SECTION VII Behavioral Health Emergencies CHAPTER 126 ■ BEHAVIORAL AND PSYCHIATRIC EMERGENCIES EMILY R KATZ, ANIK JHONSA, ERON FRIEDLAENDER, JOEL A FEIN, THOMAS H CHUN, LAURA L CHAPMAN INTRODUCTION The emergency department (ED) is frequently the setting for the initial evaluation of emotional and psychiatric difficulties of children and their families As such, ED physicians must be proficient in psychiatric evaluation, crisis intervention, and disposition planning, regardless of whether a mental health professional is consulted Even when a consultant is involved, the ED physician still shares responsibility for the patient’s care and disposition As in any other situation involving a consultant, it is critical that the ED physician and the consultant agree on a treatment plan, both from a patient care perspective and from a medicolegal standpoint GOALS OF EMERGENCY MENTAL HEALTH ASSESSMENT AND CRISIS INTERVENTION First and foremost, the assessment and management of psychiatric emergencies requires that the ED establish and maintain a safe environment for the patient, family members, and staff Systems/protocols must be in place to enable early identification of patients at high risk of violence toward self and/or others, to provide adequate observation, to immediately intervene for unsafe behaviors, and to prevent further harm ED physicians must be facile in evaluating for underlying causes of emotional/behavioral disturbances, including potential medical etiologies for the patient’s symptoms, assessing the risk for further decompensation and future harm, and developing adequate disposition and aftercare plans Additional goals include providing support and stabilization for the patient’s family and offering adequate guidance around prevention/management of any future unsafe behaviors, means restriction, and indications for return to care KEY POINTS ED physicians must be competent at assessing and managing psychiatric emergencies and have systems in place to safely manage acutely suicidal or aggressive patients All patients with mental health complaints should receive a medical evaluation to identify significant underlying or comorbid illnesses Verbal de-escalation and trauma-informed care are key components to managing agitation Specific techniques are available to help limit the distress of children with autism and other developmental disabilities All suicidal comments and acts should be taken seriously Means restriction is an essential component of disposition planning ED physicians are typically best served using their usual “pretest probability threshold” for ordering testing/interventions on children with suspected somatization/conversion disorder The Children’s Hospital of Philadelphia Clinical Pathway ED Pathway for Evaluation/Treatment of Children With Behavioral Health Issues URL: https://www.chop.edu/clinical-pathway/behavioral-healthissues-clinical-pathway Authors: J Lavelle, MD; M M’Farrej, MD; J Esposito, MD; A Jhonsa, MD; E Perry, MSW; K White, MSW; E Steinmiller, RN; A Felix, CRNP; K Crescenzo, RN; M K Abbadessa, RN; A Fu, MD; C Jacobstein, MD; K Osterhoudt, MD; E Friedlaender, MD Posted: February 2013, last revised October 2018 REQUIREMENTS OF THE EMERGENCY DEPARTMENT The ability to respond effectively to psychiatric emergencies of children and families requires special capacities of the ED and its staff Ensuring safety includes not only the physical characteristics of the patient room but also the access to medical and hospital security personnel, as well as appropriate safety procedures and policies It is vitally important to ensure patients not bring weapons or other dangerous objects into the ED Procedures to achieve this end may include use of metal detectors or a physical search of the patient and their belongings Some EDs use a protocol whereby all patients must wear a hospital gown and slippers while in the ED This separates the patient from their belongings and can facilitate a search for harmful objects Such a policy may also theoretically reduce the risk of patient elopement A safe and adequate physical space is an absolute requirement of the ED Patients with high risk of harm to self/others need to be under constant supervision by either ED medical or security staff via direct visualization of the patient or by continuous video monitoring At a minimum, the patient room should be free of objects that could cause harm including objects used for strangulation (e.g., medical tubing, electrical or equipment cords) Such objects should be either inaccessible to the patient (e.g., in locked cabinets) or physically removed from the room The optimal setting for a psychiatric evaluation is a quiet and lowstimulus environment in which interruptions are infrequent, and privacy and confidentiality are assured; ideally this environment would be a separate, distinct area from the main ED with direct access to medical and security staff and capacity for using restraints Clinicians in the ED should have a pre-existing relationship with a mental health team that is committed to providing child psychiatric consultation at all times The ED should also have relationships with (a) psychiatric inpatient unit(s), for efficient transfers and hospitalizations when needed The staff should be thoroughly familiar with the procedures for psychiatric hospitalization, including the specific legal requirements for involuntary commitment The hospital should have specific guidelines or protocols for the management of psychiatric patients requiring admission for treatment of medical conditions Finally, the ED should have relationships with other social agencies and an awareness of relevant laws The police should be aware of which children to bring to the ED for psychiatric assessment and should be prepared to remain in the ED until adequate security has been arranged Relationships should be developed with community mental health resources, temporary shelters, and other crisis intervention centers, ensuring effective referrals ... KATZ, ANIK JHONSA, ERON FRIEDLAENDER, JOEL A FEIN, THOMAS H CHUN, LAURA L CHAPMAN INTRODUCTION The emergency department (ED) is frequently the setting for the initial evaluation of emotional and... treatment plan, both from a patient care perspective and from a medicolegal standpoint GOALS OF EMERGENCY MENTAL HEALTH ASSESSMENT AND CRISIS INTERVENTION First and foremost, the assessment and... Osterhoudt, MD; E Friedlaender, MD Posted: February 2013, last revised October 2018 REQUIREMENTS OF THE EMERGENCY DEPARTMENT The ability to respond effectively to psychiatric emergencies of children and