Acute Psychiatric Emergencies E-Book
56,99 €
Mehr erfahren.
- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Serie: Advanced Life Support Group
- Sprache: Englisch
Acute Psychiatric Emergencies is designed for all medical and healthcare professionals working with patients in mental health crisis. This manual is a key component of the Acute Psychiatric Emergencies (APEx) course, which uses a structured approach developed by leading psychiatry and emergency medicine specialists with years of practical experience. This valuable resource provides a practical approach for dealing with mental health emergencies, helping healthcare professionals from different specialties speak a common language and develop a shared understanding that expedites excellent care. The manual outlines the assessment and management of patients who have self-harmed, those that are apparently drunk, the patient behaving strangely, the patient with acute confusion, and those that are aggressive. * Presents a structured, practical approach for the emergency care of patients presenting in acute psychiatric crisis * Covers common presentations of psychiatric emergencies * Emphasises close co-operation of emergency and mental health teams * Offers content designed jointly by practicing psychiatrists and emergency physicians from the Advanced Life Support Group (ALSG) Acute Psychiatric Emergencies will be useful for practitioners of emergency medicine, psychiatry, emergency and mental health nursing as well as other mental health and crisis care professionals.
Sie lesen das E-Book in den Legimi-Apps auf:
Seitenzahl: 268
Veröffentlichungsjahr: 2020
Ähnliche
Table of Contents
Cover
Working group
Contributors
Foreword
Preface
Acknowledgements
Contact details and website information
Updates
References
On‐line feedback
How to use your textbook
The anytime, anywhere textbook
CHAPTER 1: Structured approach to acute psychiatric emergencies
1.1 Introduction
1.2 Preparation
1.3 Close working between emergency and psychiatry staff
1.4 Communication
1.5 Consent
1.6 A structured approach
1.7 Summary
CHAPTER 2: Primary unified assessment and immediate psychiatric management
2.1 Introduction
2.2 Preparation
2.3 Primary assessment – the unified assessment
2.4 Primary physical risk assessment
2.5 Primary psychiatric risk assessment
2.6 Unified assessment and immediate treatment
2.9 Person‐centred care
2.10 Legal framework
2.11 Secondary assessment
2.12 Summary
CHAPTER 3: Secondary physical and psychosocial assessment
3.1 Introduction
3.2 Focused physical history and examination
3.3 Focused conversational psychosocial history
3.4 Secondary psychosocial (mental state) examination
3.5 Summary
CHAPTER 4: The patient who has harmed themselves
4.1 Introduction
4.2 General principles
PUTTING IT ALL TOGETHER – THE STRUCTURED APPROACH TO ASSESSMENT
4.3 Preparation
4.4 Primary assessment – the unified assessment
4.5 Secondary assessment
4.6 Case examples
4.7 Emergency management
4.8 Refusal to accept physical treatment following self‐harm
4.9 Summary
CHAPTER 5: The apparently drunk patient
5.1 Introduction
5.2 Pathophysiology and measurement of alcohol intoxication
5.3 Screening for alcohol intoxication
5.4 If it’s not (just) alcohol intoxication, what is it?
PUTTING IT ALL TOGETHER – THE STRUCTURED APPROACH TO ASSESSMENT
5.5 Preparation
5.6 Primary assessment – the unified assessment
5.7 Unified assessment and immediate treatment
5.8 Secondary assessment
5.9 Emergency management
5.10 Determine disposal/confirm route of care (CROC)
5.11 Handover
5.12 Brief interventions in the ED
5.13 Case example
5.14 Summary
CHAPTER 6: The patient behaving strangely
6.1 Introduction
PUTTING IT ALL TOGETHER – THE STRUCTURED APPROACH TO ASSESSMENT
6.2 Preparation
6.3 Primary assessment – the unified assessment
6.4 Secondary assessment
6.5 Emergency management
6.6 Case examples
6.7 Summary
Appendix 6.1 Organic disorders with psychiatric presentations
Appendix 6.2 Strange behaviour associated with drug and alcohol misuse
Appendix 6.3 Commonly encountered psychiatric presentations
