Introduction
Nearly one out of every eight emergency department (ED) visits in the United States is related to mental illness or substance use. ED visits for mental health issues have been rising by over 20% during the period 2006 to 2018. Acute behavioral disturbances in the ED are both common and potentially dangerous. They are most frequently caused by some combination of acute intoxication, substance withdrawal, and underlying mental illness. Knowledge of common causes of agitation and recognition of signs of escalation are vital to provide effective, patient-centered treatment.
ED technicians (EDTs) play an integral role in the care of patients with mental health disorders. Many resources are often required to effectively care for patients with acute mental health complaints and to avoid an unnecessarily prolonged length of stay in the ED. Thus a streamlined, individualized, and efficient approach to care of this population is vital. Safety of staff and other patients is always paramount.
Terminology
Mental health professionals have a rich vocabulary to describe the symptoms and behavior of their patients; key mental health terms and their definitions follow:
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Bipolar disorder: A condition characterized by manic or hypomanic episodes alternating with depressive episodes, with periods of normal mood between episodes.
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Catatonia: A dramatic reduction of psychomotor activity, may present with rigidity, mutism, failure to eat, use the bathroom, or perform other necessary functions.
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Delirium: An acute, transient, usually reversible, fluctuating disturbance in attention, cognition, and consciousness level. Causes include almost any serious illness or medication. Diagnosis is clinical, with laboratory and usually imaging tests to identify the cause. Treatment is correction of the cause and supportive measures.
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Delusions: Firmly held false beliefs.
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Hallucinations: False perceptions, often auditory or visual.
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Hypomania: Similar to mania (see below); however, symptoms are to a lesser degree.
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Mania: May include euphoric or irritable mood, impulsivity, pressured speech, hypersexuality, inflated self-esteem or grandiosity, flight of ideas, or loosely connected thoughts.
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Psychosis: Hallucinations or delusions that are caused by an underlying psychiatric, medical, neurologic, drug, or other etiology.
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Schizophrenia: A condition characterized by psychosis, hallucinations, delusions, disorganized speech and behavior, flattened affect (restricted range of emotions), impaired reasoning and problem-solving, and often occupational and social dysfunction.
Initial Patient Assessment and Room Assignment
Patients presenting to the ED with abnormal behavior must be rapidly assessed. There are several medical conditions that can mimic psychiatric symptoms, and patients must be screened for these medical problems. Hypoglycemia (low blood sugar), hypoxia (low oxygen), drug or medication overdose, infection, and brain tumors can all masquerade as acute psychiatric illness.
Room assignment is one of the early and critical decision points in the care of a patient experiencing what appears to be an acute psychiatric emergency. The patient should be rapidly evaluated and not be placed in a general waiting area. The individual should be escorted to a special behavioral health room or area with minimal medical equipment and minimal moveable furniture. This type of room most often has a plastered ceiling and walls, a door that can be locked from the outside, and an observation window in the door. Limiting noise and other distractions can help create a more therapeutic physical environment. A 1:1 patient observer (sitter) should be assigned to continually visually monitor the patient to ensure safety. In some institutions, there may be a “tele-sitter” assigned to the patient.
A clinical staff member should assist the patient to completely disrobe, don a special hospital gown that is used specifically for patients with suspected mental illness, and secure the patient’s belongings. This allows for early recognition of a patient who has surreptitiously brought a weapon or other dangerous object into the ED; it also allows easier patient identification if the patient were to elope from the ED. All belongings, including cell phones, are typically removed from the patient, placed in a belongings bag, and locked in a designated belongings area.
Medical evaluation of all patients (especially those presenting with agitation or intoxication) is necessary, as is looking for organic (physical illnesses) causes of abnormal behavior. Although not always possible, it is preferable to obtain vital signs and an electrocardiogram prior to medication administration. The technician may be asked to help with both of these tasks, as well as to obtain bloodwork and a urine specimen for laboratory studies.
