Acute Psychiatric Emergencies

A Practical Approach

Advanced Life Support Group

EDITED BY

Kevin Mackway‐Jones

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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 Hayhurst
Chair, Mental Health Committee
Royal 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‐Jones
Manchester 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 Group
ALSG Centre for Training and Development
29–31 Ellesmere Street
Swinton, Manchester
M27 0LA
Tel: +44 (0) 161 794 1999
Fax: +44 (0) 161 794 9111
Email: enquiries@alsg.org

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.

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CHAPTER 1
Structured 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 1.1 The 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 2
Primary 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 2.1 Structured 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?

Do they know the time of day, month and year?

Do they understand questions?

Do they respond appropriately?

Tell them that you need to ask them some brief questions to check that they are safe. Tell them that these are routine questions.

2.4 Primary physical risk assessment

The primary physical risk assessment should focus on four key areas:

A Airway – patency and security

B Breathing – adequacy and effectiveness

C Circulatory – adequacy

D Disability – assessment of conscious level and pupils

ABCD problems should be addressed as soon as they are identified. It is outwith the scope of this book to describe the life support techniques that might be necessary – patients should be moved to the resuscitation area as soon as possible and physical resuscitation should be continued there whilst the AEIO assessment described below is carried out.

Go on to ask the following:

Have you taken any tablets or anything else that might be harmful in the last 24–48 hours?

Have you had any alcohol?

Have you taken any street drugs, e.g. amphetamines, cocaine, spice, ketamine?

Have you suffered a recent head injury?

Do you have any physical health conditions, such as diabetes or epilepsy? Do you have any condition for which you take regular tablets or medications?

Do you have any allergies?

2.5 Primary psychiatric risk assessment

The primary psychiatric risk assessment should focus on four key areas:

A Agitation/Arousal

E Environment in which the patient is being cared for

I Intent of individual

O Objects that the patient has in their possession, which may be used for self‐harm or harm to others

This enables staff to carry out a quick assessment of risk of harm (to self or others) and of flight risk. This enables planning of a risk reduction and containment strategy, which may or may not involve rapid tranquillisation.

(A) Agitation/Arousal

This assessment depends on a quick observation of the patient. Their level of arousal or agitation is determined according to the following guide (Box 2.1).

Box 2.1 Level of arousal or agitation

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, no 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

(E) Environment

All EDs should have facilities where an acutely disturbed person can be assessed and, if necessary, can be given emergency treatment.

Dedicated ‘place of safety’ suites should be available in every locality for the assessment of mentally ill people detained for their own safety by the police. The police have the power to detain someone in a public place who they suspect is suffering from a mental illness and is at risk of harm to self or others, and convey them to hospital or other suitable facility which is deemed a ‘place of safety’ for assessment for their presumed mental health problems. This legal framework will be discussed further in Chapter 9.

Standards, for example those from the UK Royal College of Psychiatry, suggest that EDs should only be used as a place of safety where medical problems need urgent assessment and management. However, many patients who are behaving in a disturbed manner may have underlying physical health problems, so will be brought to an ED.

Comparable facilities to those described here should therefore be available in every ED so patients with behavioural disturbance can be cared for safely. Box 2.2 describes the Royal College of Psychiatry standards for place of safety rooms as outlined in Standards on the Use of Section 136 of the Mental Health Act 1983 (England and Wales).

Box 2.2 Standards for place of safety rooms

The psychiatric assessment facility must be a locked facility in order to be able to safely care for those who are disturbed

Levels of staff required to support this facility, when in use, are up to three staff trained in physical intervention, who should be available at short notice without compromising staffing levels and hence safety elsewhere. This is in addition to the staff carrying out the assessment

The room should accommodate six people to allow both treatment and restraint, have an observation hatch and be lit well, have two outward opening doors at opposite ends of the room and have fixed, soft, comfortable chairs that cannot be used as a weapon. There should be no ligature points. In addition, a clock should be visible to both patients and staff, there should be a phone line with outside dialling, a panic alarm and CCTV. It should not be isolated and should be accessed easily for containment and restraint and resuscitation teams if required

The following is compliant with the National Institute for Health and Care Excellence (NICE) guidance Violence and Aggression: Short‐Term Management in Mental Health, Health and Community Settings (www.nice.org.uk/guidance/ng10; accessed June 2019).

In the absence of such a facility, or if it is already being used by another patient, make an assessment of the environment in which the patient is being contained. Note the following, using ADELLE as an acronym:

A Alarm – is there a panic alarm in the room?

D Doors – which way does the door (or doors) open?

E Exits – how many exits are there, and how easy would it be for the patient to reach the exits from the room?

L Ligature points – identify any ligature points (including those in any bathroom or toilet facilities the patient may need to use)

L Location – how isolated is the room from the rest of the ED or ward? Is there any CCTV?

E Equipment – is there any equipment in the room (e.g. oxygen points, monitors) or items of furniture that could be used as a weapon or have sharp edges?

Never allow a patient who is disturbed, or whom you have concerns about, to be left alone in a room that has ligature points, or equipment or furniture that could be used to self‐harm.

Make an assessment of the environmental risk (Box 2.3).

Box 2.3 Environmental risk

LOW – alarm present, two doors that open both ways, exits are not easily accessible from the room, no ligature points and no equipment or furniture that is harmful. Room is centrally located in the ED or ward area

MODERATE – no alarm, single door opens outwards, no ligature points or potentially harmful objects but room is close to exit from ED and away from the central part of the department. No CCTV

HIGH – no alarm, single door opens inwards only, ligature points in room or potentially harmful objects, etc.

(I) Intent

Intent involves assessment of the current thoughts of the patient, not what they were thinking or believed in the past, but what they are actually thinking or experiencing ‘right now’. There are four aspects of intent you need to assess quickly:

Any current thoughts of harming self

Any current thoughts of harming others

Psychotic experiences that may lead to actions that involve harm to self or others

Strong impulses or desires to leave the department

Current thoughts of harming self

Assess the nature, severity and frequency of these thoughts. Ask the patient directly how likely they are to act on these thoughts in the next couple of hours. Assess how able the patient is to resist these thoughts.

Current thoughts of harm to others

Assess the nature, severity and frequency of these thoughts. Ask the patient how likely they are to act on these thoughts in the next few hours. Establish whether the thoughts of harm to others are based on a wish to inflict harm on others (possibly related to aggression) or are related to self‐protection arising from fears of persecution. In the case of the former, a calm and non‐confrontative approach may be helpful, whereas in the latter, active reassurance that the patient is safe and staff are not going to harm him/her may reduce anxiety/agitation.

Psychotic experiences

Certain psychotic experiences such as hearing voices commanding the patient to harm themselves, or others, or delusions of control are associated with a high risk of self‐harm.

Establish whether the patient appears to be responding to external stimuli or appears very agitated or frightened. Try to access the patient’s inner mental experiences by asking if anything is scaring or upsetting them or making them feel uneasy. Go on to ask specifically about command hallucinations or delusions of control.

‘Are you hearing anyone or anything telling you to harm yourself or others?’

‘Do you feel controlled in any way by anything, or made to do anything you don’t want to do?’

Desire to leave

Check whether the patient is willing to stay in the department until they can be more fully assessed. Note if the patient expresses thoughts about wanting to leave or if the patient has already tried to leave. Provide the patient with an estimate of how long he/she will need to stay in the department and explain to them what is likely to happen during this time (e.g. will they need more physical investigations, how long will the detailed psychiatric assessment take, etc.). Try to keep them informed and updated about what is happening.

