Older adults on involuntary hold status in the emergency department

BackgroundAs the United States' population ages, the health care system will experience overall change. This study aims to identify factors in the older adult that may contribute to involuntary hold status in the ED.MethodsThis study is a retrospective review conducted at a suburban acute-care hospital ED of adult patients evaluated while on involuntary hold from January 1, 2014, through November 30, 2015. Older adults (patients born on or before 06/31/1964) were compared to younger adults (born on or after 07/01/1964) according to demographic and clinical variables including medical comorbidity, ED length of stay, reason for involuntary hold, psychiatric disorder, suicide attempt, substance use disorder, serum alcohol level, urine drug testing, medical comorbidity, violence in the ED, 30-day ED readmission, and 30-day mortality.ResultsOf 251 patients, 90 (35.9%) were older adults. The most common reason for involuntary hold in both cohorts was suicidal ideation. Medical comorbidities were more prevalent in older adults [60 (66.7%) vs. 64 (39.8%), P ≤.0001]. Older adults were less likely to report current drug abuse [31 (34.4%) vs. 77 (47.8%), P = .04]. The most commonly misused substance in both groups was alcohol; however, despite similar rates, blood alcohol levels (BAC) and urine drug screen (UDS) were performed less often in older adults. Cohorts were not significantly different with respect to sex, race, violence in the ED, psychiatric diagnosis, and ED LOS.ConclusionsInvoluntary older adult patients present with medical comorbidities that impact mental health. In the ED, they are less likely report substance use, and drug screening may be underutilized. Medical needs make their care unique and may present challenges in transfer of care to inpatient psychiatric facilities.     

Etiologies of altered mental status in patients with presumed ethanol intoxication

Background

Altered mental status is a commonly evaluated problem in the ED. Ethanol intoxication is common, and prehospital history may bias emergency physicians to suspect this as the cause of altered mental status. Quantitative ethanol measurement can rapidly confirm the diagnosis, or if negative, prompt further evaluation. Our objective was to identify the etiologies of altered mental status in ED patients initially presumed to be intoxicated with ethanol but found to have negative quantitative ethanol levels.

Psychiatric emergencies

Psychiatric disorders are common in medical inpatient and outpatient populations. As a result, internists commonly are the first to see psychiatric emergencies. As with all medical problems, a good history, including a collateral history from relatives and friends, physical and mental status examination, and appropriate laboratory tests help establish a preliminary diagnosis and treatment plan. Patients with suicidal ideation usually have multiple stressors in the environment and/or a psychiatric disorder (i.e., a major affective disorder, dysthymic disorder, anxiety or panic disorder, psychotic disorder, alcohol or drug abuse, a personality disorder, and/or an adjustment disorder). Of all patients who commit suicide, 70% have a major depressive disorder, schizophrenia, psychotic organic mental disorder, alcoholism, drug abuse, and borderline personality disorder. Patients who are at great risk have minimal supports, a history of previous suicide attempts, a plan with high lethality, hopelessness, psychosis, paranoia, and/or command self-destructive hallucinations. Treatment is directed toward placing the patient in a protected environment and providing psychotropic medication and/or psychotherapy for the underlying psychiatric problem. Other psychiatric emergencies include psychotic and violent patients. Psychotic disorders fall into two categories etiologically: those that have an identifiable organic factor causing the psychosis and those that have an underlying psychiatric disorder. Initially, it is essential to rule out organic pathology that is life-threatening or could cause irreversible brain damage. After such organic causes are ruled out, neuroleptic medication is indicated. If the patient is not agitated or combative, he or she may be placed on oral divided doses of neuroleptics in the antipsychotic range. Patients who are agitated or psychotic need rapid tranquilization with an intramuscular neuroleptic every half hour to 1 hour until the agitation and combativeness are under control. Haloperidol (Haldol) is the safest neuroleptic. Chlorpromazine (Thorazine), perphenazine (Trilafon), and, in the elderly, thiothixene (Navane) can also be useful if haloperidol (Haldol) is not effective and more sedation is needed; these drugs, however, produce more side effects. Violent patients need to be physically restrained and then given antipsychotic medication or, in the case of drug abuse or alcohol withdrawal, the appropriate drug management.(ABSTRACT TRUNCATED AT 250 WORDS)     