CHAPTER 7: The acutely confused patient
7.1 Introduction
7.2 Acute confusional states
PUTTING IT ALL TOGETHER – THE STRUCTURED APPROACH TO ASSESSMENT
7.3 Preparation
7.4 Primary assessment – the unified assessment
7.5 Unified assessment and immediate treatment
7.6 Secondary assessment
7.7 Emergency management
7.8 Determine disposal
7.9 Handover
7.10 Case example
7.11 Summary
CHAPTER 8: The aggressive patient
8.1 Introduction
8.2 Principles in assessing aggression and violence
8.3 Risk formulation
8.4 Managing potential aggression and violence
8.5 Assessment, prevention and management of risk
8.6 Case examples
8.7 Summary
Appendix 8.1 Rapid tranquillisation
CHAPTER 9: Legal aspects of emergency psychiatry
9.1 Introduction
9.2 Determining mental capacity
9.3 Treating a patient who does not have mental capacity
9.4 Treating a patient who has mental capacity
9.5 Consent
9.6 Confidentiality
9.7 Documentation
9.8 Summary
CHAPTER 10: Human factors
10.1 Introduction
10.2 Extent of healthcare error
10.3 Causes of healthcare error
10.4 Human error
10.5 Communication
10.6 Team working, leadership and followership
10.7 Situation awareness
10.8 Improving team and individual performance
10.9 Summary
CHAPTER 11: The patient experience
11.1 Introduction
11.2 Aspects of a patient’s experience
11.3 Summary
Index
End User License Agreement
List of Tables
Chapter 2
Table 2.1 AEIO assessment: minimum number of staff required for safe containm...
Chapter 5
Table 5.1 Reference guide for units
Table 5.2 Alcohol levels and associated symptoms and signs
Chapter 7
Table 7.1 Pooled point prevalence of delirium in different patient population...
Table 7.2 Causes of delirium
Table 7.3 Factors that increase the risk of delirium and hinder recovery
Chapter 8
Table 8.1 Recommended drugs and doses in adults (elderly or debilitated shoul...
Chapter 10
Table 10.1 Potential causes of our example error
Table 10.2 Types of errors
Table 10.3 Elements of communication
List of Illustrations
Chapter 1
Figure 1.1 The structured approach
Chapter 2
Figure 2.1 Structured approach: primary assessment
Chapter 3
Figure 3.1 Structured approach: secondary assessment
Chapter 4
Figure 4.1 ED pathway for patients who have harmed themselves
Figure 4.2 Manchester Triage System: self‐harm chart.
Figure 4.3 Building a risk profile in self‐harm
Figure 4.4 Decision making in the event of a person refusing treatment for t...
Chapter 8
Figure 8.1 Assessment and prevention
Figure 8.2 Rapid tranquillisation
Chapter 9
Figure 9.1 The approach to a patient who refuses treatment or care
Figure 9.2 The patient who refuses treatment or care and does not have capac...
Figure 9.3 The patient who refuses treatment or care and has capacity
Chapter 10
Figure 10.1 The Swiss cheese model
Figure 10.2 Similar package design of two different medications
Figure 10.3 Team situation awareness
Guide
Cover
Table of Contents
Begin Reading
Pages
iii
iv
vi
vii
viii
ix
xi
xii
xii
xiii
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
51
52
53
54
55
56
57
58
59
60
61
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
111
112
113
114
Acute Psychiatric Emergencies
A Practical Approach
Advanced Life Support Group
EDITED BY
Kevin Mackway‐Jones
This edition first published 2020 © 2020 by John Wiley & Sons Ltd
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.
The right of Advanced Life Support Group (ALSG) to be identified as the authors of the editorial material in this work has been asserted in accordance with law.
Registered OfficesJohn Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USAJohn Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
Editorial Office9600 Garsington Road, Oxford, OX4 2DQ, UK
For details of our global editorial offices, customer services, and more information about Wiley products visit us at www.wiley.com.
Wiley also publishes its books in a variety of electronic formats and by print‐on‐demand. Some content that appears in standard print versions of this book may not be available in other formats.