Make an assessment of intent (Box 2.4).

Box 2.4 Intent assessment

LOW – no suicidal ideas, 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 the patient can resist these thoughts

HIGH – thoughts of self‐harm or harm to others that the patient finds difficult to resist. Appears to be responding to or experiencing hallucinations which the patient has described to have been commanding them to harm themself or others. Actively wants or is trying to leave

(O) Objects

Establish whether the patient has any items on them or pieces of clothing that could either be used to harm themself or others. The obvious items are firearms, sharp objects such as scissors or razor blades, or other items such as medication, illicit drugs, plastic bags or batteries. Potentially harmful items of clothing include belts or scarves.

Take note of what the patient is wearing and, if they are amenable, ask if they would consider removing any items of clothing that could be used to harm themselves (e.g. a belt or tie). Tell the patient you are doing your utmost to look after them and ensure they are safe. Ask the patient if they have anything else on them that they could use to harm themself, such as tablets or razor blades. Reassure the patient that their possessions will be kept safely for them.

The manner in which you broach these topics is more important than the actual words you use, and you will need to tailor your body language, tone of voice, phrasing and timing to each individual person, according to their cue–response. Chapter 8 will focus in more depth on specific communication skills. Do not continue to ask questions if this process is increasing the patient’s degree of agitation.

Make an assessment of risk from objects in the patient’s possession (Box 2.5).

Box 2.5 Risk from 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 (e.g. razor blades)

2.6 Unified assessment and immediate treatment

You need to make a judgement as to the measures that need to be put in place to keep the patient safe in the department, based upon:

Information you have gained about the patient

Physical degree of agitation

Current environment in which they are being contained

Likelihood they still have items on them that they could use to harm themselves or others

Their current suicidal intent (or other high‐risk thoughts or behaviours)

By synthesising the ABCD AEIO elements into overall Unified risk assessment, you will be able to specify the degree of observation that is required (ranging from no additional measures to one‐to‐one constant observation) and the number of staff trained in physical intervention that need to be present either in the room or outside the room.

Table 2.1 provides a guide as to the minimum number of staff, trained in physical restraint, required according to the unified assessment. There are no agreed published guidelines for staffing levels in such situations, and Table 2.1 has been reached by consensus agreement between the authors of the APEx course. The red boxes indicate levels of risk where you should be considering whether rapid tranquillisation will be necessary to keep the patient safe. Increase the number of members of staff required according to the size and power of the patient, and other relevant factors. Not all combinations of the AEIO are shown, but the examples included in Table 2.1 provide a quick reference guide.

Table 2.1 AEIO assessment: minimum number of staff required for safe containment

Arousal/agitation | Environment | Intent | Objects | Containment
Low | Low | Low | Low | Nil
Moderate | Low | Low | Low | One staff
Moderate | Moderate | Low | Low | Two staff
Moderate | Moderate | Low | Moderate | Three staff
Moderate | Moderate | Moderate | Low | Three staff
Moderate | Low | Moderate | Moderate | Three staff
High | Low | Low | Low | Three staff
High | Low | High | Low | Four staff
High | High | High | Low | Six staff
High | High | High | High | Six staff

Clinical judgement should always override the guidance in Table 2.1, which is a very basic starting point from which to plan care.

2.7 Rapid tranquillisation

This is discussed in detail in Chapter 8.

Rapid tranquillisation may be needed in some cases where the patient is extremely aroused and cannot be calmed down. It is used when both psychological approaches and environmental management have been ineffective. Tranquillisation should be administered orally if at all possible. If it is delivered parenterally then both patient and staff safety should be paramount. The aim of rapid sedation is to render the patient into a state where they are calmer and less distressed, not to make them unconscious. Lorazepam is usually given first (2 mg) orally or intravenously and it is recommended that further doses are not given for at least 30 minutes. If lorazepam is insufficient then haloperidol (with promethazine) can be given intramuscularly. All patients who have been sedated require regular monitoring (at least hourly or more frequently if consciousness is impaired).

2.8 Staff safety

If you find yourself alone with an acutely disturbed patient, do not approach them. Keep your distance (at least two arms’ length away). Locate the nearest exit and make your way towards it. Tell the patient your name, tell them you are a member of staff and you are going to get some more help for them. Speak in a calm voice and keep looking at the patient, but do not make intense eye contact. Do not turn your back. As soon as you can, leave via the exit and shout for help.

If you are concerned you are going to be attacked:

Use your personal alarm if you have one

Use the hospital alarm system, if one is installed and you can reach it

Shout ‘fire’ (this is more likely to illicit a response from staff than ‘help’)

Try to run or get away

If you are caught or seized by the patient, you may have to use basic techniques to extricate yourself. There are many courses available that offer training in these skills.

2.9 Person‐centred care

All patients and healthcare professionals have rights and responsibilities. The focus in this chapter has been on the need to conduct a primary physical and psychiatric assessment to keep someone safe in the ED department, whilst further physical or mental health assessments are undertaken.

This does not obviate the need to adopt a person‐centred, values‐based approach to care in which people’s rights are respected and efforts are made to develop a trusting therapeutic relationship. It has been shown that dedicated mental health support workers, whose role is to provide reassurance, listen and engage with patients who are contained in a room for their own safety, can have a positive impact upon the patient’s experience. Such workers can explain any legal processes, help to de‐escalate tension or aggression, provide basic comforts such as food or drink, and help the patient to contact family members or friends.

2.10 Legal framework

The legal framework under which staff provide assessment and care for patients with acute behavioural disturbance in the ED will vary depending upon the nature of the person’s disturbance and their pathway to the department. A full discussion of the legal framework, which covers acute psychiatric emergencies, is given in Chapter 9, including the role of advance directives.

2.11 Secondary assessment

Once steps have been put in place to minimise the risk of harm to the patient or others, the ED team and liaison psychiatric team should work collaboratively to undertake a parallel physical and full mental health assessment. The aim is to determine the most likely cause of the patient’s disturbance and the most appropriate facility to which the person should be admitted. In most cases the degree of disturbance will warrant an admission to either a medical ward or mental health facility.

2.12 Summary

It is important to use a structured approach to the assessment of someone who is acutely disturbed to ensure their safety and minimise any potential harm to others.

CHAPTER 3
Secondary physical and psychosocial assessment

Learning outcomes

After reading this chapter, you will be able to:

Describe how to implement the structured approach to combined secondary physical and psychosocial assessment

Explain the structure of a focused conversational psychosocial history

Describe the mental state examination

3.1 Introduction

In this chapter we will explore the secondary assessment of both the physical and the psychosocial illness that may have contributed to the acute psychiatric emergency. This element of the structured approach is shown in Figure 3.1.

Figure 3.1 Structured approach: secondary assessment

3.2 Focused physical history and examination

The principal aim of the focused physical history and examination are to:

Explore whether there might be a physical element to the acute psychiatric presentation and, if there is, to determine the appropriate emergency treatment

Document the cause and examine any physical sequelae of the psychiatric emergency (such as wounds in self‐harm) to determine necessary treatment

Determine the physical health status of the patient

Before deciding that the patient is suffering from a psychiatric disorder you will need to consider whether there is an alternative physical cause for their presentation. There are many physical illnesses that can present as psychiatric illnesses and these are important to keep in mind especially if this is a first presentation. If the patient has an established diagnosis of a major mental illness then it is less likely that the cause is organic illness, but this does not rule it out completely.

