What are the considerations for emergency psychiatry care in complex patients?

From the Guidelines

Emergency psychiatry care for complex patients necessitates a comprehensive approach that prioritizes immediate safety, medical clearance, and long-term treatment planning, as outlined in the clinical policy for critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department 1. The initial assessment should focus on determining if the patient's symptoms are caused or exacerbated by a medical illness, assessing and treating any medical situation that needs acute intervention, and determining if the patient is intoxicated, which can prevent an accurate psychiatric evaluation 1. Key considerations include:

• Establishing a focused medical assessment to exclude medical etiologies for the patient's symptoms and detect other illnesses or injuries in need of acute care 1
• Evaluating for cognitive disorders such as dementia or delirium, which can significantly impact patient management 1
• Implementing safety measures, including observation levels or involuntary holds, when there is a risk of self-harm or harm to others
• Utilizing medication interventions, such as rapid tranquilization protocols, when necessary for acute agitation
• Addressing substance withdrawal and psychiatric symptoms in patients with dual diagnosis
• Conducting comprehensive laboratory testing to identify medical contributors to psychiatric presentations
• Fostering interdisciplinary collaboration to develop comprehensive discharge plans that address housing, outpatient follow-up, and medication access, ultimately improving patient outcomes and quality of life.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Emergency Psychiatry Care for Complex Patients

• The treatment of complex patients in emergency psychiatry settings requires a comprehensive approach, including symptomatic relief, maintenance of ongoing treatment, and referral and facilitation for entering treatment 2.
• The use of antipsychotic agents in older patients is a common practice, but it can be complex due to the presence of comorbid conditions, side effects, and interactions with other medications 3.
• The implementation of standards for emergency psychiatric evaluations, including obtaining collateral information, writing a safety plan, and identifying the next best provider, can improve the quality of care for complex patients 4.
• Olanzapine, an atypical antipsychotic, has been shown to be effective in the management of schizophrenia, with benefits against symptoms of aggression and agitation, and a lower risk of extrapyramidal symptoms compared to haloperidol and risperidone 5.
• The use of emergency psychiatric assessment, treatment, and healing (EmPATH) units can decrease hospital admissions for patients presenting with suicidal ideation, reduce ED boarding time, and increase 30-day follow-up care 6.

Key Considerations for Complex Patients

• The presence of comorbid conditions, such as diabetes, dyslipidemia, or obesity, requires careful consideration when selecting antipsychotic medications 3.
• The use of antipsychotics in older patients with cognitive impairment, constipation, or other conditions requires careful monitoring and dose adjustment 3.
• The implementation of EmPATH units can improve the management of patients presenting with suicidal attempts/ideation, but requires careful evaluation and follow-up to ensure effective care 6.

Treatment Options for Complex Patients

• Antipsychotic medications, such as olanzapine, risperidone, and quetiapine, can be effective in the management of schizophrenia and other psychiatric conditions, but require careful selection and monitoring 3, 5.
• The use of mood stabilizers, such as lithium or valproate, can be effective in the management of bipolar disorder, but requires careful monitoring and dose adjustment 3.
• The implementation of EmPATH units can provide a comprehensive approach to the management of complex patients, including symptomatic relief, maintenance of ongoing treatment, and referral and facilitation for entering treatment 6.