Limit of Liability/Disclaimer of WarrantyThe contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.
A catalogue record for this book is available from the Library of Congress and the British Library.
ISBN 9781119144922
Cover image: © Purestock/Getty Images (Negative Space 2002 Diana Ong)Cover design by Wiley
Note to text:
Drugs and their doses are mentioned in this text. Although every effort has been made to ensure accuracy, the writers, editors, publishers and printers cannot accept liability for errors or omissions. The final responsibility for delivery of the correct dose remains with the physician prescribing and administering the drug.
Working group
Roger Alcock
MB ChB, BSc(hons), FRCP Edin, DCH, FRCEM, Consultant in Emergency Medicine and Paediatric Emergency Medicine, Forth Valley Royal Hospital, Larbert
Helen Bradford
MA, DClinPsy, CPsychol, AFBPsS, Consultant Clinical Psychologist, Bradford Psychology
Mark Buchanan
Consultant in Adult and Paediatric Emergency Medicine, Arrowe Park Hospital
Vanessa Craig
MBBCh, BAO, MRCPsych, Consultant Liaison Psychiatrist, Greater Manchester Mental Health NHS Foundation Trust, Manchester Royal Infirmary
Sandrine Dénéréaz
Paramedic – Paramedics School Director, École Supérieure d’Ambulancier et Soins d’Urgence Romande, Lausanne, Switzerland; President, Commission for Emergencies Health Measures, Lausanne
Fiona Donnelly
BSc, MBChB, MRCPsych, PgDip Psychiatry, PGDip Health and Public Leadership, Consultant Psychiatrist, Mental Health and Home Treatment Team, Wythenshawe Hospital
James Ferguson
MBChB, FRCSEd, FRCS(A&E), FRCEM, FRCPE, Professor in Remote Medicine, Robert Gordon University; Reader in Emergency Medicine, Aberdeen University; Clinical Lead, Scottish Centre for Telehealth and Telecare and Digital Health and Care Institute
Sarah Gaskell
DClinPsy, PGDip, Consultant Clinical Psychologist, Head of Paediatric Psychosocial Services, Royal Manchester Children’s Hospital
Elspeth Guthrie
MBChB, MSc, MD, FRCPsych, Professor of Psychological Medicine, Leeds Institute of Health Sciences, University of Leeds
Damien Longson
PhD, FRCPsych, Consultant Liaison Psychiatrist, Greater Manchester Foundation Trust; Associate Dean, Royal College of Psychiatrists
Kevin Mackway‐Jones
MA, DH, FRCP, FRCS, FRCEM, Professor of Emergency Medicine, Manchester Royal Infirmary and the Royal Manchester Children’s Hospital; Director of Postgraduate Medicine, Manchester Metropolitan University
Laura McGregor
FRCEM, MRCP, DTMH, DIMC, Consultant in Emergency Medicine, University Hospital Monklands; Educational Coordinator, Emergency Medicine, Scottish Centre for Simulation and Clinical Human Factors
Aaron McMeekin
MRCPsych, Consultant Perinatal Psychiatrist, Greater Manchester Mental Health NHS Foundation Trust; Honorary Lecturer, Academic Unit of Medical Education, University of Sheffield
Andrew McNeill Russell
MBChB, MRCS, FRCEM, Consultant in Emergency Medicine, University Hospital Monklands
Rachel Thomasson
PhD, MRCPsych, Consultant Neuropsychiatrist, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust
Sue Wieteska
CEO, Advanced Life Support Group
Damian Wood
MBChB, DCH, MRCPCH, Consultant Paediatrician, Nottingham Children’s Hospital, Queen’s Medical Centre
Contributors
Helen Bradford
MA, DClinPsy, CPsychol, AFBPsS, Consultant Clinical Psychologist, Bradford Psychology
Fiona Donnelly
BSc, MBChB, MRCPsych, PGDip Psychiatry, PGDip Health and Public Leadership, Consultant Psychiatrist, Mental Health and Home Treatment Team, Wythenshawe Hospital
Richard J. Drake
BSc, MBChB, MRCPsych, PhD, Clinical Lead for Mental Health, Health Innovation Manchester; Honorary Consultant, Greater Manchester Mental Health NHS Foundation Trust; Senior Lecturer, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester
Peter‐Marc Fortune
FRCPCH, FFICM, FAcadMEd, Consultant Paediatric Intensivist, Associate Medical Director, Royal Manchester Children’s Hospital
Elspeth Guthrie
MBChB, MSc, MD, FRCPsych, Professor of Psychological Medicine, Leeds Institute of Health Services, University of Leeds
Mark Hellaby
MSc, Med, PG Cert, BSc(Hons) RODP, FHEA, North West Simulation Education Network Manager, NHS Health Education England
