Posts filed under Psychiatry

COVID-19 and Mental Health

**Written by:** Evelyn Huang, MD (NUEM ‘24) **Edited by:** Julian Richardson (NUEM ‘21)
**Expert Commentary by**: Tyler Black, MD, FRCPC

COVID-19 has been difficult for everyone. Deaths, isolation, loss of work, and countless other hardships abound. With this, comes the concern for mental health crises. In a survey from June 2020, 11% of adults reported thoughts of suicide in the past 30 days [1]. It can be hypothesized that the pandemic has increased suicide rates. However, does this bear out in the literature? As frontline workers, and oftentimes the only interaction that patients have with the healthcare system, it is particularly important that we identify the impact of COVID-19 on the mental health of the patients that we see every day.

In Japan, researcher used a cross-sectional study to analyze national suicide rates during the COVID-19 pandemic. They found that suicide rates in 2020 were increased in October and November for men and in July through November for women when compared to 2016-2019. Increases in suicide rates were more pronounced with men and women that are younger than 30 [2]. This supports the idea that suicide rates increased as a result of the pandemic, especially with the younger population.

However, the trends in the United States are different. A study conducted in the US looked at suicide rates in Massachusetts from March to May 2020. Excluding data from pending death investigations, they found that the incident rate for suicide death was 0.67 per 100,000 person-months for the pandemic period as compared to 0.80 in the corresponding period in 2019. The researchers point to a sense of shared purpose, connections via video platforms, anticipated government aid, and mental health awareness campaigns as possible explanations for the stable rate of suicide deaths [3]. Another study looked at United States suicide related searches during the beginning of the pandemic. Researchers found that internet searches for suicide decreased during the early stages of the COVID pandemic (March to July 2020). While this may be surprising, there is literature that shows that catastrophic events can be associated with increased social support and reduce suicidal outcomes [4]. However, as the pandemic lengthens, more research is needed to see the trends in the data.

The next question is whether the same trend of decreased suicidality also applies to the pediatric population. A pediatric emergency department in Texas looked at the resulted of their routine suicide risk screenings for patients aged 11-21. They found a significantly higher rate of suicidal ideation in March and July 2020 and a higher rate of suicide attempts in February, March, April, and July 2020 when compared to the same months in 2019 [5]. It has also been cited that prior to the pandemic, suicide was the 10th leading cause of death in the United States, but the 2nd leading cause of death among people aged 12-17 [1]. This makes our interactions with the pediatric population even more important and argues for suicide risk screening for every patient.

Looking historically, there are differing trends for different global catastrophes. One researcher found that World War I did not influence United States suicide rates, whereas the great Influenza Epidemic increased suicide rates [6]. Another study looked at suicide rates in Hong Kong during the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003. They found an increase in older adult suicide in April 2003 when compared to 2002. These researchers cited loneliness and disconnectedness in the older community as a possible explanation [7]. While there are many different factors that go into increased suicidality, trends seen in the past can help guide policy and actions today.

Research is still needed to look at the current trends of suicide rates. The question is whether suicide rates will change as the pandemic continues to lengthen and the sense of shared purpose wanes and social isolation continues. The mental health of our patients is likely to be impacted long after the pandemic ends.

A study conducted in California found that emergency department patients presenting with deliberate self-harm or suicidal ideation had an increased risk of suicide or other mortality during the first year after their initial presentation in the emergency department [8]. This is a troubling trend, but also presents an opportunity for improvement. As emergency physicians, it is also important that we keep vigilant and take the time to talk about mental health. A common fear is that asking about suicide will prompt suicidal ideation, but research has shown that this is not the case [9]. There are several suicide screening tools that can be used in the ED, such as the Suicide Assessment 5‐step Evaluation and Triage (SAFE‐T) and American College of Emergency Physicians ICAR2E [9]. What is important is to ask, because patients will often reveal things to us that they do not mention to their loved ones. Build suicide screenings into your general practice, watch out for risk factors, and support those that are seek help.

References

1. Panchal, Nirmita, et al. The Implications of COVID-19 for Mental Health and Substance Use. Kaiser Family Foundation, 10 Feb. 2021, www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/.

2. Sakamoto H, Ishikane M, Ghaznavi C, Ueda P. Assessment of Suicide in Japan During the COVID-19 Pandemic vs Previous Years. JAMA Netw Open. 2021;4(2):e2037378. doi:10.1001/jamanetworkopen.2020.37378

3. Faust JS, Shah SB, Du C, Li S, Lin Z, Krumholz HM. Suicide Deaths During the COVID-19 Stay-at-Home Advisory in Massachusetts, March to May 2020. JAMA Netw Open. 2021;4(1):e2034273. doi:10.1001/jamanetworkopen.2020.34273

4. Ayers JW, Poliak A, Johnson DC, et al. Suicide-Related Internet Searches During the Early Stages of the COVID-19 Pandemic in the US. JAMA Netw Open. 2021;4(1):e2034261. doi:10.1001/jamanetworkopen.2020.34261

5. Hill RM, Rufino K, Kurian S, Saxena J, Saxena K, Williams L. Suicide ideation and attempts in a pediatric emergency department before and during COVID-19. Pediatrics. 2020; doi: 10.1542/peds.2020-029280

6. Wasserman IM. The impact of epidemic, war, prohibition and media on suicide: United States, 1910-1920. Suicide Life Threat Behav. 1992 Summer;22(2):240-54. PMID: 1626335.

