STRUCTURED APPROACH TO
ACUTE PSYCHIATRY EMERGENCIES
Raimondo Romanazzi
ACCS Emergency Medicine ST2
North West - Mersey
Learning outcomes
• Practical system for initial assessment
• Ensure patient safety anf minimise potential
harm to others
• Avoid common pitfalls
20-year-old girl, transferred from Psychiatric Facility after
swallowing a battery at approximately 5 pm.
Underwent endoscopic extraction of the battery under
sedation/GA.
Admitted to Upper GI ward post-op, at around 8 pm, for
period of monitoring.
Mental illness diagnosis and prolific self harm history.
Quick assessment done in ED as patient went quickly to
theatre for emergency foreign body extraction. Handed over
to F1 on night to complete patient clerking.
INTRODUCTION
• 35-40% (6-8 million each year in England) of
presentations to ED are defined as psychiatric and
behavioural, if substance abuse is included
• Major challenges
▫ Emergency department and acute hospital staff receive
little training in managing psychiatry emergencies
▫ Responses of mental health staff can be delayed,
inconsistent, unsystematic
▫ The acute hospital environment is often non conductive
to the provision of good psychiatry care
PREPARATION
• Ensure that appropriate help is available
• Ensure there are appropriate facilities to assess
the patient
• Gather any available information
Gathering information
• 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 give me an example of the most
disturbed behaviour you have witnessed?
Key factors
• Prior history of self harm
• Prior history of harm to others
• Alcohol and illicit drug use
• Prior hisotry of severe mental illness
• Prior history of violence, forensic history,
criminal record
STRUCTURED APPROACH:
PRIMARY ASSESSMENT
PRIMARY PHYSICAL RISK ASSESSMENT
• AIRWAY – patency and security
• BREATHING – adequacy and effectiveness
• CIRCULATORY – aadequacy
• DISABILITY – assessment of conscious level
and pupils
PRIMARY PSYCHIATRY RISK ASSESSMENT
• AGITATION / AROUSAL
• ENVIRONMENT in which the patient is being
cared for
• INTENT of the individual
• OBJECTS which the patient has in their
possessin, which may be used for self-harm or to
harm others
AGITATION/AROUSAL
Assessment based on a quick observation of the patient:
• LOW – can sit still during the brief assessment and is not
unduly agitated
• MODERATE – easily aroused, gets up and paces about, but
then settles again, not overt aggression or severe distress
• HIGH – pacing up and down, unable to settle for more
than a few seconds, may include overt aggression or severe
distress
ENVIRONMENT
• ALARM
• DOORS
• EXITS
• LIGATURE POINTS
• LOCATION
• EQUIPMENT
INTENT
Involves assessment of current thoughts of the
patient, what they are thinking or experiencing right
now
• Any current thoughts of harming self
• Any current thoughts of harming others
• Psychotic experiences that may lead to actions
which involve harm to self o others
• Strong impulses or desires to leave the department
INTENT
• LOW – No suicidal idea or thoughts of harm to others.
No command hallucinations or thoughts of wanting to
leave
• MODERATE – some thoughts of self-harm or thoughts
of harming others, or thoughts of wanting to leave. But
patient can resist these thoughts
• HIGH – thoughts of self-harm or harm to others thta the
patient finds difficult to resist. Actively wants or is trying
to leave
OBJECTS
• LOW – no potentially harmful objects
• MODERATE – patient denies having any
harmful objects, but refuses to allow staff to
check pockets or other items of clothing
• HIGH – patient has potentially harmful objects
that he/she is reluctant to hand over
Unified risk assessment
• Patient safety and degree of observation
required
• Number of staff needed
• Staff safety
• Appropriate environment
• Rapid tranquilisation may be needed in some
cases
STRUCTURED APPROACH: PRIMARY ASSESSMENT
PREPARE TO SEE PATIENT
Very severe Very severe
ABCD AEIO
Rapid
Resuscitation
tranq
Not very severe
Unified assessment
THE PATIENT WHO HAS HARMED
THEMSELVES
• 200.000 presentation per year to ED in England
following self harm
• Self harming behaviour is linked to with a thirty-fold
increase in the risk of future complete suicide
• High prevalence of psychiatric morbidity
• Between 15-30% of people will repeat self-harm
within 12 months
26-year-old man, brought to ED after overdose of paracetamol
(patient unsure of the amount, probably 1-2 boxes) taken on
Saturday evening.
Started vomiting and having abdo pain over the 24h following the
ingestion. He told his mom to be unwell because had alcohol on
Saturday night with friends. Spent all Sunday and Monday in bed.
A friend checked on him and he disclosed what happened and
therefore was brought to ED approximately 48h after OD.
He is a student, is planning to get a degree. He was left by his
girfriend during the previous week. Mum came to hospital and
looks upset.