Damien Longson
PhD, FRCPsych, Consultant Liaison Psychiatrist, Greater Manchester Foundation Trust; Associate Dean, Royal College of Psychiatrists
Kevin Mackway‐Jones
MA, DH, FRCP, FRCS, FRCEM, Professor of Emergency Medicine, Manchester Royal Infirmary and the Royal Manchester Children’s Hospital; Director of Postgraduate Medicine, Manchester Metropolitan University
Aaron McMeekin
MRCPsych, Consultant Perinatal Psychiatrist, Greater Manchester Mental Health NHS Foundation Trust; Honorary Lecturer, Academic Unit of Medical Education, University of Sheffield
Rachel Thomasson
PhD, MRCPsych, Consultant Neuropsychiatrist, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust
Foreword
This text and the associated course are very valuable at many levels. Emergency mental health presentations in the UK have increased out of proportion to other presentations, and care of these patients in crisis has become an essential core skill for an emergency clinician.
Mental health and emergency clinicians may work in silos due to organisational structure and lack of experience of each other’s fields. The APEx course teaches both emergency and mental health clinicians together, bridging the gaps in experience and knowledge and allowing the professionals to learn from each other.
The unified approach of: A, agitation; E, environment; I, intent; O, objects; alongside the traditional ABCD approach gives confidence to both sets of professionals to ensure safety. It uses a common language which has the potential to become a universal language. It supports the important principle of assessing and managing a patient’s physical and mental health problems alongside each other with equal parity.
A great strength of this course is high‐fidelity simulation in a safe environment and this is supported by the excellent material in this book.
Catherine HayhurstChair, Mental Health CommitteeRoyal College of Emergency Medicine
Preface
Emergency departments offer open access healthcare 24 hours a day, 7 days a week, 365 days a year. The number of patients attending these departments in England increased by 7.4% between 2010–11 and 2016–17 and is currently at an all‐time high. It is unsurprising that a significant proportion of the patients attending emergency departments present with mental health problems, and the number of patients in crisis is increasing at 10% per year and now make up more than 5% (one in 20) of all attenders.
Despite the high numbers of patients attending in mental health crisis (more attend with this presentation than attend with chest pain), the vast majority of emergency department staff are not trained specifically to deal with patients with mental health emergencies or, indeed, to deal with mental illness at all. A value clarification exercise that looked into emergency mental healthcare in one emergency department in London established that the work most valued by the staff was trauma ‘because of the excitement and drama it provided’. The environmental values for good mental healthcare (privacy, quietness, safety, calmness and having time) were noted to be the ‘antithesis’ of the environment found in the emergency department. Experienced emergency department nurses noted a ‘deficit in mental health knowledge’ but were unable to further identify the deficits. A key theme emerged of ‘a perceived conflict between two cultures’ which gives mental health a low status.
The course that this book supports (APEx) is designed to fill some of the gap and more closely align the cultures of care. The content has been designed jointly by psychiatrists and emergency physicians and is presented in a structured manner. Recognisable presentations (such as ‘overdose and poisoning’, ‘aggression’ and ‘behaving strangely’) are dealt with rather than focusing on diagnoses. Primary assessment is achieved with a new bespoke structured approach (ABCD AEIO U) that is similar to the more familiar ABCD emergency care approach to physical emergencies. Secondary assessment consists of parallel physical and psychosocial history and examinations. Throughout the text close co‐operation between emergency and mental health teams is emphasised as is the value of joint working.