Involuntary patient length-of-stay at a suburban emergency department

BackgroundPatients who may be a danger to themselves or others often are placed on involuntary hold status in the Emergency Department (ED). Our primary objective was to determine if there are demographic and/or clinical variables of involuntary hold patients which were associated with an increased ED LOS.MethodsRecords of ED patients evaluated while on involuntary hold from January 1, 2014 through November 30, 2015 at a suburban acute-care hospital ED were reviewed. Data collected included demographics information, LOS, suicidal or homicidal ideation, suicide attempt, blood alcohol concentration (BAC), urine drug test (UDT), psychiatric disorder, substance use, medical illness, violence in the ED, and hospital admission. Linear regression based on the log of LOS was used to identify factors associated with increased LOS.ResultsTwo-hundred and fifty-one patients were included in the study. ED LOS (median) was 6 h (1, 49). Linear regression analysis showed increased LOS was associated with BAC (p = 0.05), urine drug test (UDT) (p = 0.05) and UDT positive for barbiturates (p = 0.01). There was no significant difference in ED LOS with respect to age, gender, housing, psychiatric diagnosis, suicidal or homicidal ideation, suicide attempt, violence, medical diagnosis, or admission status.ConclusionsInvoluntary hold patients had an increased ED LOS associated with alcohol use, urine drug test screening, and barbiturate use. Protocol development to help stream-line ED evaluation of alcohol and drug use may improve ED LOS in this patient population.     

Health Status and Access to Care for Homeless Adults with Problem Alcohol and Drug Use

Problem alcohol and drug use by adult homeless persons may put them at higher risk for other health problems and impact their access to health care. The purpose of this study was to determine if those with a positive screen for problem alcohol or drug use were at increased odds for having a lower health status and less access to care than those without problem alcohol or drug use. This was a secondary analysis of health survey data from a study related to the health of homeless adults. The survey included the Alcohol Use Disorders Identification Test (AUDIT) and the Drug Abuse Screening Test 10 (DAST-10) for evaluating problem substance use; health related quality of life, health care utilization, and medical history were also included. The impact of problem alcohol use or drug use on the odds of reporting lower general health status, a history of physical or mental illness, use of the emergency department (ED), and problems getting health care when needed, were estimated using logistic regression. A total of 112 adult homeless participants completed the survey. Participants with problem alcohol use tended to be less likely to obtain health care when needed (OR = 2.3, p = 0.05). Those with problem alcohol or drug use were not at increased odds of reporting a lower general health status, a positive medical history, or ED use. Problem alcohol use was associated with decreased access to health care when needed. Screening for problem alcohol use among homeless adults may not only help to identify those in need of interventions related to alcohol use but also help to identify those in need of help in accessing general health care.     

The mental status examination

The mental status examination is a diagnostic procedure used to detect changes in or abnormalities of orientation, intellectual function (such as language, memory and calculation), thought content, judgment, and mood or affect in patients with medical, neurologic or psychiatric conditions that may affect brain function. The mental status examination can also be used to localize lesions in the brain. Much of the information needed for a mental status assessment can be obtained during a routine history. The elements of the examination depend on a patient's clinical presentation and cultural and educational background.     

预防冠状动脉旁路移植术后患者精神障碍的护理干预

目的 探讨护理干预对减少冠状动脉旁路移植术(CABG)术后精神障碍发生的效果.方法 将202例CABG患者分为对照组100例和干预组102例,对照组患者采用心脏外科常规治疗和护理,干预组患者接受系统的护理干预.采用简易精神状态检查量表对2组患者的精神状况进行评价.结果 对照组发生精神障碍16例,发生率16.00%,干预组发生精神障碍4例,发生率3.92%,2组比较差异有统计学意义.结论 采取有效的护理干预,配合有效的治疗,CABG术后患者精神症状是可以预防与控制的.     

The relationship between psychiatric medication and course of hospital stay among intoxicated trauma patients.