7. Cheung YT, Chau PH, Yip PS. A revisit on older adults suicides and Severe Acute Respiratory Syndrome (SARS) epidemic in Hong Kong. Int J Geriatr Psychiatry. 2008 Dec;23(12):1231-8. doi: 10.1002/gps.2056. PMID: 18500689.

8. Goldman-Mellor S, Olfson M, Lidon-Moyano C, Schoenbaum M. Association of Suicide and Other Mortality With Emergency Department Presentation. JAMA Netw Open. 2019;2(12):e1917571. doi:10.1001/jamanetworkopen.2019.17571

9. Brenner, J. M., Marco, C. A., Kluesner, N. H., Schears, R. M., & Martin, D. R. (2020). Assessing psychiatric safety in suicidal emergency department patients. Journal of the American College of Emergency Physicians Open, 1(1), 30-37.

Expert Commentary

This review is a comprehensive summary of the challenges and nuances of suicide epidemiology. Though it goes against the narrative many hold, in the United States we have preliminary but reliable data for suicides two years into the pandemic, we have not seen an increase in suicide rate in any age group (Figure 1) [1,2]. This reassuring news is tempered by the knowledge that prior to the pandemic, a decade-long trend of increasing suicide rates has maintained, and children, adults, and older adults are much more likely to die of suicide now in America than they were in 2010 [3].

**Figure 1.** Odds ratio for suicide, by age groups (A = under 18 years; B = 18 to 64 years; C = above 64 years). Years are grouped to match with the onset of the pandemic (March 2020), such that each data point represents April of that year to the following March (instead of the typical January to December presentation). The comparator for each year’s odds of suicide is a sum of the odds between April 2017 and March 2020. The shaded vertical lines represent the 95% confidence interval for odds ratio, and they are hidden behind the markers for the adult group due to the small confidence interval.

Whenever considering suicide risk, it is crucial to remember that there are not direct links between suicidal thinking, suicide attempts or visits to the emergency department, and deaths by suicide. Up to 60% of people die of suicide on their first attempt, and the vast majority (95%) of people who attempt suicide do not die of suicide, so while it is important to see the danger in suicidal presentations to emergency department, it is crucial to be aware of the challenges in predicting who will live and who will die by suicide and focus on a person-centered approach to understanding an individual’s risk and protective factors[4, 5].

I applaud the authors for encouraging all clinicians to consider suicide risk in all patients and to become comfortable with routine screening. This may never demonstrate a reduction in suicide rates in rigorous research, but we have ample evidence that having open, genuine discussions about psychological, social, and health problems regarding suicide risk is beneficial to the patients we care for [6].

References

1. Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Mortality 1999-2020 on CDC WONDER Online Database, released in 2021. Data are from the Multiple Cause of Death Files, 1999-2020, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at http://wonder.cdc.gov/ucd-icd10.html on Dec 1, 2022.

2. Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Provisional Mortality on CDC WONDER Online Database. Data are from the final Multiple Cause of Death Files, 2018-2020, and from provisional data for years 2021-2022, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at http://wonder.cdc.gov/mcd-icd10-provisional.html on Dec 1, 2022

3. Centers for Disease Control and Prevention. (2022, June 28). Suicide data and statistics. Centers for Disease Control and Prevention. Retrieved December 1, 2022, from https://www.cdc.gov/suicide/suicide-data-statistics.html

4. Bostwick, J. M., Pabbati, C., Geske, J. R., & McKean, A. J. (2016). Suicide attempt as a risk factor for completed suicide: Even more lethal than we knew. American Journal of Psychiatry, 173(11), 1094–1100.

5. Hawton, K., Lascelles, K., Pitman, A., Gilbert, S., & Silverman, M. (2022). Assessment of suicide risk in mental health practice: shifting from prediction to therapeutic assessment, formulation, and risk management. The Lancet Psychiatry.

6. Dazzi, T., Gribble, R., Wessely, S., & Fear, N. T. (2014). Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence?. Psychological medicine, 44(16), 3361-3363.