Patients in mental health crisis clearly deserve better than they currently get. This book, and the APEx course it supports, is for them.
Kevin Mackway‐JonesManchester 2019
Acknowledgements
We acknowledge the contribution of Satveer Nijjar, Independent Trainer with Lived Experience, ‘Attention Seekers Training’, who provided her personal account to inform Chapter 11: The patient experience.
Contact details and website information
ALSG: www.alsg.org
For details on ALSG courses visit the website or contact:
Advanced Life Support GroupALSG Centre for Training and Development29–31 Ellesmere StreetSwinton, ManchesterM27 0LATel: +44 (0) 161 794 1999Fax: +44 (0) 161 794 9111Email: [email protected]
Updates
The material contained within this book is updated on approximately a 4‐yearly cycle. However, practice may change in the interim period. We will post any changes on the ALSG website, so we advise you to visit the website regularly to check for updates (www.alsg.org).
References
To access references, visit the ALSG website www.alsg.org – references are on the course pages.
On‐line feedback
It is important to ALSG that the contact with our providers continues after a course is completed. We now contact everyone 6 months after his or her course has taken place asking for on‐line feedback on the course. This information is then used whenever the course is updated to ensure that the course provides optimum training to its participants.
How to use your textbook
The anytime, anywhere textbook
Wiley E‐Text
Your textbook comes with free access to a Wiley E‐Text: Powered by VitalSource version – a digital, interactive version of this textbook which you own as soon as you download it.
Your Wiley E‐Text allows you to:
Search: Save time by finding terms and topics instantly in your book, your notes, even your whole library (once you’ve downloaded more textbooks)
Note and Highlight: Colour code, highlight and make digital notes right in the text so you can find them quickly and easily
Organise: Keep books, notes and class materials organised in folders inside the application
Share: Exchange notes and highlights with friends, classmates and study groups
Upgrade: Your textbook can be transferred when you need to change or upgrade computers
Link: Link directly from the page of your interactive textbook to all of the material contained on the companion website
The Wiley E‐Text version will also allow you to copy and paste any photograph or illustration into assignments, presentations and your own notes.
To access your Wiley E‐Text:
Visit
http://support.wiley.com
to request a redemption code via the ‘Live Chat’ or ‘Ask A Question’ tabs (with a proof of purchase).
Go to
https://online.vitalsource.co.uk
and log in or create an account. Go to Redeem and enter your redemption code to add this book to your library.
Or to download the Bookshelf application to your computer, tablet or mobile device go to
www.vitalsource.com/software/bookshelf/downloads
.
Open the Bookshelf application on your computer and register for an account.
Follow the registration process and enter your redemption code to download your digital book.
The VitalSource Bookshelf can now be used to view your Wiley E‐Text on iOS, Android and Kindle Fire!
For iOS:
Visit the app store to download the VitalSource Bookshelf:
http://bit.ly/17ib3XS
For Android and Kindle Fire:
Visit the Google Play Market to download the VitalSource Bookshelf:
http://bit.ly/BSAAGP
You can now sign in with the email address and password you used when you created your VitalSource Bookshelf Account.
Full E‐Text support for mobile devices is available at: http://support.vitalsource.com
We hope you enjoy using your new textbook. Good luck with your studies!
CHAPTER 1Structured approach to acute psychiatric emergencies
Learning outcomes
After reading this chapter, you will be able to:
Describe the approach to preparing for an assessment for a patient with possible mental health problems
Recognise the importance of close working between emergency medicine and psychiatry staff
Recognise the importance of good communication
Identify a structured approach to managing psychiatric emergencies
1.1 Introduction
Psychiatric and behavioural presentations to emergency departments are common – if substance abuse is included in these figures then some 35–40% of presentations (6–8 million each year in England) are defined as such.
Systematic assessment and management of a person with acute mental health problems in the emergency department or other acute hospital setting can present major challenges. Key considerations include:
Emergency department and acute hospital staff receive little training in managing psychiatric emergencies
Responses of mental health staff can be delayed, inconsistent and unsystematic
The acute hospital environment is often not conducive to the provision of good psychiatric care
This text seeks to provide a safe, practical system for practitioners.
