TRIAGE

Triage should be performed as with all emergency department patients along standardised lines (see Table 39.1). A team approach for the reception of involuntary patients should involve mental health, medical, nursing, security and other staff working with established and practised protocols. Police, when initially present, should stay until safety and control have been established. A rapid sedation protocol should be used as required (see Figure 39.1).

Safety must be taken into consideration. Physical environments must be assessed for potential hazards to either patients or clinicians. Assessment rooms specifically set up for this kind of examination are essential. Security and other staff should be trained in aggression minimisation, and de-escalation techniques and protocols should include routine security checks for possible weapons or dangerous objects at the time of triage.

Interviewing the potentially violent patient needs to be undertaken in a manner that minimises the chances of escalation while maintaining your safety and that of the patient. This is best done in an environment which has at least two exits and which can be observed by other staff (this may need to be done discreetly out of respect for the patient’s privacy). The presence of potential dangers should be considered and appropriate steps taken; furniture should be too heavy to throw and anything that could be used as a weapon (e.g. IV poles) should be removed. Consider removing neckties/necklaces, stethoscopes, pens etc from your person. Tell others where you will be and who you are with. Carry a ‘personal duress alarm’ and make sure you know how to activate it.

The initial contact is aimed at defusing the situation, but this will often depend on elucidating and treating the underlying cause. Therefore, history taking, assessment of mental state and looking for other diagnostic clues should proceed simultaneously. Your approach should be empathic and non-confrontational; avoid making the patient feel verbally (e.g. by using ultimatums) or physically threatened (e.g. by standing over a seated patient or blocking their exit).

CONTROL OF AGGRESSION

There are a number of different ways of controlling aggression, ranging from verbal de-escalation to pharmacological and/or physical restraint. Often a number of strategies will need to be employed. The underlying cause, especially if it is organic in nature, needs to be identified and treated. Verbal de-escalation and distraction is almost invariably the initial means of approaching the aggressive patient. This needs to be done in a non-judgemental and non-confrontational manner; allow the patient to state their concerns while stating your desire to sort things out in the manner most appropriate for everyone. Although there is often a role for the setting of limits of acceptable behaviour, issuing ultimatums will frequently result in escalation of the situation. Avoid getting drawn into long-term grievances or issues beyond your control. Simple courtesies, such as offering something to eat or drink (this should be avoided if sedation is likely to be required) or somewhere to sit, may assist you in establishing a rapport with the patient. If appropriate, try to get the patient to accept help such as psychiatric assessment or to voluntarily take oral sedative/antipsychotic medication.

Should this approach fail a ‘show of force’ may be necessary, such as the obvious presence of security/police officers to back up the clinician with the aim being to convince the patient that further escalation is unwise and in the hope that they will then agree to take medication. One person (usually the clinician involved) should lead the staff and interact with the patient. A fallback plan should always be in place at this stage: if the violence/aggression appears to be due to a medical or psychiatric condition and physical/pharmacological restraint is legally justifiable, it should be the next step; if not, the patient/subject should be escorted from the department by security or police.

Physical restraint should only be performed in an emergency situation in the initial treatment of a delirious or psychiatrically unwell patient. In these cases, it must be done in a manner aimed at minimising the chance of injury to patient or staff, and should always be followed by pharmacological sedation. There must be sufficient staff with well-defined roles. Usually seven staff are required; one to immobilise each limb, one for the head and neck, one to administer medication, and a runner/scribe. One person should be in charge; they will nominate when immobilisation will take place and will be responsible for talking to the patient. Throughout, extreme care must be taken to avoid injury to staff (e.g. punching, biting, spitting by patient) or to the patient (e.g. asphyxia, broken limbs during restraint). Universal precautions, such as gloves and face masks, should be used and great care should be taken with sharps.

Figure 39.1 St Vincent’s Hospital Emergency Department rapid tranquillisation guidelines

As many of these patients may be frequent re-presenters, an ‘alerts system’ may be worthwhile to warn of potential violence risk as well as other important information, such as adverse reactions to drugs or concurrent chronic physical illness. For patients who present very often, an agreed multidisciplinary management plan may be prepared and kept in the medical record or in a linked database. It is important that such plans are regularly reviewed and do not prejudice or limit care.