Tyler Black, MD, FRCPC

Assistant Clinical Professor

Department of Psychiatry

The University of British Columbia

How To Cite This Post:

[Peer-Reviewed, Web Publication] Huang, E. Richardson, J. (2023, Jan 2). COVID-19 and Mental Health. [NUEM Blog. Expert Commentary by Black, T]. Retrieved from http://www.nuemblog.com/blog/covid-mental-health

Malingering in the Emergency Department

Written by: Aaron Wibberley, MD (PGY-2) Edited by: Kaitlin Ray, MD (PGY-4) Expert commentary by: Chris Lipp, MD

Expert Commentary

Malingering is a patient behaviour with a profound hazard: the misdiagnosis of a “deceptive” patient who in reality has a serious medical illness. Chief complaints associated with malingering may coincide with a vast differential of possibilities: neck pain, symptoms after head trauma, and abdominal pain. Just like musculoskeletal back pain is a diagnosis of exclusion for a patient presenting with acute discomfort, malingering can be considered when a patient has been thoroughly assessed based on their history and physical examination (with appropriate diagnostic testing). Tools exist to help psychiatrists, neurologists and occupational physicians in diagnosing malingering, but these are largely out of the skill set of most emergency physicians. To determine if malingering should be suspected there are several questions to consider: are there any rewards the patient may be seeking after? What incentive may the patient have to seek after hospitalization, time off work, or addictive medication prescriptions? In most cases a team-based approach involving interdisciplinary professionals and sufficient collateral information are required to (1) make the diagnosis of malingering substantiated and (2) free from the excessive medicolegal risks of misdiagnosis. Emergency department clinicians must vigilantly consider malingering, factitious disorders, and other psychiatric illness as diagnoses of exclusion.

Chris Lipp, MD

Attending Physician

Calgary Emergency Medicine

Author at CanadiEM

Co-Founder of CRACKCast

How To Cite This Post

[Peer-Reviewed, Web Publication] Wibberley, A. Ray, K. (2020, Feb 24). Malingering in the ED. [NUEM Blog. Expert Commentary by Lipp, C]. Retrieved from http://www.nuemblog.com/blog/malingering

Assessment of the Suicidal Patient

Written by: Kaitlin Ray, MD (NUEM PGY-4) Edited by: Matt Klein, MD (NUEM ‘18) Expert commentary by: Julie Cooper, MD (NUEM ‘11)

Approach to Assessing Suicidal Ideation in the Emergency Department

As the 10th leading cause of death in the United States, suicide has become a pervasive public health issue taking over 44,000 lives annually [1]. Each year, over 12 million emergency department (ED) visits are related to mental health and substance abuse issues, and over 650,000 patients are evaluated for suicide attempts [2]. An estimated 9.3 million American adults reported having suicidal thoughts in 2015, among which 2.7 million thought through a suicide plan. Of those adults who have thought through a plan, half 1.3 million actually attempted suicide [3]. Unfortunately, suicidal ideation is one of the most common psychiatric chief complaints encountered by emergency medicine physicians, and the ED is playing an increasingly critical role in providing acute psychiatric care [3].

The unfortunate reality is that many mental health programs and community initiatives have limited resources and are at maximum capacity [2]. As such, the ED is often the only available option for management of acute and subacute psychiatric illness [2]. In fact, the Joint Commission’s National Patient Safety Goal (NPSG) orders that general hospitals “conduct a risk assessment that identifies specific characteristics of the individual served and environmental features that may increase or decrease the risk for suicide”. Further, the National Action Alliance Clinical Care and Intervention Task Force specifies that suicide assessment “should be completed by a professional with appropriate and specific training in assessing for and evaluating suicide risk…and [the professional] must have the skills to engage patients in crisis and to elicit candid disclosures of suicide risk in a non-threatening environment” [4].

In an attempt to meet these goals and provide psychiatric care to those in need, EM physicians are faced with the unique expectation to execute an organized, efficient, and effective approach to suicide assessment that ensures patient and public safety. The process of eliciting the aforementioned ‘candid disclosure’ can be a daunting task during an emergent visit without a previously established relationship [2]. This problem is further complicated by the increasing reliance on the ED for acute psychiatric care which can exacerbate overcrowding, leading to decreased quality of care and increased likelihood of medical error. Further, mental health associated visits are 2.5x more likely to result in an admission requiring resource intensive care, which can negatively impact quality of care for other patients [5].

The continued emphasis on screening for suicidal ideation in the ED necessitates EM physicians to understand and perform a suicide risk assessment [6]. Of note, it is critical to differentiate suicide screening and suicide assessment. Screening refers to a standardized instrument or protocol that identifies individuals at risk for suicide; a process often performed in triage independent of chief complaint or presenting symptoms. Assessment refers to a comprehensive evaluation performed by a clinician to not only confirm suspected suicide risk, but also to estimate immediate danger to the patient and implement a treatment plan [4]. The focus of this piece is targeted toward the assessment and evaluation of a patient once already determined to be at risk for suicide per various screening methods (Mental Health Triage Scale, Behavioral Health Screening, Manchester Self-Harm Rule, ReACT Self-Harm Rule, P4 Screener, Beck Depression Scale, Geriatric Depression Scale) [7].