1.2 Preparation
Before starting any assessment for a patient with possible mental health problems:
Ensure that appropriate help is available (a person who is showing signs of acute behavioural disturbance requires a team approach)
Ensure there are appropriate facilities to assess the patient
Gather any available information
There must be a safe area where people who are acutely disturbed can be assessed and managed appropriately.
1.3 Close working between emergency and psychiatry staff
The safe and successful management of people with acute mental health problems requires close working between emergency/acute hospital teams with liaison mental health teams. Each team needs to carry out their own tasks, be aware of each other’s skills, and work collaboratively to ensure the best possible outcome.
1.4 Communication
Good communication and basic rapport building with a person with acute mental illness are essential. Communication is no less important with families of patients and with clinical colleagues – especially between those of different disciplines. Detailed records of current clinical findings, the patient’s history, prior mental health records, physical test results and management plans must be completed, and communicated to staff who will be taking over the care of the patient when he/she leaves the emergency department.
1.5 Consent
In an emergency, if it is deemed in the patient’s best interests, hospital staff have a duty of care to treat the patient, provided treatment is limited to that which is reasonably required in that emergency situation.
As consent legislation and practice are complex areas with different practices in different countries and jurisdictions, we will highlight the medicolegal aspects of patient care in relevant chapters, by detailing the principle of what they achieve. Chapter 9 summarises legal aspects in more detail and maps the principle of the relevant laws. The details will differ depending on the jurisdictions where the Acute Psychiatric Emergencies (APEx) course is available.
1.6 A structured approach
A structured approach will enable all clinicians (whether mental health trained or not) to manage psychiatric emergencies optimally, so that patients receive high‐quality care. It will also ensure that important steps in the care process are not forgotten. As it is common for mental and physical health problems to occur at the same time, both require consideration.
A structured approach focuses initially on a primary assessment designed to identify and manage any immediate threats to safety, either for the patient or for others. This involves a rapid assessment of ABCD physical risk and an AEIO psychiatric risk assessment. These then inform the Unified assessment.
After a primary assessment has been completed and relevant steps have been taken to ensure safety, a secondary assessment needs to be undertaken. This includes establishing the key features of the presentation. In particular, it is important to establish whether the presentation is predominantly a physical health or a mental health problem (or a combination of both). This process involves being able to interact with the patient in a manner which conveys understanding and empathy, builds rapport, reduces anxiety and enables information gathering in an effective and efficient manner. Secondary mental health assessment includes a focused conversational psychosocial history and examination of the mental state, while secondary physical health assessment involves a focused physical history and full top‐to‐toe examination. Following on from this, an appropriate emergency treatment and management plan can be identified.
The final phase of the structured approach is to stabilise the patient so that transfer to an appropriate care environment can occur.
Throughout this text the same structure will be used so the clinician will become familiar with the approach and be able to apply it to any clinical emergency situation.
Figure 1.1 shows the structured approach in diagrammatic form.
Figure 1.1The structured approach
1.7 Summary
This book will introduce the structured approach in more detail and then explore its use in the common psychosocial presentations to the emergency department.
CHAPTER 2Primary unified assessment and immediate psychiatric management
Learning outcomes
After reading this chapter, you will be able to:
Explain how to assess someone who is acutely disturbed
Describe how to take structured steps to ensure safety and minimise any potential harm to others
2.1 Introduction
The effective management of an acutely disturbed patient who has presumed mental health problems is a key emergency skill. By using the basic techniques and strategies described, a safe framework can be established, from which a more detailed assessment or intervention can then be carried out. It is essential that all staff who work in an acute hospital setting have these basic skills.
In the structured approach, the person who is acutely disturbed should have a primary assessment that includes ABCD and AEIO risk assessments (see Figure 2.1). It may not be possible to carry out a full physical assessment because of the level of disturbance, but consideration should be given to physical status and potential organic causes of the presentation.
In this chapter, we focus on the mental health assessment, but physical factors should always be considered, and accompanied by a parallel physical assessment, when appropriate.