He is willing to stay in hospital. Was referred to the medical team
ASSESMENT OF RISK
The main role of the risk assessment is not to
predict the future but to manage risk in the short
term
• Risk of harm to self/others
• Likelyhood of the patient leaving ED/hospital
SLIPA
• SUICIDAL thoughts at the time of self harm
• LETHALITY of the episode
• INTENT now
• PROTECTIVE factors
• ADVERSE factors
SUICIDAL THOUGHTS
• «I know you may have been asked this when you first come to the
Emergency Department, but could you tell me what was going
through your mind when you…»
Depending on the patient’s response, you can then clarify their
INTENT by
• «So at the time you…you wanted to die and intended to kill
yourself?»
Or
• «So at the time you…you just wanted a break, a kind of timeout and
you didn’t have thoughts of actually wanting to end your life?»
LETHALITY
• Violent method
• Patient would have died without medical
intervention
• Avoided discovery
• Made plans to kill self
• Anticipated death
• Made no active efforts to be found post self-
harm episode and di not seek help
INTENT
Can be established in two ways:
• Does the patient have any regret?
• Does the patient have any current thoughts of
self harm?
PROTECTIVE/ADVERSE FACTORS
• Job
• Personal relationships
• Family and friends
• Housing
• Finances
• Criminal charges
Approximately 70% of all self-harm episodes are
precipitated by some kind of interpersonal problem
USEFUL ADDITIONAL RELEVANT
INFORMATION
• DEMOGRAPHICS AND HISTORICAL RISK
FACTORS
Male, middle age, living alone, previous history of
self harm or severe mental illness, drug dependance,
violent behaviour, frequent ED attendances, alcohol
problems, unemployed, socially isolated,
severe/long-term physucal illness
USEFUL ADDITIONAL RELEVANT
INFORMATION
• CO-MORBID MENTAL ILLNESS
▫ MOOD SYMPTOMS
Persistent low mood, anhedonia
▫ COGNITIVE SYMPTOMS
Guilt, hopelessness, belief that is not woth living, feeling a
burden, poor concentration
▫ PHYSICAL SYMPTOMS
Poor sleep/appetite, weight loss, lack of energy
SLIPA
DEMOGRAPHIC CO-MORBID
AND HISTORICAL MENTAL
FACTORS ILLNESS
RISK PROFILE
26-year-old man, brought to ED after overdose of paracetamol
(patient unsure of the amount, probably 1-2 boxes) taken on
Saturday evening.
Started vomiting and having abdo pain over the 24h following the
ingestion. He told his mom to be unwell because had alcohol on
Saturday night with friends. Spent all Sunday and Monday in bed.
A friend checked on him and he disclosed what happened and
therefore was brought to ED approximately 48h after OD.
He is a student, is planning to get a degree. He was left by his
girfriend during the previous week. Mum came to hospital and
looks upset.
He is willing to stay in hospital. Was referred to the medical team
SLIPA
• Suicidal thoughts at the time of episode: Yes
• Lethality: High
• Intent now: no current intent when assessed in
hospital
• Protective factors: student, has good family and
friends
• Adverse factors: left by her girlfriend
• Demographic and historical factors:
Male
• Co-morbid mental illness:
Possible depressive symptoms developing in the
week prior to the self-harm episode.
OVERALL RISK PROFILE
The overall risk profile is moderate-high. 3/5 SLIPA
items are positive, the patient has one demographic
factor and may be suffering from a depressive illness.
The patient requires immediate treatment for his
physical health, consider level of observation on
ward. Full mental assessment needed when
medically fit
A 23-year-old woman took an overdose of antidepressants
which she has been prescribed by her GP. She had been under
increasing pressure at work and had felt low in mood, and
panicky for the last 3 months. She was constantly tired but
couldn’t sleep well and has lost 4 Kg in weight.
She had begun to drink a bottle of wine per night to help with
panicky feeling and her sleep. Her husband was in the harmed
forces and had been away on a tour of duty for several months.
She had had a miscarriage in the previous year, which was
found very difficult to come to terms with.
She took the tablets (20 mirtazapine 15 mg tablets) late at night
after she had been drinking heavily. She said that she wanted to
sleep but panicked after taking them and phoned a friend who
brought her to hospital
SLIPA
• Suicidal thoughts at the time of episode: No
• Lethality: low
• Intent now: no current intent when assessed in
hospital
• Protective factors: working, married, has good
friend
• Adverse factors: stressful work, husband is away,
recent miscarriage
• Demographic and historical factors:
None identified
• Co-morbid mental illness:
Evidence of a depressive illness developing in the
weeks prior to the self-harm episode. Excessive
alcohol intake and self-harm epsiode took place in
the context of heavy drinking that evening
OVERALL RISK PROFILE
The overall risk profile is low, most of the SLIPA items are
negative and the patient has no identified
demographic/historical risk factors. The patient has
developed a depressive illness, which has not responded to
antidepressants and appears to have been precipitated by a
variety of interpersonal difficulties
The patient needs help for depression: an alternative
antidepressant plus psychology treatment.
WHY I FIND IT USEFUL
• Dont’t forget/underestimate any aspect
• Quick and systematic approach
• Common language/ better commmunication
• Improve documentation
• I can use it in my daily practice
• Physical health = Mental health
Reference
• «Acute Psychiatric Emergencies. The practical
approach», First Edition, ALSG 2016
www.alsg.org
GRAZIE!