While a full secondary assessment (incorporating a comprehensive and systems enquiry, together with a head‐to‐toe physical examination) might be needed to definitively determine physical health status, it is often neither necessary nor possible. A pragmatic approach must be taken and best use made of available history and permitted examination. The vast majority of patients in psychiatric crisis can be examined safely and adequately once they feel safe. Practitioners should remember, however, that the required proximity to the patient for physical examination (a stethoscope length) puts them at increased risk of being unable to escape if the situation suddenly escalates, and they should not undertake those physical examinations without a clear risk assessment. It is better (and more informative) to ‘talk down’ an acutely agitated patient to persuade them to permit basic observations, than to end up taking observations from and fully examining a very stressed restrained patient under duress.

Many practitioners will have their own approach to history taking and physical examination – and this book does not aim to change well‐established and personal practice proven processes. For those who are looking for a system to follow or who wish to change the one they currently use, the PHRASED approach to history taking is presented (Acute Medical Emergencies: the Practical Approach (ALSG, 2010)):

P Presenting complaint

H History of presenting complaint

R Relevant medical history

A Allergies

S Systems review

E Essential family and social history

D Drugs

The physical examination that is necessary for the secondary assessment of the patient in psychiatric crisis is outlined in the relevant chapters that follow. As previously mentioned, this may be constrained by the psychiatric crisis itself – a pragmatic approach should be taken, weighing up the access to the patient, their compliance with the examination, the risk to the clinician and the necessity of physical examination in determining future care and disposal. In extreme circumstances it may be necessary to tranquillise the patient prior to examination (obviously at the cost of a clear history).

On occasion it is necessary to further investigate the possible physical causes or effects of the psychiatric crisis. The investigations (blood tests, x‐rays, scans and others) should be as indicated by the findings of the physical history and examination. There is no standard investigation panel for psychiatric emergency presentations, and no particular tests that are universally needed to ‘physically clear’ the patient.

3.3 Focused conversational psychosocial history

The principal aim of the psychosocial history at this stage is to:

Engage in a dialogue with the patient that will contribute to the de‐escalation of the emergency

Identify or exclude substance misuse as a contributory factor

Further explore those issues of risk that informed the immediate decisions on the degree of supervision and risk management required

Identify non‐organic (‘functional’) symptoms that would support referral to an acute psychiatric service in the absence of an organic cause

General principles

Allow the patient to talk freely initially so that they can tell you what has been happening to them and what has led to them coming into hospital. A conversational style should be adopted. By spending some time at this stage you will uncover many of the symptoms contributing to the mental state. The headings below constitute a focused psychosocial history, and should sufficiently uncover the information needed to manage the psychiatric emergency at this stage:

P Problem

H History of presenting psychiatric problem, e.g. SLIPA

R Relevant psychiatric history and forensic history

A Allergies

S Substance (mis)use and self‐harm

E Emotional trauma

D Drugs

Key symptoms contributing to presentation

Duration of onset

Past psychiatric history or previous similar episodes, including treatments received

Prescribed medication (for psychiatric and non‐psychiatric reasons). Recent new prescriptions, or dose changes, are particularly relevant (e.g. new prescriptions for steroids)

Recent changes in physical health, including recent diagnoses, or the onset of physical symptoms; positive findings here may require physical examination and further testing later in the assessment

Recent physical or emotional trauma

Recent alcohol or illicit drug consumption, with a brief screen for longer term misuse of or dependence on alcohol and other substance/s

Thoughts of self‐harm or harm to others, as a matter of routine, and follow through with more detailed questioning if necessary

Any previous forensic history – especially a history of violence

3.4 Secondary psychosocial (mental state) examination

Once you have a basic history, review which aspects of the mental state assessment you have already covered, and what may require further specific exploration. The mental state examination consists of both verbal and non‐verbal elements, so even if the patient is unable to give any coherent history, or is unwilling to engage in the assessment, you will be able to complete the majority of the sections of the mental state examination by observing the patient. The mental state examination can be structured using the mnemonic ABC SMITH:

A Appearance

B Behaviour

C Cognition

S Speech

M Mood and affect

I Insight and capacity

T Thoughts

H Hallucinations and illusions

Appearance and Behaviour

How are they dressed? Patients with psychotic illness, mania, severe depression, alcohol and substance misuse, or dementia may present with evidence of poor self‐care alongside inappropriate clothing for the weather. Patients with mania may be dressed in bright or inappropriate clothes. Psychotic patients may be wearing odd items, such as sunglasses on a rainy day, or tin foil on their head, giving you hints about underlying unusual beliefs. Do not be anxious about being inquisitive if necessary

How active are they?

Underactivity (psychomotor retardation) – this may be seen in severe depression, severe physical illness including head injury, and intoxication with both drugs and alcohol

Stupor – the patient presents as mute with complete immobility although there may be occasional short periods of excitement and overactivity. Stupor has a range of both physical and psychiatric causes including severe depression and mania, catatonia, epilepsy and hysteria

Overactive (psychomotor agitation) – may be due to mania, anxiety, acute drug intoxication, acute confusional state or head injury

Akathisia – agitation and restlessness due to neuroleptic medication

Rapport – how does the patient relate to you? Patients may be overfamiliar if they have frontal lobe damage, are intoxicated or are manic. A difficulty in forming a rapport and poor eye contact may be seen in severe depression. Patients with psychotic disorders may appear suspicious, frightened, guarded and reluctant to give you information

Aggression – can be a symptom of many different conditions and is not necessarily pathological. For assessment and management of aggressive patients please see the relevant chapters

Abnormal movements are often non‐specific, but often indicate organic or functional pathology that may be relevant to the emergency presentation:

In particular look for tics, movements of the mouth or tongue, and abnormal movements of the upper and lower limbs, and seek more specialised support if these are seen

Patients may exhibit features of an acute neurological emergency, such as catatonia or features of chronic neurological illnesses such as Parkinson’s disease or multiple sclerosis

Patients with chronic schizophrenia can exhibit a range of movement disorders as echopraxia, stereotypies, mannerisms, posturing or negativism. The chronology of these may indicate longer term mental health issues but, again, if observed seek more specialised support

Fidgeting with hair, clothes or nails may all be seen in patients with anxiety disorders or substance misuse

Patients scratching themselves, repeatedly banging their head against the wall or rocking may be them trying to cope with severe distress but should raise suspicions that the patient may have a learning difficulty

Patients looking toward an unseen object or responding to unseen stimuli. This may indicate hallucinatory experiences in any modality

Cognition

Psychiatric emergencies commonly have an organic contribution, with degrees of impairment of consciousness as a significant contributory factor to the behavioural disturbance. Assessment tools for delirium are beyond the scope of this chapter (bearing in mind that delirium can present with personality change, mood disturbance, anger, irritability, agitation, anxiety, apathy, depression or any other affective state). However, any secondary assessment in a psychiatric emergency should at least check for orientation in time, place and person, and check for signs of poor concentration such as an inability to concentrate on the interview, or recite days of the week in reverse. Poor estimation of the length of the interview is also a subtle sign of delirium. If there are signs of delirium/acute confusional state see Chapter 7 for full assessment and management.

Speech

Think about the rate of the speech and form of the speech (the form of speech is described later, under ‘Thoughts’). Clarify that the patient does not communicate via sign language because they are deaf, or only speaks a language other than English. You may need to find an interpreter before continuing with your secondary assessment.