Suicide assessment and evaluation in the ED is an imperfect science with a limited evidence base to guide management [4]. Further, neither the American Psychiatric Association nor the American College of Emergency Physicians (ACEP) have issued guidelines addressing acute ED management of suicidal patients, leading to markedly varied practice patterns in hospitals across the United States [2]. While there are efforts to develop a quantitative method through which to identify those at highest risk of suicide, there is no universally accepted scoring system, and currently clinical judgment remains the most essential factor [6].

In the majority of emergency departments across the country, the EM physician is responsible for the assessment and disposition of patients with suicidal ideation. Multiple factors are taken into account when defining the role of an EM physician during this process including the following:

Providing a safe environment: Take care to ensure the safety of both the patient and other health care providers. This process often requires taking patient’s clothing in exchange for a hospital gown, searching and withholding personal belongings, 1:1 observation, and physical or chemical restraints if deemed appropriate. Conduct the evaluation in a non-judgmental fashion, preferably in a private or semi-private setting utilizing open-ended questions [2].
Ruling out “reversible” causes of depression/suicidal ideation: Consider toxic ingestions, infectious processes, toxic-metabolic etiology, and trauma as possible causative factors when clinically indicated. ACEP issued a Level B recommendation regarding obtaining routine laboratory testing in alert, cooperative patients with normal vital signs and a non-focal history and physical. Routine urine drug screens (UDS) are a Level C recommendation and should not delay patient evaluation or transfer to more advanced psychiatric care [2]. Of note, one should insist on a clinically sober assessment, not based on BAC, given the disinhibiting effect of alcohol.
Assessing the degree of imminent risk to the patient: Arguably the most challenging yet critical component of the process. The Suicide Prevention Resource Center (SPRC) has developed a 5-step process to guide the clinical assessment of patients with suicidal ideation and is one that can be implemented in the ED setting [8]. SAFE-T, the Suicide Assessment Five-Step Evaluation and Triage, is a simple methodical approach that focuses on identifying risk factors for suicide, identifying protective factors, conducting the suicide inquiry, determining the risk level of the patient, and finally documenting the clinical assessment [8]. Each component will be elaborated on separately.

Identifying risk factors for suicide:

Prior history of suicide attempts: The single strongest predictor of suicide with these patients being 6x more likely to make another attempt [2].
Current lethal plan: Highly predictive of future suicide attempt [6].
Older age: While younger patients typically have more attempts at suicide, older patients are more likely to succeed2. The highest rates of suicide are found among middle-aged populations between 45-64 years old [1].
Coexisting psychiatric disorder: Major Depressive Disorder, schizophrenia, personality disorder, borderline personality disorder, bipolar disorder, PTSD [2]
Recent psychosocial stressor: Ask about marital status, employment, social support, homelessness, financial stressors
Caucasian Race: Highest suicide rates among whites, specifically white males who account for 7/10 suicides in the US [1]. The 2nd highest suicide rate is among American Indians/Alaska Natives, where suicide is now the leading cause of death in those aged between 10-34 years of age [3].
EtOH/Drug Abuse: Chronic use elevates suicide risk long term, while acute intoxication disinhibits and impairs thought process, increasing suicide risk in a more immediate context [6].
Other factors to consider [6]:
- Gender: Women attempt suicide 4x more frequently than men; however men are 3x as successful as women in completing suicide [2].
- Access to firearms: Utilization of firearms accounts for 50% of all suicides in the US, with higher rates among men1. Poisoning is the most common method among females [3].
- Impulsivity: Look for behaviors and statements from the patient that establish a pattern of impulsive behavior [2].
- Family history of suicide/mental illness
- History of childhood trauma
- Chronic physical illness

Identifying protective factors for suicide

No past suicidal ideation: Denies feelings of hopelessness and depression [6]
Supportive family and social network [9]
Willingness to seek and accept help [9]
Strong personal relationships [9]
Female gender [9]
Ethical, moral, or religious suicide taboos [9]
Employment and financial stability [9]
Having dependents [9]
Positive self-esteem [9]

Conducting suicide inquiry [8]

Ideation: Frequency? Intensity? Duration? How often in past 48 hours? Past month?
Plan: Inquire about timing, location, lethality, availability, and any preparatory acts that may be involved
Behaviors: Past attempts? Aborted attempts? Any rehearsals—tying a noose? Loading a gun?
Intent: Evaluate the extent to which the patient intends to carry out the plan and believes the act to be lethal versus self-injurious. If possible discuss with patient their reasons to die vs. reasons to live.

Determining risk level and need for interventions

A patient’s risk level and subsequent treatment disposition is based on clinical judgment!
Charted below is a general rule of thumb in guiding a patient’s disposition from the ED [8]:

Screen Shot 2019-09-29 at 10.07.16 AM.png

Documenting the clinical assessment

Documentation is the fifth and final component of a suicide assessment in the ED. Be clear to document the patient’s estimated risk level as well as the rationale for doing so. Specify the treatment plan that will address the patient’s current risk [8].

