepressants, neuroleptic malignant syndrome, lithium toxicity, anticholinergic delirium, and acute dystonia (4). Another critical factor in evaluating geriatric patients in the psychiatric emergency service is the risk of suicide, which is much higher among geriatric patients than younger patients. The suicide rate for white men aged 80 to 84 years is six times that of the general adult population (5). Clinicians in the psychiatric emergency service need to calibrate their index of concern about the risk of completed suicide for elderly psychiatric emergency service patients who present with depression, alcohol abuse, or other risk factors for suicide. Because of these and other special considerations that apply to the geriatric patient, we suggest certain maxims that may prove useful in guiding the clinician’s work. They are formulated as ten “do’s” and “don’t’s” for the psychiatric emergency service clinician, constituting a list that cannot claim to be comprehensive.

Psychiatric consultation to a general hospital medical evaluation service

Psychiatric consultation to a general hospital medical evaluation service was reviewed and compared with consultation patterns for general hospital inpatients and psychiatric emergency service patients. Results of a questionnaire survey indicated nearly 1 in 5 patients admitted to this acute medical service (24-hour maximum stay) required psychiatric consultation. A study of those patients seen by psychiatric consultants is reported. The prevalence of depressive illness as well as the psychiatric hospitalization referral rate was substantially greater than in general hospital inpatient or psychiatric emergency service evaluations. The implications of this relatively new area of consultation-liaison for hospital staffing and medical education are discussed.