HISTORY AND ASSESSMENT

Gathering reliable information can be very difficult and may be important for medical and legal reasons, as involuntary admission and treatment may be required. Documentation from ambulance, police and others must be completed.

If a friend, relative, case worker or health professional has accompanied the patient, this will help the assessment process; however, the patient should be asked if they would prefer privacy initially. Some people in psychosocial distress will feel more willing to share personal information when given this option.

A medical history and physical examination should be performed. Basic blood tests are indicated in most new patients. As is the case with many presentations in emergency medicine, assessment may need to proceed concurrently with treatment; indeed, thorough history taking, mental state and physical examination may need to be deferred until the acute situation is under control. More involved investigations, including cerebral CT scanning and drug or septic screening, may sometimes be required. There are many medical conditions that can give the appearance of mental illness or may be concurrently present. Particular care is required in the presence of:

There are many causes of aggressive behaviour, which vary from psychosis and antisocial/borderline personality traits to organic causes such as head injury, delirium, drugs, sepsis and post-ictal states. Use of a Mini Mental State Examination (refer to Table 34.1 in Chapter 34, ‘Geriatric care’) will help to identify cognitive deficits or a possible delirium. It can be especially useful if a change over time can be identified and can also help you decide if the patient is too sedated, sleepy or disorientated to provide a valid history.

INITIAL APPROACH

In the emergency department the following points will help you to rapidly assess psychosocial distress for potential mental health problems, establish the degree of urgency for psychiatric referral and identify any need for safety and/or security measures to be instituted.

Establish the nature of the problem and whether immediate action is needed to prevent the patient from self-discharging or failing to wait for a thorough psychiatric assessment. Consider:

Establish why this problem requires attention now:

Context is important: why here and why now? Preliminary information gathering can significantly expedite the assessment process. In some instances there may be an existing ‘management plan’. Early enquiries and review of previous presentations or an existing mental health record can reveal valuable information regarding the involvement of other healthcare providers or provide an established working diagnosis.

Corroborative history from others is especially valuable; however, you will need to seek the patient’s consent if not under a mental health act. People/places to approach are:

FURTHER ASSESSMENT AND MANAGEMENT

Having formulated provisional diagnoses, medical and psychiatric management should be commenced concurrently when required. For patients with significant comorbidities, inpatient care in a medical setting with mental health consultation is often safer.

Treating medical issues (e.g. sepsis, pain) may well lead to improvement in mental health symptoms. Management of intoxication or withdrawal states such as with methamphetamine or alcohol (see Figure 39.2) is important. Basic needs such as food and personal hygiene need to be addressed. Psychiatric medication should be instituted (or reinstituted) with care and ideally specialist consultation. A basic understanding of antipsychotics, antidepressants, sedatives and neuroleptics as well as their interactions is required (see Table 39.2).

Figure 39.2 St Vincent’s Hospital guidelines for the treatment of methamphetamine intoxication Developed by Jamie Houlahan (CNC), Gary Nicholls (Clin Pharm) and Beaver Hudson (CNC) in association with Emergency, D&A, Psychiatry & Clinical Pharmacology, St Vincent’s Hospital Sydney Ltd.

Adapted from ‘Development of clinical guidelines for the pharmacological management of behavioural disturbance and aggression in people with psychosis’ by D Castles, Australian Psychiatry 2005; 13(3):247–252.

Table 39.2 Care levels for mental health patients

Ideally, use defined criteria to assign a care level to each patient to ensure appropriate supervision and observation (see Table 39.2). Documentation should clearly explain the reasons that sedation and/or restraint were required, and the doses, routes of administration and timing of any medications used. At the earliest possible time, fill out the legal forms (schedules) if indicated.

COMMON DRUGS USED IN PSYCHIATRY

EDITOR’s COMMENT

Australia has one of the world’s highest rates of youth suicide. Mental health problems during all segments of the patient’s life are increasing. Know and practise your standard approach to these common emergency department patients.