Some patients will present as mute. This may be due to expressive aphasia, aphonia, learning difficulty, catatonia or depressive stupor. A reduced volume of speech may be related to a number of disorders including cerebrovascular accidents, severe depression, schizophrenia and learning difficulties. Conversely, patients may talk rapidly, loudly or are difficult to interrupt. This is most commonly seen in intoxication, mania and hypomania, and sometimes in anxiety.

Mood and affect

Your own observations on the patient’s mood state are important, although they rarely help differentiate between organic and non‐organic emergencies. The important aspect here is to ensure that the mood and affect observed are integrated into your understanding and explanation of the psychiatric emergency.

The patient could be:

Depressed (multiple pharmacological and organic causes in addition to a range of psychiatric diagnoses)

Elated (multiple pharmacological and organic causes in addition to a range of psychiatric diagnoses and intoxicants)

Irritable; this is often overlooked as a psychiatric symptom, but can be the only feature of a range of disorders such as intracranial tumours, hyperthyroidism and other organic disorders, intoxication, bipolar disorder or dementia, amongst many others.

Insight and capacity

It should rapidly become apparent during the secondary assessment whether the patient has an understanding of their symptoms and illness, whether they understand the treatment or investigations being offered, and if they have capacity to consent for any admission, examination or treatment necessary. Capacity and insight should be documented in every secondary assessment, with demonstration that appropriate steps have been taken in cases where the patient does not have the capacity and/ or insight to participate in, or agree to, the clinical decision‐making process.

Thoughts

This is a complex and detailed area of the mental state examination, beyond the scope of a primer on psychiatric emergencies.

In brief, this is where a description of how the patient is thinking is documented; of course this can only usually be inferred from what they are saying. Two headings are used.

Disorders of thought – form

This is often identified by observing that the patient’s responses to your questions are not making sense. In its mildest form the interviewer may wonder whether it is in fact the interviewer who is failing to concentrate! Some of the disorders of thought include:

Circumstantiality (the patient eventually answers the question with a lot of unnecessary detail)

Tangential thinking (the patient starts off as if to answer the question but continues on various tangents, never answering the initial query)

Loosening of associations (strange or absent associations between elements of speech, which may be very mild so that simple speech is normal but complicated ideas have their elements muddled up, or so severe that most sentences become impossible to follow)

Neologism (made‐up words)

Flight of ideas (the patient jumps from one topic to the next, often with connections that seem odd and are difficult to follow)

Perseveration

Echolalia (the patient immediately repeats your speech)

Slow, simplified thoughts (e.g. in hypothyroidism, catatonia, depression, intoxication, fatigue) and thought block

Finding of any of these is probably significant, and as described earlier the important aspect here is to ensure that any observed abnormalities of thought form are integrated into your understanding and explanation of the psychiatric emergency.

Disorders of thought – content

Although exploration of the content of thoughts is relevant to a full understanding of the patient’s experience, it makes only a limited contribution to the management of the emergency situation.

In broad terms, thoughts are either non‐psychotic or psychotic. In both cases, the causes can be organic or non‐organic, with only very few experiences being strongly indicative of a specific diagnosis.

Non‐psychotic thoughts can be hypochondriacal, catastrophic, depressive, obsessional or phobic, for example. These can be accompanied by emotions such as fear, hopelessness, anxiety and distress. Some ‘out‐of‐body’ experiences such as feeling detached from their own body can be classified here, caused by severe anxiety or a range of organic disorders.

Psychotic thoughts are frequently frightening and very unusual experiences which are in almost all cases not normal, and are not experienced by healthy people in day‐to‐day life. Examples of psychotic experiences include:

Delusions, which are generally false and unshakeable beliefs that are held contrary to the patient’s normal culture and experiences. Examples might include that the world has been filled with green smoke, or that aliens have filled the water supplies with poison

Delusions of control and passivity phenomena are very specific experiences of a delusional belief that some aspects of the patient’s sensorium (thoughts, feelings, movements and sensations) are being controlled by an external agency, or that there is some form of external control of the patient’s thoughts outside their control

Overvalued ideas sit in‐‐between psychotic and non‐psychotic thoughts; these are ideas that are unreasonable and strongly maintained with many elements of a delusional belief, but where the patient is able to recognise that the idea may not be true or culturally appropriate

Under the heading of thought content the clinician should remember to check that there has been sufficient enquiry about thoughts of self‐harm, and harm to others.

Hallucinations and illusions

Illusions are the misinterpretation of a real stimulus, and arise in some mood states such as anxiety (e.g. misperceiving a shadow as a potential assailant on a dark night due to increased anxiety). Illusions may contribute to distress and a psychiatric emergency.

Hallucinations, on the other hand, are perceptions in the absence of a stimulus, and can occur in any sensory modality (taste, smell, touch, sight and hearing). They are not usually part of a normal human experience and so should be considered as significant in almost all cases. Auditory hallucinations (often ‘voices’) are generally non‐diagnostic – they are almost ubiquitous in delirium, occur commonly in other organic disorders, and are frequent in a wide range of psychotic disorders. Other hallucinations, however, should significantly raise suspicion of organic disorders or intoxication with illicit drugs.

Collateral information

Once this stage in the assessment has been reached it can be useful to obtain any collateral information available, this may be from friends or relatives, staff in the department who have previous knowledge of the patient or previous medical or psychiatric records. Collateral information can be particularly useful if the patient is unwilling to engage with the assessment.

3.5 Summary

This chapter has outlined both the physical and psychosocial secondary assessments. The elements of the structured approach will be explored in more detail in the context of specific patient presentations in the following chapters.

CHAPTER 4
The patient who has harmed themselves

Learning outcomes

After reading this chapter, you will be able to:

Describe how the structured approach can be applied to patients who have self‐harmed

Perform a mental health assessment in patients who have self‐harmed

Identify how to integrate the mental health assessment with the physical healthcare of the patient with self‐harm

4.1 Introduction

There are 200 000 presentations per year to emergency departments (EDs) in England following self‐harm. Not all people who self‐harm have suicidal intent, but self‐harming behaviour is linked with a 30‐fold increase in the risk of future completed suicide, as compared with the general population. There is also a high prevalence of psychiatric morbidity in those who self‐harm, with over 80% suffering from one or more types (e.g. depression, anxiety disorders). Between 15% and 30% of people will repeat self‐harm within a 12 month period, and these people are at even higher risk of suicide.

Many people who attend an ED following self‐harm report negative attitudes from hospital staff, which may cause an unnecessary increase in their distress. This may arise from a lack of understanding of the nature of emotional pain (which can be as severe as or even more distressing than physical pain), a lack of awareness of the high risk of eventual suicide of such patients, or a lack of training of emergency staff to appropriately manage patients who present with self‐harm.

Many people who self‐harm have a background of childhood difficulties, including abuse and neglect and many have led difficult and challenging lives. They are an extremely vulnerable group of people who find it difficult to cope with adversity.

Approximately 40% of people who die by suicide in England attend an ED in the year prior to death. The majority of these attendances are either for self‐harm or a request for psychiatric help. Individuals who attend on multiple occasions for mental health reasons or for self‐harm are at particularly high risk of suicide. Clinicians should therefore be alert to the risk associated with such presentations and be able to assess and treat patients according to their risk profile and mental health needs.