INTRODUCTION: The purpose of this study was to determine whether trauma patients requiring psychiatric medication who were admitted with positive alcohol or drug screen require more pain medications or sedation resulting in longer length of stay. METHODS: Data were retrospectively collected from 1997 through 2003 on patients with positive alcohol or drug screen who also received psychiatric medication during their hospital stay in a trauma center. Patients were matched by age, injury severity score, and injury to controls who had negative alcohol and toxicology screens and no psychiatric medication. An additional group consisted of positive alcohol or drug-screen trauma patients without psychiatric medication during hospitalization. Each group had 25 patients. RESULTS: No significant differences between the three groups regarding comorbidities or pain-medication doses given per day were found. The patients with positive alcohol and with psychiatric medication were more likely to have respiratory complications such as pneumonia or respiratory failure requiring ventilator support (36 versus 4%, P=0.005), to develop other infections (8 versus 0%), or other complications (26 versus 4%, P=0.0007) compared with the controls. A significant difference in hospital length of stay between the group with positive toxicity and psychiatric medication and that with negative toxicity and psychiatric medication (mean: 12.8 and 5.5 days, respectively; P=0.01) was found. CONCLUSION: Psychiatric medication and positive drug or alcohol screens are associated with longer length of stay and increased respiratory complications. Factors influencing these outcomes need more clarification and prospective studies.     

Safety and compliance with an emergency medical service direct psychiatric center transport protocol

Objectives

To evaluate compliance and safety of an emergency medical service (EMS) triage protocol that allows paramedics to transport patients directly to psychiatric emergency services.

Methods

A psychiatric patient diversion protocol was developed for our system. Protocol compliance was evaluated the following 3 ways: (1) psychiatric facility intake forms completed by mental health workers on patients transported by EMS directly to a psychiatric emergency service (PES) bypassing the ED, (2) hospital records for patients who were redirected from PES to the ED for medical evaluation, (3) retrospective analysis of ambulance charts. Study outcomes included protocol noncompliance rate, protocol failure rate, and any morbidity associated with either noncompliance or protocol failure. Data were analyzed using proportions and 95% confidence intervals (CI).

Results

A total of 174 patients were directly transported to PES bypassing ED medical clearance. The protocol effectively screened for medical issues in 96% of cases. Protocol noncompliance occurred in 51 cases for a frequency of 29% (CI, 22%-36%). One patient in the paramedic noncompliance group required hospital admission. There was protocol failure in 5 (2.9%; 95% CI, 0.9-6.6) of the patients who fit all protocol requirements for transport to PES but required secondary transport to the ED. All were subsequently transferred back to PES. Nine patients (5.2%; CI, 2.7%-9.5%) required secondary transfer to the ED. No patient had critical or life-threatening problems.

Conclusions

Emergency medical service providers showed a poor level of compliance with vital sign criteria, but the protocol provided a high level of safety.     

Validity of self-reported drug use in chronic pain patients.

OBJECTIVE: Previous researchers have reported that in psychiatric populations many patients provide incorrect self-report information on current drug use. Therefore, the purposes of the present study were to determine the percentage of chronic pain patients (CPPs) using illicit drugs (cannabis, cocaine), to determine the percentage of CPPs who provide incorrect self-report drug use information in the psychiatric examination, and to identify some variables that could help in identifying the CPP likely to provide an incorrect drug use history using drug urine toxicologies. DESIGN/SETTING/PARTICIPANTS/OUTCOME MEASURES: Two hundred seventy-four CPP consecutive admissions to a pain facility were psychiatrically examined according to criteria in the Diagnostic and statistical manual of mental disorders (3rd ed., rev; DSM-III-R), with special emphasis on all current drug use. Immediately after the psychiatric examination, all CPPs were asked to consent to urine toxicology. Urine was tested for benzodiazepines, opioids, tricyclics, propoxyphene, cannabinoids, barbiturates, amphetamines, methadone, methaqualone, phencyclidine, alcohol, and cocaine. CPPs were then segregated into three groups: negative toxicology, positive toxicology but concordant with self-report of current drug use, and positive toxicology discordant with self-report of current drug use. These groups were statistically compared with each other with regard to age, gender, race, workers' compensation status, and prevalence of individual DSM-III-R psychoactive substance use disorders. Sensitivities were also calculated for two conditions: accuracy of toxicology and accuracy of self-report. RESULTS: Toxicologies were obtained from 226 (82.5%) of the CPPs. Toxicologies were negative in 121 (53.5%) and positive in 105 (46.5%) of the CPPs. Of the 226 CPPs, 8.4% had illicit drugs in the urine (6.2% cannabis, 2.2% cocaine). Twenty (8.8%) of the CPPs provided incorrect self-report information about current drug use, the incorrect information most frequently about illicit drugs. Drug urine toxicology sensitivity results indicated that a significant percentage of CPPs was claiming to be taking a drug but was not taking it or taking it incorrectly. The psychiatric examination drug self-report sensitivity results indicated that a significant percentage of CPPs was withholding or providing incorrect information on current drug use. Lowest self-report sensitivity results were in reference to illicit drugs. CPPs who were more likely to provide incorrect psychiatric examination self-report information about current drug use were more likely to be younger, to be a workers' compensation CPP, and to have been assigned a DSM-III-R diagnosis of polysubstance abuse in remission. CONCLUSIONS: A significant percentage of CPPs appears to provide incorrect information on current illicit drug use. Urine toxicology studies may have a place in the identification of drugs for which incorrect information may be provided by CPPs. There are many possible reasons, such as assay error, that could lead to apparent misinformation. In the clinical setting, these possibilities should be considered if urine toxicology results appear to be incongruent with psychiatric examination drug use self-report.     