Perhaps the most challenging portion of assessing a suicidal psychiatric complaint is determining the patient’s disposition. In many facilities, a formal psychiatric assessment would require an inpatient hospitalization. Additionally, it is state (not federal) laws that govern conditions in which you may involuntarily hold a patient for an emergency psychiatric evaluation, with a hold >72 hours typically requiring a court order. Unfortunately there is no clear evidence to support the use of suicide contracts in the ED—i.e. written or verbal agreements between the physician and the patient in which the patient agrees to abstain from self-harm behaviors while in the ED and for a set amount of time thereafter. While psychotropic medications are rarely initiated in the emergency department, it may be reasonable to prescribe a short course of anxiolytics as a bridge to psychiatric follow up in a patient determined safe for discharge home. Patients determined safe for outpatient follow-up should be given strict return precautions in addition to resources that include emergency and crisis phone numbers. Finally, as with all other life threatening conditions that come through the ED, documentation regarding the risk assessment and disposition of the patient is critical [2].

Ultimately, until our mental health and community resources have the means to meet the growing psychiatric demands of our country, the emergency department will continue to be a resource to provide acute psychiatric care. Limited evidence-based recommendations and no official standardized guidelines exist to assist emergency physicians in assessing risk of suicidality; however, adhering to the basic process of identifying high risk features in addition to protective factors, while simultaneously asking direct questions regarding suicidal ideation, plan, behavior, and intent, can guide EM physicians towards making an appropriately and timely disposition for the suicidal patient.

Expert Commentary

Thanks so much for this excellent review of the approach to the patient with suicidal ideation. What a complex task to perform in our already complex practice, but also what a pleasure to care for someone when the major tool in our toolbox is taking the history! This review correctly notes that the emergency physician “must have the skills to engage patients in crisis and to elicit candid disclosures of suicide risk in a non-threatening environment”. So, what exactly are those skills?

First, we know that the typical ED environment is not always conducive to sensitive conversations. I once heard a resident walk up to a patient in the hallway and say “Hi! I heard you were suicidal!”. Whether the patient is mean, intoxicated, or has some kind of perceived secondary gain, observe your cognitive biases and overcome the urge to minimize their perceived risk. Consider location bias when they are in a hallway, anchoring bias when staff tell you “they were just discharged yesterday”. Those all may be reasons a patient is destabilized and at high risk, so be on alert. Many of these patients wait for hours, have difficult lives and none of us went into medicine to be mean to vulnerable people. Get them the sandwich and a warm blanket, create some privacy and pull up a chair.

Conversations surrounding mental health and suicidality can trigger intense feelings of shame or embarrassment (in both the patient and clinician), elicit anxiety surrounding the consequences of seeking help or conjure memories of negative experiences with the mental health system. Language really does matter when it comes to building trust and conveying empathy. I always start my history open ended with “how did you end up here today?” and assume no knowledge of the events that brought them in. The details of how a person actually came to be in the ED can shine a light on their risk. Did they come seeking help themselves? Did another person encourage them who may have important collateral information? Was law enforcement involved? If they are not forthcoming I might try “I heard … is that correct?”

If a patient doesn’t bring up suicidal thoughts on their own I often start with “It sounds like you have been feeling really badly leading up to today, were you worried about your safety?”. I’ll work up to “were you worried you might harm or kill yourself?” and try to tease out “how close” they might have gotten by asking “did you actually do something to try to harm yourself or was there something you were worried about doing?” For an attempt that doesn’t seem serious to me (a small over the counter ingestion or superficial self-injurious behavior like cutting) I will ask what they thought was going to happen when they did that. Often it might be a serious attempt in their eyes. When considering protective factors I always ask “what kept you from going through with it?”. This might bring up mitigating factors that reduce their suicide risk.

The assessment of a suicidal patient can be an opportunity to switch gears during a shift and focus on the kind of communication that is fundamental to the practice of medicine. If you’re looking to build your skills, consider seeking feedback from mental health professionals like psychiatrists, nurses or social workers in your department or observe them on shift to learn language you might integrate. That is how I picked up one of my favorite tools for an emotional patient encounter: expressing gratitude. If a patient acknowledges suicidal feelings, try “thank you so much for sharing that with me, I know it was hard and we are here to help.”

Julie Cooper, MD

How To Cite This Post

[Peer-Reviewed, Web Publication] Ray K, Klein M. (2019, Sept 30). Assessment of the Suicidal Patient. [NUEM Blog. Expert Commentary by Cooper J]. Retrieved from http://www.nuemblog.com/blog/assessment-SI.

Chemical Sedation of the Agitated Patient in the ED

Written by: Zach Schmitz, MD (NUEM PGY-3) Edited by: Jason Chodakowski (NUEM PGY-4) Expert commentary by: Spenser Lang, MD (NUEM 2018)

Expert Commentary

Chemical Sedation of the Agitated Patient

This is a wonderful infographic from Dr. Schmitz discussing the various tools at the disposal of the emergency physician regarding agitated patients. Unfortunately, this type of encounter in the Emergency Department occurs rather frequently. Agitated patients can represent danger to themselves, staff, and even other patients, and thus the shrewd emergency physician should be prepared to act quickly and efficaciously. Importantly, organic illness can manifest with agitation as well, and trainees do well to remember that the cause of the agitation is just as important as the management.