4.2 General principles

National Institute for Health and Care Excellence (NICE) guidelines have suggested some general principles for all healthcare professionals when helping people who have self‐harmed (NICE CG16, 2004). They are as follows:

Always treat people with care and respect

Take full account of the likely distress associated with self‐harm

Involve the person who has self‐harmed in clinical decision making and provide information about treatment options

PUTTING IT ALL TOGETHER – THE STRUCTURED APPROACH TO ASSESSMENT

4.3 Preparation

People who self‐harm require assessment of both their physical and mental health. Whenever possible this should be conducted in a flexible and fluid way, to increase efficiency and minimise any distress to the patient. It involves close, collaborative, working between ED staff and mental health liaison teams, with each member of staff facilitating the work of others.

If the patient is acutely physically ill, medical care should follow the structured approach described in Acute Medical Emergencies: the Practical Approach (ALSG, 2010) with a focus on primary physical assessment, with resuscitation, if necessary. A secondary mental health assessment is not practical, feasible or indeed a priority in these circumstances.

Most patients will undergo a form of triage when they attend the ED; either as part of this process, or immediately following it, a primary (AEIO) assessment must be carried out. This should include a plan for immediate management within the department, which specifies the degree of observation required to keep the patient safe. In the case of the acutely ill patient, this assessment should occur as soon as they are physically stable and conscious. Figure 4.1 shows the pathway that most patients will follow within the ED, depending upon their risk status and whether they are intimating that they wish to leave.

If the patient is transferred from the ED to an acute ward or intensive care unit before an assessment has taken place in the ED, the patient should be assessed as soon as possible in the new environment. It may only be possible to carry out a brief assessment of immediate risk at this stage, but a plan regarding the level of observation the patient requires must be written in the medical notes and conveyed to all relevant staff. It should not be assumed that because the patient is still physically unwell, he or she is free from risk of further self‐harm. Patients can and do commit suicide in the acute hospital setting (either in the ED or on hospital wards), or leave the hospital precipitously with the intention of taking their own lives.

Mental health staff should not wait until the patient is medically fit before carrying out an assessment. Risk needs to be assessed and managed as soon as the patient is conscious, followed by a more detailed assessment, when the patient is capable of participating more fully in the assessment process.

If immediate medical management is not required to save life, a more integrated physical and mental health assessment should be conducted. A common error in the management of self‐harm is to delay mental health assessment until all medical treatment is completed.

Figure 4.1 ED pathway for patients who have harmed themselves

4.4 Primary assessment – the unified assessment

Before any physical investigations are carried out, establish the following:

Immediate or short‐term risk of further self‐harm or suicide (or harm to others)

Likelihood of the patient leaving the ED before physical and mental health assessment can be carried out

Put in place measures to mitigate risk if either is deemed to be high, as outlined in Chapter 2. Use this structured approach if the patient is highly aroused, agitated, aggressive or actively trying to leave the department. The following discussion assumes that the patient is relatively calm and is able to participate in the triage process, as is the case for the overwhelming majority of people who self‐harm. The approach follows the basic principles of an AEIO Unified assessment, but is specifically tailored for people who have self‐harmed.

Triage – risk of further self‐harm or suicide

As part of the triage process practitioners will need to prioritise the patient with self‐harm for further clinical assessment. This will require an integrated approach to the assessment of physical and psychiatric risk. A recognised tool should be used. One such is the self‐harm algorithm in the Manchester Triage System in Emergency Triage, 3rd edition (ALSG, 2013), shown in Figure 4.2. Emergency nurses are well versed in assessing physical risk such as that of breathing difficulties in someone with an insecure airway. They are probably less experienced in the assessment of risk of further self‐harm during the brief triage assessment.

Questions about risk are best asked in context, when gathering information about what the person has actually done to harm themselves. It may be useful to ask the patient the following:

‘And when you took the tablets (or cut your throat, etc.), what thoughts were in your mind at the time?’

Staff should note how the patient responds and if necessary then ask a supplementary question to clarify their response:

‘So when you took the tablets (or tried to hang yourself), you intended to die’ or

‘So when you took the tablets, you didn’t actually intend to die.’

Triage staff should also enquire about immediate risk:

‘Do you have any current thoughts of harming yourself?’

‘Do you have any thoughts of harming anyone else?’

‘Are you okay to stay and wait in the department here until we can sort out the right help for you?’

If the patient responds to any of the above questions in a way which causes concern, then the patient is at high risk (priority 2) of further self‐harm and measures to keep them safe should be put in place. This will involve either arranging for a member of staff to stay with the patient or moving them to a location in the ED where they can be safely observed. The mental health team should be involved at this stage, to help with the assessment process and help form plans to keep the patent safe. Explain to the patient what you are doing and why.

‘Because it was a very serious attempt (or because you still have thoughts or harming yourself) we need to keep you safe while we sort out how best to help you. We will arrange for someone to come and sit with you in the department to keep you safe.’

In most cases, close observation will not be required and the medical part of the assessment will take priority at this stage. However, if the person is identified to be at risk, a discussion should take place between the ED staff and the liaison team as to how best to integrate the physical and mental health assessments.

Figure 4.2 Manchester Triage System: self‐harm chart.

Source: ALSG (2013) reproduced with permission of John Wiley & Sons

Likelihood of the patient leaving the ED before physical and mental health assessment can be carried out (flight risk)

Approximately 10–20% of patients who attend the ED following self‐harm will leave the department before a full assessment has been completed. These patients are at higher risk of further self‐harm and eventual suicide. Of most concern are those patients who walk out of an ED and go on to commit suicide within a few hours of taking their leave.

It is not always possible to anticipate or prevent such behaviour, but it is important to note if the patient appears restless and agitated and to alert mental health staff early if this is the case. It is helpful to explain to patients that they will be seen as quickly as possible, but they may have to wait for certain investigations to be carried out and for an assessment and help with their problems. Patients should be asked directly if they are happy with this and are willing to stay and wait. If they appear unhappy or ambivalent, discuss the situation with the mental health team, who should be available to give advice or quickly see the patient to carry out a brief risk assessment.

If a patient leaves the department before a full assessment has been done, staff need to consider whether there needs to be any further action. If staff had concerns about that person, but were not able to organise sufficient care to keep them safe, then the police must be informed as soon as possible, with a request that the person should be detained using police legal powers.

If patients have capacity to make decisions about their care, they have a legal right to leave the ED. However, the assessment of capacity following self‐harm is not straightforward and help should be sought from the mental health team, particularly if the consequences of refusal are potentially life threatening. The assessment of capacity in this situation is discussed in more detail later in the chapter.

Medical/surgical management

In the case of self‐poisoning, methods to minimise drug absorption may need to be considered, and specific toxicological advice sought from the National Poisons Centres, either by accessing TOXBASE or by telephone consultation. Specific antidotes may need to be administered, specific investigations may need to be undertaken and particular observation regimens may need to be followed.

4.5 Secondary assessment

Notwithstanding these considerations, if the patient is conscious and alert, a mental health assessment can be undertaken in parallel with physical assessment and treatment. This assessment is usually undertaken by a member of the mental health team, but such assessments can be carried out by ED staff, if suitably trained.

Mental state assessment should begin as soon as possible following a physical assessment, and can take place whilst blood results are awaited or other investigations are being considered. A detailed assessment, however, can only occur if the patient is alert and fully conscious, and a period of waiting may be necessary if the patient is intoxicated. Flexible working between the ED staff and the liaison mental health team should ensure both physical and mental health assessments are completed in a timely fashion. If the patient is too intoxicated for a detailed assessment to be undertaken, the mental health team should still be available to help the ED staff manage the patient if there are concerns regarding safety and risk.