β-内酰胺类抗生素致血液透析患者神经系统不良反应

目的 探讨β-内酰胺类抗生素在肾功能衰竭血液透析中的合理应用.方法 回顾性分析我院13例肾功能衰竭血液透析的患者应用β-内酰胺类抗生素时引起的神经精神症状及相关临床资料.结果 患者于开始透析后或维持透析期间均出现神经精神症状,神经精神症状表现多样:神志恍惚,兴奋多语或语无伦次,嗜睡,其中2例伴有肌肉震颤.均无神经定位症状,其中7例经头颅CT检查,均未发现急性颅脑病变.所有患者停药后继续血液透析或血液透析滤过治疗后症状消失.结论 肾功能衰竭血液透析患者使用常规剂量的β-内酰胺类抗生素可引起一过性的脑病,与药物半衰期延长有关.     

Emergency Psychiatric Service in general hospitals: a retrospective study

The Emergency Psychiatric Service in General Hospitals (SEPHG, acronym in Portuguese) is a service included in the psychiatric reform movement. The purpose of the present study was to characterize patients with psychological distress treated at the Dr. Estevam SEPHG, located in Sobral, Cear state. This exploratory study was performed using documental analyses with a quantitative approach, and involved 191 clients treated at the referred SEPHG from January to December 2007. Data collection was performed using a client register book, which contained information obtained from the patients' medical record. There was a predominance of male patients (70.15%), aged 30-49 years (48.71%) and single (74.86%). Most patients were from the city of Sobral (69.64%). In 42.40% of cases, the diagnosis was of alcohol use/abuse. Most clients (66.50%) sought the service voluntarily. After being evaluated at the SEPHG, 43.45% of patients were referred to the local Center for Psychosocial Care-Alcohol and other Drugs. The results emphasize the importance of mental health.     

"Medical clearance" of psychiatric patients without medical complaints in the Emergency Department

This study was conducted to evaluate the benefit of comprehensive "medical clearance" (history, physical examination, vital signs, laboratory, radiography) in patients presenting to the Emergency Department (ED) with isolated psychiatric complaints. All patients 16 years and older who presented with a psychiatric complaint and required a psychiatric evaluation before discharge from the ED were included in the study. Data, obtained in a 5-month consecutive, retrospective chart review, included patient age, sex, initial complaint, past medical and psychiatric history, initial vital sign measurement, physical examination findings, laboratory analysis (electrolytes, complete blood count, toxicology screen), chest X-ray study results, and final disposition. The number of patients who could have been referred to a psychiatric unit after a history, physical examination, and stable vital signs, without additional laboratory or radiographic studies, was determined. There were 212 patients who met the inclusion criteria, and all their charts were available for review. Eighty patients (38%) presented with isolated psychiatric complaints coupled with a documented past psychiatric history. All received a comprehensive "medical clearance" in the ED followed by a psychiatric consultation. None of the patients had positive screening laboratory or radiographic results. All were either dispositioned home or to the psychiatric ED. The remaining 132 patients (62%) presented to the ED with medically based chief complaints or past medical history requiring further evaluation in the ED before discharge. The initial complaints of these patients correlated directly with the need for laboratory and radiographic "medical clearance" in the ED. Patients with a primary psychiatric complaint coupled with a documented past psychiatric history, negative physical findings, and stable vital signs who deny current medical problems may be referred to psychiatric services without the use of ancillary testing in the ED.     