I want to highlight the ethical aspect of chemical sedation. Given that this is a relatively frequent encounter in the ED, physicians and nurses risk becoming desensitized to these patients. The decision to chemically sedate a patient is paramount to taking away a patient’s autonomy, so should never be taken lightly. Also, in an academic environment, it is especially important to model professionalism in this vulnerable population. For this reason, I tend to discourage the use of terms such as “chemical takedown” and “B52.” Still, the safety of the patient and staff remains the most important factor, and if this is in question, it’s time to proceed rapidly and efficaciously.

I always attempt verbal de-escalation – in the “agitated but cooperative” population this will often work (see http://www.nuemblog.com/blog/verbal-deescalation). More often, an experienced nurse or tech can have a tremendous impact on these patients. However, if I am called back to the bedside for a 2nd time to attempt this process, that is usually another trigger for medications. If I have been called twice, that means this patient is taking up an abundance of nursing and support staff, putting other patients at relative risk. At this point I offer oral medications (olanzapine, benzodiazepines) if the patient is receptive, or proceed with IM medications if necessary.

Once you have made the decision to chemically sedate the patient, it is important to do so safely. Gather the necessary staff – this will include security if available, at least one person per limb, plus someone able to control a patient’s head. Before any needles come near the body, it is of utmost important to ensure the limbs are controlled, to avoid accidental needle sticks for the staff. For the best positioning for patients in restraints, see the image below. I always recommend keeping the head of the bed elevated to around 30 degrees. After the patient is appropriately sedated, feel free to remove the restraints if appropriate and safe, and monitor with both pulse oximetry and end-tidal capnography if there is concern for significant respiratory depression.

Image from: Scott Weingart. Podcast 060 – On Human Bondage and the Art of the Chemical Takedown. EMCrit Blog. Published on November 13, 2011. Accessed on March 8th 2019. Available at [https://emcrit.org/emcrit/human-bondage-chemical-takedown/ ]. — Image from: Scott Weingart. Podcast 060 – On Human Bondage and the Art of the Chemical Takedown. *EMCrit Blog*. Published on November 13, 2011. Accessed on March 8th 2019. Available at [https://emcrit.org/emcrit/human-bondage-chemical-takedown/ ].

I want to point out one of the tables above comparing the time of onset in the most common medications administered for agitation. As you can see, both antipsychotics and benzodiazepines have significant delays to onset when given intramuscularly. With this significant delay in onset, it can be tempting to redose the medications. I find nursing staff, since they typically remain at the bedside of these patients, can become impatient with a slow time of onset. As the table shows, midazolam works much more quickly than lorazepam and can prevent a second dose of medications which may be unnecessary and potentially harmful to the patient. As part of my process of administering these medications, I try to counsel everyone involved (security, nursing staff) about what to expect and what our next step will be if the first attempt truly fails.

Spenser Lang, MD

Assistant Professor

Department of Emergency Medicine

University of Cincinnati Medical Center

How to Cite This Post

[Peer-Reviewed, Web Publication] Schmitz Z, Chodakowski J. (2019, Sept 2). Chemical Sedation. [NUEM Blog. Expert Commentary by Lang S]. Retrieved from http://www.nuemblog.com/blog/chemical-sedation .

Verbal De-escalation in the ED

Written by: Vidya Eswaran, MD (NUEM PGY-3), Zach Schmitz, MD (NUEM PGY-2), Abiye Ibiebele, MD (NUEM PGY-2) Edited by: Michael Macias, MD and Arthur Moore, MD (NUEM Alum ‘17) Expert commentary by: John Bailitz, MD

Introduction

I’ve been suffering in that waiting room for hours!
That worthless tech stabbed me with a needle ten times!!
If you don’t give what I want right now, I am going to hurt someone!!!

Every emergency physician can recall a time when they hear these words or similar phrases echoing throughout the Emergency Department (ED). As a patient becomes increasingly agitated, nearby staff and visitors become distracted, and ultimately concerned about everyone’s safety. Emergency Physicians can help restore the calm amidst the chaos by recognizing subtle clues and intervening early.

According to the Bureau of Labor Statistics, those who work in the healthcare sector had three times the rate of illness and injury from violence compared to all private industries [1]. In a survey of emergency medicine residents, 65.6% reported an experience of physical violence by a patient, 96.6% reported verbal harassment from a patient, and 52.1% reported sexual harassment by a patient. Often these patients were under the influence of drugs or alcohol, had a psychiatric disease, or an organic cause of their agitation, such as dementia [2]. In Australian emergency departments, 3 of every 1000 ED visits are associated with an episode of violence or acute behavioral disturbance [3].