Focused conversational psychosocial history

It is best to start the mental state assessment with a brief introduction and an explanation of the purpose of the assessment, followed by an open question about the episode of self‐harm:

‘Could you tell me a little about what you’ve done?’

Try to establish the sequence of events leading up to the self‐harm and what the patient actually did. How did he/she come to have thoughts of self‐harm? What precipitated the episode? Was the self‐harm planned or impulsive? Establish how he/she came to seek treatment in the ED.

There are many reasons why people self‐harm, one of which includes a wish to end life. The most common reasons are shown in Box 4.1.

Box 4.1 Reasons why people self‐harm

Wanting to die

Wanting to die and not wanting to die

As a way of regulating/relieving distress

Having time out

To seek a reaction from others

To express anger towards self or others

To stop feeling isolated

To avoid suicide

A lot of information can usually be obtained from the patient by asking relatively few questions and many of the key points you need to know may be answered naturally during the flow of the conversation. As the assessment continues, you will need to focus upon the points below, if they have not already been addressed.

Assessment of risk

Identifying patients at ‘high risk’ of suicide or further self‐harm is the aim of most assessments following self‐harm. However, in reality this is very difficult to do and most risk factors have very low predictive power.

It may be helpful to think of predicting risk as similar to trying to predict the weather. The weather forecast can be reasonably accurate over the short term (24 hours) but the longer the range, the less accurate it becomes. This is because weather is influenced by a complex, interacting pattern of meterological systems which are in constant flux. This is not so dissimilar to human behaviour, which is also subject to continual modification and change. The computer programs used to predict the weather are considerably more powerful and sophisticated than the rather crude assessments that are carried out in the ED to predict future self‐harm or suicide. Therefore, any professional undertaking an assessment in an emergency situation such as the ED, should focus upon the short‐term risk (a few days), and be cognisant of the uncertainty of the clinical process. The main role of risk assessment is not to predict the future but to manage risk in the short term.

It is helpful to group the information gathering into five key areas (SLIPA):

S Suicidal thoughts at the time of self‐harm

L Lethality of the episode

I Intent now

P Protective factors

A Adverse factors

SLIPA

Suicidal thoughts at the time of self‐harm

This refers to the thought processes the person experienced at the time of the self‐harm episode. The patient may already have been asked about this during triage to assess any immediate risk. If so, acknowledge this:

‘I know you may have been asked this when you first came to the emergency department this evening, but could you tell me about what was going through your mind when you …’

Depending upon the patient’s response, you can then clarify their intent by asking:

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?’

Although the patient may have been asked this previously, it is important to establish it for yourself. The previous questioning will have been carried out in the context of a brief triage/screen, and the patient may have minimised their intent.

Lethality of the episode

Establish the likelihood that the episode of self‐harm would have resulted in death. This includes the nature of the self‐harm, the steps the patient took not to be discovered, and the preparation and planning involved in the episode (Box 4.2).

Box 4.2 Potential high lethality of episode of self‐harm

Violent method (e.g. hanging, gunshot, stabbing, jumping from height)

Patient would have died without medical intervention (includes self‐poisoning)

Avoided discovery (e.g. checked into hotel, drove to a remote place, ensured he/she was alone)

Made plans to kill self (e.g. bought rope, stockpiled medication)

Anticipated death (e.g. made will or wrote a note which clearly implies patient intended to die)

Made no active efforts to be found after the self‐harm episode and did not seek help

Violent methods such as hanging, jumping off a high building, shooting or stabbing oneself are methods that are highly likely to result in death. Taking large amounts of medication such as paracetamol or aspirin, or taking poison, are also high‐risk actions.

A degree of preparation and planning such as stockpiling medication, or trying to avoid discovery by checking into a hotel or driving to an isolated location, all convey greater intent.

Find out details of the pathway to treatment. Was the person discovered by chance or did they play an active role in seeking help following the self‐harm episode? In the latter case there may still have been suicidal intent but the person changed his/her mind shortly after the self‐harm episode, or the person may not have intended suicide and may have had some other reason for the action. Some people leave notes, which may or may not indicate suicidal intent.

Intent now

This refers to whether the patient has any current thoughts of self‐harm or suicide. This can be established in two ways.

Does the person have any regrets that the self‐harm episode did not lead to death?

Does the person have any current thoughts of self‐harm?

Protective and Adverse factors

Consider these two areas together as they often refer to aspects of the patient’s life which can either be protective or stressful, e.g. a job can be stressful or protective or both. Common aspects are personal relationships, family and friends, job, housing, finances and criminal charges.

Approximately 70% of all self‐harm episodes are precipitated by some kind of interpersonal problem, e.g. marriage break up, bereavement, domestic abuse, miscarriage or argument. So always enquire about this aspect of the patient’s life, and find out about their living circumstances. Are they living alone, or if they are living with someone, is this a supportive relationship?

Assessment of these five SLIPA areas provides the basis for the assessment of risk to which other relevant factors can be added to produce an overall risk profile. As stated earlier this is not an exact science and advice from a more experienced professional should be sought if there are concerns or doubts about the process. Some examples of how a risk profile is constructed are given later in this chapter.

Demographic or historical risk factors

Identified risk factors are listed in Box 4.3. Individually these factors have low predictive power, as they have been identified from large longitudinal cohort studies, in which basic information recorded in patients’ notes has been used to predict later suicide. Such studies rarely include detailed information obtained by assessing people’s actual mental states at the time of the self‐harm episode. We suggest that the demographic/historical risk factors should be combined with the information obtained from SLIPA, to enhance the accuracy of the risk assessment. Many patients who present with self‐harm have at least one or two or more of these demographic/historical factors (e.g. male and unemployed), so it is difficult to make clinical judgements based upon these factors alone.

Box 4.3 Demographic or historical risk factors for suicide

Male

Middle or older age

Living alone

Previous history of self‐harm

Previous history of severe mental illness (includes schizophrenia, bipolar disorder and depression)

History of drug dependence

History of violent behaviour

Frequent ED attendances

Alcohol problems

Unemployed

Socially isolated

Severe or long‐term physical illness

Co‐morbid mental illness

Self‐harm is not a psychiatric diagnosis in itself. It is a behaviour which signals that an individual is not able to cope with a particular situation or set of circumstances. Self‐harm is often associated with mental illness, as mental illness often impairs an individual’s ability to cope. Approximately 70% of patients who self‐harm have a co‐morbid mental illness, and mental illness is a strong risk factor for suicide. Often there is a pattern of symptoms worsening or building, which lead up to the self‐harm episode.

Appropriate treatment of any co‐morbid conditions may reduce the risk of future self‐harm or suicide. Patients with severe mental illness, either schizophrenia or bipolar affective disorder, who have self‐harmed must have a detailed assessment from a mental health professional to ensure an appropriate treatment and management plan is put in place.

The most common co‐morbid problems associated with self‐harm are depression or substance misuse. Key symptoms for depression include persistent low mood for at least 2 weeks or longer, poor sleep, poor appetite, weight loss, poor concentration, morbid thoughts, inability to enjoy things, low energy and drive, irritability, fatigue, guilt or a feeling that life is not worth living. Box 4.4 lists all of the most common symptoms of depression. Feelings of hopelessness have been linked to an increased risk of suicide and should always be enquired about.