Structured team approach to the agitated patient in the emergency department

Objective: Behavioural disturbance and aggression in the ED is an increasing problem. The present study describes the characteristics of patients with acute behavioural disturbance and their emergent treatment in an ED with a structured team approach. Methods: This was a retrospective review of acute behavioural emergencies that required response from the Code Black (CB) Team (duress response team) in the ED during 2006. The hospital security log and hospital incident‐reporting system identified all documented CB, and the patients' medical records were reviewed. Information extracted included patient demographics and presenting complaint, details of the CB, the use of pharmacological sedation, physical restraint and patient disposition. Injuries to hospital staff were also extracted. Results: There were 122 patients, median age 32 years (interquartile range: 24–43 years, range: 14–81 with 71 male patients (58%) who accounted for 143 CB activations. The primary problems were deliberate self‐poisoning or self‐harm (38%), alcohol and illicit drug intoxication (33%) and psychiatric, organic illness and drug withdrawal (29%). One hundred and eight (89%) patients had a past history of alcohol/illicit drug abuse or psychiatric illness. Indications for CB activation were threatening harm to others or behaving violently in 67% of cases. Combined pharmacological sedation and physical restraint were required on 66 (46%) occasions, pharmacological sedation alone on 20 (14%), physical restraint alone on 14 (10%) and neither on 43 (30%) occasions. Benzodiazepines were most commonly used for initial sedation, including i.m. (29%), i.v. midazolam (20%), diazepam (42%) and antipsychotics (9%), most commonly droperidol. More diazepam and droperidol were used for subsequent pharmacological sedation. A staff member was injured on only one occasion (0.7%). Conclusions: Acute behavioural disturbance was common in the present study, and underlying causes were predominantly organic in nature. A team approach appears to be valuable in managing these incidents.     

Psychiatric disorders in patients presenting to the Emergency Department for minor injury

BACKGROUND: Thirty-five percent of all Emergency Department (ED) visits are for physical injury. OBJECTIVES: To examine the proportion of patients presenting to an ED for physical injury with a history of or current Axis I/II psychiatric disorders and to compare patients with a positive psychiatric history, a negative psychiatric history, and a current psychiatric disorder. METHODS: A total of 275 individuals were selected randomly from adults presenting to the ED with a documented anatomic injury but with normal physiology. Exclusion criteria were: injury in the previous 2 years or from medical illness or domestic violence; or reported treatment for major depression or psychoses. Psychiatric history and current disorders were diagnosed using the Structured Clinical Interview for the Diagnostic and Statistical Manual Disorders, 4th edition (DSM-IV), a structured psychiatric interview. Three groups (positive psychiatric history, negative psychiatric history, current psychiatric disorder) were compared using Chi-square and analysis of variance. RESULTS: The sample was composed of men (51.6%) and women (48.4%), with 57.1% Black and 39.6% White. Out of this sample, 103 patients (44.7%) met DSM-IV criteria for a positive psychiatric history (n = 80) or a current psychiatric disorder (n = 43). A past history of depression (24%)exceeded the frequency of a history of other disorders (anxiety, 6%; alcohol use/abuse, 14%; drug use/abuse, 15%; adjustment, 23%; conduct disorders, 14%). Current mood disorders (47%) also exceeded other current diagnoses (anxiety, 9%; alcohol, 16%; drug, 7%; adjustment, 7%; personality disorders, 12%). Those with a current diagnosis were more likely to be unemployed (p <.001) at the time of injury. CONCLUSIONS: Psychiatric comorbid disorders or a positive psychiatric history was found frequently in individuals with minor injury. An unplanned contact with the healthcare system (specifically an ED) for treatment of physical injury offers an opportunity for nurses to identify patients with psychiatric morbidity and to refer patients for appropriate therapy.     