When violence by a patient is imminent or has already occurred, the patient requires immediate restraint by either chemical or physical means [4]. ACEP guidelines for patient restraints supports the careful and appropriate use of restraints or seclusion if “careful assessment establishes that the patient is a danger to self or others by virtue of a medical or psychiatric condition and when verbal de-escalation is not successful [5].” Verbal “de-escalation techniques aim to stop the ascension of aggression to violence, and the use of physically restrictive practices, via a range of psychosocial techniques [6],” and should be tried before one simply grabs “5 and 2.”

Clinical Approach to Agitation

How do you determine which patients would benefit from verbal de-escalation?

Look for the agitated patient, the one who has an angry demeanor, using loud and aggressive speech, seems tense and is grasping their bed rails or clenching their fists, the one who is pacing or fidgeting [4]. These patients are in the pre-violent stage, and may have the potential to be successfully talked down. If a patient has already engaged in violent acts, it is too late to intervene with verbal de-escalation methods.

What principles should be used to assist with verbal de-escalation of the agitated patient?

In 2012 the American Association for Emergency Psychiatry offered a consensus statement on verbal de-escalation and created ten key domains to guide care of agitated patients. These domains offer a great framework for how to approach the agitated patient before the situation escalates [7].

Domain 1: Respect the patient’s and your personal space. First and foremost in any patient encounter, especially one with an agitated patient, is your safety. Aim to keep at least 2 arms lengths distance between you and the patient. This offers you room for your own personal safety, and is seen as non-confrontational and non-threatening in the eyes of the patient. Ensure that both you and the patient have an unobstructed pathway to the exits and that you do not stand in the way of the patient’s path to leaving the room.

Domain 2: Do not be provocative. The majority of our interpersonal interactions is communicated not by the words we say, but how we say them. Our body language is crucial and we must be mindful of it when attempting to calm a patient. Keep your hands visible and at ease, bend your knees slightly, avoid excessive direct eye contact and approach your patient from an angle instead of head-on. These positions convey a non-threatening demeanor.

Domain 3: Establish verbal contact. The first person to interact with the patient should be the one who leads the verbal de-escalation. Introduce yourself and tell the patient your role and orient them to their surroundings. Then, ask the patient what they would like to be called. This gives the patient the impression that you believe he or she is important and has some control over the situation.

Domain 4: Be concise and caring. Use short sentences and simple vocabulary to get your point across. Give your patients time to process what you have said and to respond before continuing. You should be prepared to repeat your message multiple times until your patient understands.

Domain 5: Identify wants and feelings. In order to provide empathetic care, you must understand your patient’s perspective. Listen carefully to what your patient says to pick up clues and respond to their desires. One tactic is to say “I really need to know what you expected when you came to the ED today. Even if I can’t provide it, I would like to know so that we can work on it together.”

Domain 6: Listen closely to what the patient is saying. This is closely related to Domain 5. Practice closed loop communication, repeat what the patient has told you to ensure you have understood them correctly.

Domain 7: Agree, or agree to disagree. Look for something that you can agree with in what the patient is saying. “I agree, waiting can be frustrating” or “Yes, I understand that the nurse has stuck you three times.” However, if you can’t find something to agree with the patient about, do not lie - agree to disagree.

Domain 8: Lay down the law and set clear limits. Draw a line which the patient must not cross. Let him or her know that harming himself or others is unacceptable and will result in specific consequences (seclusion, arrest, prosecution). This should not be portrayed as a threat, but rather be conveyed in a respectful manner. You can preface it with “Your behavior is making our staff uncomfortable and that makes it difficult for us to help you.”

Domain 9: Coach the patient on how to stay in control. Give the patient tactics they can use to help de-escalate the situation. “If you sit down we can discuss why you are here.”

Domain 10: Be optimistic and provide hope that the patient will be able to get to a favorable outcome. “I don’t want you to stay here longer than you need to. Let’s work together to help you get out of here feeling better.” Be sure to debrief with the patient and staff after the de-escalation, so that there is a strategy in place if this were to happen again.

Other strategies include recruiting the patient’s friends and family to help and to employ the three Fs technique - feel, felt, found [8]. “I understand that you feel X. Others in the same situation have felt that way to. Most have found that doing Y can help [4].”

Think of verbal de-escalation as a procedure just like intubations or central lines - with practice, comes mastery. Rehearse what you plan to say, and do mental run-throughs of de-escalations. Watch and learn from others who do this well. The English Modified De-Escalating Aggressive Behaviour Scale (EMDABS) is a validated tool you can use to assess your performance during de-escalations [9].

Summary

Unfortunately, physical and chemical restraint of the severely agitated patient is sometimes needed to protect ED staff, visitors, and the patient themselves. [10,11]. But by recognizing subtle signs of agitation early, we can often utilize effective verbal-de-escalation techniques to create safety for everyone!