Box 4.4 Common symptoms of depression

Mood symptoms

Persistent low mood

Diurnal variation in mood (typically worse in the morning)

Anhedonia – being unable to enjoy things

Physical symptoms

Poor sleep – early morning wakening or repeated waking throughout the night or difficulty getting off to sleep

Poor appetite

Weight loss

Lack of energy

Cognitive symptoms

Guilt

Hopelessness

Belief that life is not worth living

Suicidal ideation

Feeling a burden on others

Poor concentration

Forgetfulness

Alcohol and drug problems

Many episodes of self‐harm occur in the context of taking alcohol or drugs. This may indicate an underlying problem with alcohol or drugs, which will increase the likelihood of further episodes of self‐harm if the problem is not addressed. Try to ascertain how much alcohol or drugs the patient took prior to the self‐harm and whether this made a significant contribution to the self‐harm act. Does the patient recognise the contribution that alcohol or drugs made, and want help to cut down or abstain?

Try to establish how much alcohol the patient consumes on a weekly basis, and the amount of illicit drugs the patient takes. Screen for any evidence of alcohol dependence, particularly if the patient is likely to be admitted, as they will need to be started on an appropriate withdrawal and vitamin replacement regime by the admitting team. The management of patients with alcohol and drug‐related problems are covered in detail in Chapter 6.

Co‐morbid physical health problems

The risk of suicide is significantly elevated in patients with severe physical illness. Screen for any physical health problems, particularly those associated with excessive alcohol consumption; including a history of fits, liver problems, neurological problems or gastrointestinal disorders. Have a high index of suspicion for patients who self‐harm in the context of terminal illness. Although an individual may come to a careful and thoughtful decision to end their life in the context of a terminal illness, a sudden or impulsive action is unlikely to have been thought through, and often indicates the patient is struggling to come to terms with the illness, or may have become depressed.

Developing a risk profile

Start with the information from SLIPA and use additional relevant information to build the profile, as in Figure 4.3. This will include taking account of demographic and historical factors, and the presence or absence of mental illness. The information from SLIPA should carry the most weight, as it is most directly related to managing current risk, with ‘co‐morbid mental illness’ also important. The demographic and historical factors should be used as adjuncts but not as stand‐alone measures.

Figure 4.3 Building a risk profile in self‐harm

4.6 Case examples

Case 4.1
A 42‐year‐old Polish man, Aleksander, jumped 40 feet from scaffolding, resulting in multiple fractures to his back and pelvis. His right lower leg had to be amputated at the scene as it became trapped in the scaffolding on his way down. Aleksander had worked as a labourer but had been unable to find work for several months prior to the episode, and was about to be evicted from his flat. He was estranged from his wife who was preventing him from having access to his 9‐year‐old daughter, whom he had been unable to see for several months. He had been low in mood for several weeks prior to the self‐harm episode. He intended to die.

My risk assessment

Case 1: Developing a risk profile

SLIPA
Suicidal thoughts at time of episode: yes
Lethality: very high
Intent now: no current intent when assessed in hospital
Protective factors: none identified
Adverse factors: inability to find work, low income, homelessness, lack of access to daughter; social isolation; amputation of leg will impair likelihood of being able to work again as a labourer in the future

Demographic or historical factors
Male
Middle aged
Homeless
Social isolation
Unemployed

Co‐morbid mental illness
Evidence of a depressive illness developing in the weeks prior to the self‐harm episode. No alcohol or drug misuse

Overall risk profile
The overall risk profile in this case is high as most of the SLIPA items are positive; the patient also has four demographic/historical risk factors and in addition is suffering from a depressive illness
The patient requires immediate treatment for his physical injuries and fractures with admission to an orthopaedic ward. He will require close observation (one‐to‐one) on the orthopaedic ward by a mental health nurse, and a full mental health assessment, when he is medically more stable and alert

Case 4.2
A 29‐year‐old woman, Aoife, took an overdose of antidepressants which she had 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 had lost 4 kg in weight. She had begun to drink a bottle of wine per night to help with the panicky feelings and her sleep. Her husband was in the armed forces and had been away on a tour of duty for several months. She had had a miscarriage in the previous year, which she had 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 immediately phoned a friend who brought her to the hospital.

My risk assessment

Case 2: Developing a risk profile

SLIPA
Suicidal thoughts at time of episode: no
Lethality: low
Intent now: no current intent when assessed in hospital
Protective factors: working, married, has good friend
Adverse factors: work is stressful, husband is away, recent miscarriage

Demographic or historical factors
None identified

Co‐morbid mental illness
Evidence of a depressive illness developing in the weeks prior to the self‐harm episode. Excess alcohol intake and self‐harm episode took place in context of heavy drinking that evening

Overall risk profile
The overall risk profile in this case is low as 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 requires help for her depression, which will include an alternative antidepressant (with advice from her GP to prescribe only a maximum of 1 week’s supply at a time) plus psychological treatment (referral to the Improving Access to Psychological Therapies programme). She has agreed to reduce her alcohol intake and her GP will be asked to monitor this over the next few weeks

Case 4.3Leah, a 23‐year‐old woman, is brought to the ED after she has tried to hang herself. She had taken ketamine with some friends at a party. She had become very distressed after taking the drug and had used a belt to try to hang herself in the toilet. Two friends had found her and cut her down. She was alert when being assessed in the ED, but had a deep circular wound to her throat from the belt. She had very little memory of the incident or why she had tried to kill herself. She had a prior history of taking an overdose when she was 16 years old, after the break up of a relationship, but otherwise had been well and had not been in contact with mental services. She is doing a PhD at the local university. She has a supportive circle of friends, and a boyfriend of 2 years. All her friends use recreational drugs.

My risk assessment

Case 3: Developing a risk profile

SLIPA
Suicidal thoughts at time of episode: unknown
Lethality: high
Intent now: no current intent when assessed in hospital
Protective factors: PhD course, friends, boyfriend
Adverse factors: all her friends use recreational drugs which may make it difficult for her to abstain in the future

Demographic or historical factors
None identified

Co‐morbid mental illness
Uses recreational drugs, mainly ketamine, at weekends

Overall risk profile
The overall risk profile in this case is moderate as there is a mixed response to the SLIPA items and the episode itself had high lethality, although it did not appear to have been planned. There are no demographic or historical risk factors. The patient uses recreational drugs, which appear to be the precipitant of the self‐harm episode. There is no evidence of a depressive illness
The patient does not appear to be at risk of further self‐harm in the immediate future but there is a major concern regarding her drug use and the likelihood it could trigger another episode of self‐harm

4.7 Emergency management

If the patient requires admission to the acute hospital for either monitoring of cardiac status or requires further treatment, a clear initial plan for managing psychiatric aspects of care should be written in the notes and conveyed to the staff who will take over the medical care. This should first include the level of observation required over the next 24–48 hours (Box 4.5).

Box 4.5 Potential levels of observation

No additional observation

No specific observation but should not be allowed to leave without full mental health assessment. If necessary in an emergency situation, use legal powers to hold the patient on a mental health ward in order for an assessment to be arranged (provided the patient has been formally admitted to hospital)

Close observation required (every 15 minutes)

One‐to‐one observation required (preferably by a mental health trained nurse)

One‐to‐one observation requiring more than one member of staff (preferably by mental health trained nurses)

The plan should state when the patient should be reviewed by a member of the liaison psychiatry team (e.g. the patient should be reviewed by liaison psychiatry when conscious and alert, or if staff have concerns about the patient’s mental health or behaviour).