Dual diagnosis screening: preliminary findings on the comparison of 50 clients attending community mental health services and 50 clients attending community substance misuse services

While dual diagnosis research has often focussed on substance misuse disorders among mental health clients, relatively little is known about comparable rates of dual diagnosis in community mental health and substance misuse settings because of, inter alia, limitations and lack of consistency in screening. In the current study clinicians administered a brief screening tool, which detects problematic alcohol, drug use, psychosis and common mental health symptoms, to 50 substance misuse and 50 mental health treatment attenders. Sixty-four per cent of the total sample screened positive for dual diagnosis (positive for any psychiatric disorder and either a drug or alcohol problem). Highest rates were observed in the alcohol sample (92.3%), followed by the drug sample (87.5%), and lowest in the community mental health (CMHT) sample (38%). Current depression and social phobia were most prevalent in alcohol clients compared to psychosis, mania and suicidal ideation in CMHT clients. Around one-third of CMHT clients reported using drugs (mainly cannabis) and around a fifth reported problematic alcohol use. The study demonstrates the feasibility of incorporating a dual diagnosis screen into routine clinical practice. The screen can be used in both mental health and substance misuse treatment settings, which are evidently managing complex client caseloads.     

Acamprosate (Aotal): could adverse effects upset the treatment of alcohol dependence?

Acamprosate, a stimulant of central inhibitory GABA neurotransmision and an antagonist of excitatory amino acids, is used in alcohol withdrawal and for the maintenance of abstinence. After identification of several cases of treatment discontinuation during alcohol abstinence because of acamprosate-induced adverse drug reactions (ADRs), a retrospective study was conducted in order to investigate and quantify acamprosate-induced ADRs. Up to July 2002, 472 patients were included for treatment of alcohol withdrawal: of these, 68% (n = 322) received acamprosate. At least one ADR occurred in 98 patients (30%). The mean age of the patients was 41.5 +/- 8.8 years (range: 24-65) and 70% were male. All ADRs were classified as 'non serious'. However, ADRs required a dose decrease in 61 cases or acamprosate discontinuation in 76 cases (62.2% and 77.5%, respectively, of patients with an ADR). We identified mainly gastrointestinal ADRs in 67 patients (mean delay before occurrence: 7.6 days), i.e. 20.8% of patients treated with acamprosate (corresponding to 68.3% of ADRs), with a positive rechallenge in five cases. Moreover, cutaneous ADRs (pruritus) occurred in 29 patients (mean delay before occurrence: 9.0 days), and required acamprosate withdrawal in 22 patients (75.9%) with a prior dose decrease in 18 of these patients (62.1%). Our results show that a dose decrease or withdrawal of acamprosate was necessary in 18.9% and 23.6%, respectively, of patients because of the occurrence of ADRs. The present study shows the important role of acamprosate-induced ADRs among the various causes for failure of alcohol abstinence.     

Medical Clearance and Screening of Psychiatric Patients in the Emergency Department

Objectives : To study the frequency of medical complaints and need for routine ED medical, laboratory, and toxicologic clearance for patients presenting with psychiatric chief complaints.
Methods : A retrospective, observational analysis of psychiatric patients seen in an urban teaching hospital ED over a 2-month period was performed. The individual sensitivities of history, physical examination, vital signs, and complete blood counts and chemistry panels for identifying medical problems were determined. The sensitivities and predictive values of patient self-reporting of recent illicit drug and ethanol use were also determined.
Results : 352 patients were seen with psychiatric chief complaints. A complete data set was available for 345 patients (98%). Of those with complete data, 65 (19%) had medical problems of any type. History, physical examination, vital signs, and laboratory testing had sensitivities of 94%, 51%, 17%, and 20%, respectively, for identifying these medical problems. Screening without universal laboratory testing would have missed 2 asymptomatic patients with mild hypokalemia. Patient self-reporting had a 92% sensitivity, a 91% specificity, an 88% positive predictive value (PPV), and a 94% negative predictive value (NPV) for identifying those with a positive drug screen, and a 96% sensitivity, an 87% specificity, a 73% PPV, and a 98% NPV for identifying those with a positive ethanol level.
Conclusion : The vast majority of medical problems and substance abuse in ED psychiatric patients can be identified by initial vital signs and a basic history and physical examination. Universal laboratory and toxicologic screening of all patients with psychiatric complaints is of low yield.