Signs of psychiatric illness are not always immediately identified upon patient presentation to the ED. Likewise, a patient may not initially share symptoms such as suicidal thoughts or thoughts of harming others with ED staff. The EDT may be the first staff member aware of such thoughts, and it is important that they alert/inform a nurse or other higher-level provider. If the technician is with the patient and not able to quickly maintain a safe environment or prevent the patient from absconding, the technician should escalate the situation immediately.
If the EDT begins the evaluation on a patient who seems angry or whose potential for violence has not yet been assessed by the physician, they should always stay between the patient and the door or exit. The EDT should keep a safe distance from the patient to avoid physical harm when managing a patient with the potential for aggressive behavior. It is also recommended to avoid wearing a badge or badge clip, jewelry, stethoscope, or a hair style (e.g., a ponytail) that can be used by a patient to cause harm. If the EDT feels threatened at any time during their interaction with the patient, they should call for help, leave the patient’s bedside, and seek assistance immediately.
Techniques for Verbal De-escalation
It is vital to develop a rapport with the patient by introducing oneself with a smile and using a calm tone of voice. If the technician is not sure how to respond to a patient concern, an effective technique can be to repeat terms that the patient used to describe their condition. Initially, use open-ended questions while talking with a patient, and transition to more specific, detailed questions. Many institutions also offer specific training or coursework, including simulation sessions, to practice these techniques in a protected environment. Practice and training in managing patients experiencing psychiatric emergencies is essential to success in caring for this particular population. Table 21.1 describes the elements of verbal de-escalation.
| Maintain a distance of two arm’s length when possible. Respect personal space. |
| Keep hands relaxed. Do not stare at the patient. Do not be provocative. |
| Team leader establishes verbal contact with the patient. |
| Use clear, concise language. |
| Identify the patient’s feelings and desires: “What are you hoping for?” |
| Listen, and restate what the patient said. |
| Set limits related to violent or disruptive behavior. |
| Offer choices and optimism. |
Chemical Sedation
When verbal de-escalation is ineffective and a patient is identified as a risk to themselves or others, or if behaviors have quickly escalated to a dangerous level before verbal de-escalation can be used, patients and those around them must be kept safe. Medication administration will help calm the patient by decreasing their anxiety, treating their psychosis, or sometimes sedating them. The technician will often assist the nurses with persuading the patient to accept medications.
If a patient is willing to take oral medications, this is usually preferable. If not, intramuscular (IM) injections can be used. Multiple categories of antipsychotic medications can be given this way, (e.g., haloperidol) or benzodiazepines (e.g., lorazepam). There are often regional or institutional preferences for which medications to use. Although the onset of medications given by IM injection is slower than those administered intravenously, it is much easier to give an IM injection to an agitated patient than to start an IV. If the patient already has an IV placed, however, the IV administration route may be preferable.
Physical Restraints
Physical restraints are another tool that can be used to ensure safety if verbal de-escalation is insufficient. These are usually placed by a team of no fewer than five persons, often including the EDTs, nurse, and security personnel. A team leader coordinating the response assigns one person to each limb. A patient can often be safely restrained in the supine or side-lying position. Avoid restraining the patient in the prone position as this increases the risk for suffocation. The team leader is responsible for the patient’s head to avoid cervical spine trauma and to maintain an open airway. Typically, if four-point restraints are used, one arm should be up while the other one is down. This is intended to reduce the possibility that the patient will be able to overturn the stretcher. With two-point restraints, the contralateral arm and leg should be used. A sheet or a lap belt may also be used alone or in addition to existing restraints if extra support is needed. Fig. 21.1 demonstrates a type of restraint that can be used to maintain a patient in a seated position, and Fig. 21.2 demonstrates a softer restraint that can be used for patients who need less constricting restraints. Every institution is required to have a detailed protocol for the use of restraints, including team activation, reasons for restraints, and which type of restraints may be used. All patients who are restrained should be reevaluated frequently and the restraints discontinued as soon as possible ( https://www.acep.org/patient-care/policy-statements/use-of-patient-restraints ).