Check out our infographic for an easy to use mnemonic which summaries key points.

Expert Commentary

Thank you for this outstanding review of an incredibly important topic topic with tragically little supporting evidence to guide best practice. Colleagues and patients in multiple different practice settings throughout Chicago have repeatedly taught me several key pearls and pitfalls when dealing with the agitated patient.

For the mildly agitated patient, always open with an apology that empathically validates the patient or visitor emotions. “I am very sorry that you have been suffering in the waiting room for so long. That must have been very frustrating. My sincere apologies.” Never reply with a sharp justification or any explanation. Just acknowledge their frustration, own it, and the patient will quickly move past the emotion. Often times, this first connection forms the foundation of a healthy patient physician relationship and even a thank you letter to your ED Director.

For the patient whose agitation is escalating despite appropriate efforts by trained ED staff, call security or hit the duress button for back up before stepping into any potentially risky situation. If you are single covered at 3 AM, you cannot become another patient. When help arrives, ask security to simply stand in the hallway as you begin your DEFUSE techniques. Politely but purposefully excuse inexperienced staff members who have themselves become agitated and entered into a shouting match with patients or visitors. Always keep your own emotions in check and debrief with everyone involved after each learning opportunity.

Finally, when the sedation is needed for patient and staff safety, assemble your team, and proceed with the utmost professionalism. As a physician, you have no role in the physical restraint process unless absolutely necessary. Your security staff has been trained in proper physical restraints while chemical sedation catches up with the dangerous patient. If the patient is acutely agitated without concerns for respiratory depression, utilize 5 mg of Haldol + 5 mg of versed instead of the traditional 2 mg of Ativan. Everyone in the ED will become safer more quickly and the patient will wake up more rapidly for reassessment.

Just remember, “Patients First” always starts with everyone’s safety first!

John Bailitz, MD

Program Director, Northwestern Emergency Medicine

How To Cite This Post

[Peer-Reviewed, Web Publication] Eswaran V, Schmitz Z, Ibiebele A, Macias M, Moore A. (2019, March 4). Verbal De-escalation in the ED. [NUEM Blog. Expert Commentary by Bailitz J]. Retrieved from http://www.nuemblog.com/blog/verbal-deescalation

References

Nonfatal Occupational Injuries and Illnesses Requiring Days Away From Work, 2014.Bureau of Labor and Statistics News Release. 2015. http://www.bls.gov/news.release/archives/osh2_11192015.pdf
Schnapp et al. Workplace Violence and Harassment Against Emergency Medicine Residents, WJEM 2016: 17(5) 567-573. https://www-ncbi-nlm-nih-gov.ezproxy.galter.northwestern.edu/pmc/articles/PMC5017841/pdf/wjem-17-567.pdf
Downes et al. Structured team approach to the agitated patient in the emergency department. Emergency Medicine Australasia (2009) 21, 196-202 http://onlinelibrary.wiley.com.ezproxy.galter.northwestern.edu/doi/10.1111/j.1742-6723.2009.01182.x/epdf
Moore, G and Pfaff, J. Assessment and emergency management of the acutely agitated or violent adult.Up to Date. https://www-uptodate-com.ezproxy.galter.northwestern.edu/contents/assessment-and-emergency-management-of-the-acutely-agitated-or-violent-adult?source=search_result&search=Assessment%20and%20emergency%20management%20of%20the%20acutely%20agitated%20or%20violent%20adult&selectedTitle=1~150#H17
ACEP Policy on Patient Restraints https://www.acep.org/Clinical---Practice-Management/Use-of-Patient-Restraints/
Price et al. Learning and performance outcomes of mental health staff training in de-escalation techniques for the management of violence and aggression. The British Journal of Psychiatry (2015) 206, 447-455 http://bjp.rcpsych.org.ezproxy.galter.northwestern.edu/content/bjprcpsych/206/6/447.full.pdf
JS Richmond et al. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health 2012: 13(1) 17-25. http://escholarship.org/uc/item/55g994m6
Nickson, C. De-Escalation. Life in the Fast Lane. 2014. http://lifeinthefastlane.com/ccc/de-escalation/
Mavandadi et al. Effective ingredients of verbal de-escalation: validating an English modified version of the ‘De-Escalating Aggressive Behaviour Scale’. Journal of Psychiatric and Mental Health Nursing, 2016, 23, 357-368. http://onlinelibrary.wiley.com.ezproxy.galter.northwestern.edu/doi/10.1111/jpm.12310/epdf
Weingart, S. Podcast 060 – On Human Bondage and the Art of the Chemical Takedown. EMCrit. 2011. http://emcrit.org/podcasts/human-bondage-chemical-takedown/
Nickson, C. Chemical Restraint. Life in the Fast Lane. 2014. http://lifeinthefastlane.com/ccc/chemical-restraint/

Posted on March 4, 2019 by NUEM Blog and filed under Psychiatry and tagged verbal de-escalation psychiatry violence patient safety.

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