2.2 Preparation
Never approach a patient who is acutely disturbed by yourself. Wait until a sufficient number of appropriately trained staff, police officers and security guards are present. The number required will depend upon the size of the patient, the nature and degree of their disturbance, and the physical characteristics and resources of the facility in which you are working.
In most circumstances, there is time to gather information quickly before seeing the patient (e.g. if the patient is brought to the emergency department (ED) by the family, the police or the paramedic emergency service). The aim at this point is to access relevant information that will inform the rapid assessment.
Information may include verbal accounts from the family, paramedics, police, relevant others and the hospital record systems. Ask and obtain answers to the following questions:
Can you tell me about the behaviour of X whilst in your care?
On a 10 point scale (0 being not disturbed at all, to 10 being extremely agitated/violent/aroused) how would you rate this person’s behaviour?
Can you tell me about/give me an example of the most extreme or disturbed level of behaviour you have witnessed?
Do they speak English and, if not, what language do they speak?
Many mental health record systems have specific, designated subsections for flagging information about ‘risk of harm to self and others’. However, ED or hospital staff may not have access to these systems. Make sure all relevant information is shared between all staff involved with the patient.
Key factors to note are:
A prior history of self‐harm
A prior history of harm to others
Alcohol and illicit drug use
Prior history of severe mental illness
Prior history of violence, forensic history (mental health treatment in a secure setting because of criminal behaviour) or a criminal record
Before entering a room with a disturbed patient, make sure you have back‐up in terms of available staff who can help if necessary. Have at least two other members of staff with you. There may already be staff or police officers in the room. Stay close to the door and keep it open. Do not allow yourself to be trapped behind the door.
Make sure there is a way to sound an alarm, if needed, with a suitable response. Many ‘safe rooms’ in EDs do not have alarms because of inappropriate, frequent use. So make sure you have a personal attack alarm, or that there is someone outside the room who can call for back‐up.
It is usual for most patients to undergo triage from a member of the ED nursing staff soon after they present. However, if patients are either very physically unwell (for instance if they have stabbed themselves) or are significantly behaviourally disturbed, it may not be possible to do this. Do not assume that behavioural disturbance is due solely to mental health issues. Seek relevant physical health signs or symptoms that need to be addressed.
The structured approach is applicable to patients of all ages, but consideration of developmental factors is vital when dealing with both adults with learning disabilities and children and adolescents. For example, understanding of the irreversibility of death typically develops in middle childhood, so may not be present in adults with learning disability or young children, and this would need to be considered in an assessment of intent. There are additional considerations about child and adult safeguarding. There is also an increased significance in the role of parents and carers who may be a helpful source of information and support but may also be a potential risk.
Figure 2.1Structured approach: primary assessment
2.3 Primary assessment – the unified assessment
The first priority is to ensure that the patient is kept safe (both physically and psychologically) whilst they are awaiting detailed psychiatric assessment or are undergoing physical investigations. They must be prevented from either intentional or unintentional harming of themselves or others. A fast and focused assessment is required to:
Establish the level of physical and psychiatric risk
Put in place appropriate measures to minimise that risk
Observe the patient. Note his/her conscious level, degree of agitation and current behaviour. Introduce yourself:
‘I’m X, I’m a doctor/nurse, I’m here to try and help you’
Ask the patient their name and what they like to be called
Ask them if they know where they are
If they do not know, explain they are in a hospital, they are safe, and you are here to try and help them
As you are doing this, make a quick assessment of the patient’s overt physical health. Look for skin colour (pallor or flushed), whether or not they are sweating, pupil size (pinpoint or dilated), any obvious injuries, any signs of self‐harm (ligature mark around neck, scars to arms) or disabilities.
Ask the patient if they are hurt or in pain. If they respond positively, you will need to get details of their concerns to establish the nature of the injury or their physical health problems. Ask them if it would be okay for someone to check their pulse, temperature and blood pressure.
As you are doing this, make an assessment of their cognitive function, including basic orientation and attention.
Can they give you their name and address and date of birth?
Do they know where they are?