The plan should also include advice regarding psychotropic medication. If the patient is known to services and the regular medication he/she takes can be established then this should be continued unless there are medical contraindications. This is particularly important in the case of clozapine, as if the treatment is interrupted for more than 48 hours, the drug has to be restarted from baseline, and titrated slowly up to therapeutic dosage, which can take several weeks.

Do not give advice about sedation or suggest any PRN medication at this stage. If the ward staff request that the patient be given sedation, they will need to be reviewed by the mental health liaison psychiatric team before advice regarding sedation or PRN medication is given. Never give advice about sedation over the phone about a patient you have not seen.

If the patient is medically fit and does not require psychiatric admission or treatment from the crisis or home treatment team, a clear management plan must be developed and agreed with the patient. This will include advice about further treatment and referral to or follow‐up by other services. It should also include advice about seeking help in a crisis situation with telephone help lines and contact numbers of crisis services. Most centres usually provide a leaflet with such advice and information. In some centres, patients will be offered brief psychological treatment following self‐harm by a specialist self‐harm team, and will be contacted the following day by the team. Wherever possible, arrangements should be made for the patient to return home with a partner, family member or friend and for someone to be with them over the next 24–48 hours. It is important to discuss with the patient and a family member/friend (if possible) the removal of any tablets that could be used for further self‐harm, or if the person has any razor blades, etc. that these too could be removed.

If the patient is medically fit and requires either admission to an in‐patient psychiatric unit or crisis team input, this will be organised by the mental health liaison team. Advice about observation regimes and routine medication should be clearly recorded and discussed with the accepting team members (either ward or crisis team).The patient’s physical health needs and physical health medications should also be recorded and this information should be discussed fully with the accepting team.

4.8 Refusal to accept physical treatment following self‐harm

Some patients attend the ED following self‐harm but then refuse the physical investigations or physical treatment that is necessary either to save life or treat the physical consequences of the self‐harm.

This can be a difficult and somewhat frustrating scenario for staff, who may not feel they have time to negotiate or persuade someone to have treatment whilst other patients in the department are waiting and, in some cases, urgently need care.

Staff, however, have a duty of care to all patients and must try to offer appropriate help and treatment. The refusal is often linked to a continued desire to die or, more commonly, to deeper psychological difficulties or problems the patient has with caring or being cared for.

Whatever the reason, clear guidance about what to do in such a scenario often relieves staff anxiety.

Firstly, most patients, given some time and the ability to talk about their problems, will consent to treatment. A calm, sympathetic and compassionate approach by staff, and a willingness to try to understand the reasons why the patient is refusing treatment, usually results in a resolution of the situation. The use of written information about any treatment that is being proposed can help improve understanding and retention of information, and enable the person to think through the options.

Secondly, if the person continues to refuse, NICE has given clear guidelines as to how to manage the situation. This is principally determined by a judgement staff make about the person’s capacity to make a potentially life‐threatening decision regarding their care.

Capacity in self‐harm

The law states that patients have the right to refuse treatment for their health even if it might seem unwise, if they have capacity to do so. Capacity is presumed, but in the case of someone refusing life‐saving treatment, capacity must be assessed. This section refers specifically to issues concerning the assessment of capacity following refusal for treatment after a person has self‐harmed. It is presumed that the treatment under consideration is potentially life threatening, and refusal of the treatment would result in either serious physical harm or death.

It is possible for people who are suffering from severe mental illness to make capacitous decisions about certain aspects of their medical care or treatment, and there is case law to support this. The mental disturbance, however, must not impair the decision‐making process regarding the treatment decision in question. Mental capacity assessment has a two‐stage test. First, a person must not be suffering from a disturbance of mind. Second, they must be able to:

Understand information given to them about treatment options and the necessity for treatment

Retain information relevant to the treatment options

Use or weigh that information in coming to a decision

Communicate that decision

A patient who is delirious or severely intoxicated from either drugs or alcohol is likely to be unable to either understand or retain information, and this is usually fairly straightforward for most staff to determine.

In cases where the patient is conscious, alert and fully orientated, a common mistake is to ask the patient some brief questions about the self‐harm episode and the person’s wishes, and assume from that brief contact that the patient has capacity. In this scenario, the patient probably meets the first two criteria for capacity (can understand and retain information). However, the third criteria (whether the person can weigh in balance the decision he/she needs to make) is the key issue. This can be affected by serious emotional turmoil, depression and other forms of mental illness, and has been shown to be more affected in psychiatric in‐patients in comparison with medical in‐patients.

As an example, when people become depressed, the way they view the world, and themselves, changes. As part of their depressive disorder, they may develop negative thoughts which can be wide ranging and may include ideas about being worthless, or being a bad person, or feeling hopeless, feeling guilty and that life is not worth living. These thought processes are regarded by psychiatrists as symptoms of an illness, which will change with treatment. However, a person with these symptoms, if questioned by an ED member of staff, may well say that they do not want treatment and want to die. This may then be accepted at face value as a capacitous decision, whereas the person is actually suffering from a mental illness that is impairing their decision‐making abilities. High emotional arousal or distress, both of which are common in self‐harm, can also affect decision making. Even if the patient does not appear grossly intoxicated, the presence of drugs or alcohol in their blood may also have an effect upon decision making.

For these reasons, it is recommended that emergency staff should always ask for a psychiatric opinion for patients who are refusing life‐saving treatment and who appear to pass the first two criteria for capacity (i.e. can understand and retain information relevant to the decision‐making process). Although all health professionals should be able to determine capacity to consent to medical treatment, a judgement as to whether the patient’s ability to weigh the decision is impaired by mental health issues should be made by a psychiatrist.

Figure 4.4 Decision making in the event of a person refusing treatment for the physical effects of self‐harm. MHA, Mental Health Act.

Source: Based on NICE guidelines (CG133, 2011)

Figure 4.4 is a flow diagram that follows NICE guidelines (CG133, 2011) and provides guidance for the management of patients who refuse treatment. Box 4.6 also provides further details about the assessment of capacity in patients whose ability to understand and retain information is intact, but their decision making may be impaired.

Box 4.6 Assessment of mental capacity in a person refusing life‐saving treatment following self‐harm

Explain the treatment that is required, what it entails and why it is necessary

If possible provide written information

Can the person understand the information (if no – treat under common law)

Can the person retain the information you have given them (if no – treat under common law)

NB Patients who are delirious or are severely intoxicated are very unlikely to meet these first two criteria

Try to establish whether the person can weigh in the balance their refusal to have treatment

Ask why the person is refusing to have the treatment

Check he/she understands the likely physical consequences of refusing the treatment (i.e. death or serious physical sequelae)

Ask the person to describe to you how he/she has come to this decision and what things he/she has considered

Ask the person about how he/she has been feeling recently. Specifically ask if he/she has been feeling fed up or low, anxious or stressed

Ask about contact with mental health services or psychotropic medication such as antidepressants

Ask about recent contact with the GP for stress or depression

Assess if they have recently consumed drugs or alcohol in the last 24 hours

IF YES TO ANY OF THE ABOVE REQUEST A PSYCHIATRIC OPINION

If the person’s responses to questions 1 to 7 lead you to believe his/her decision making is impaired, and urgent treatment is required to save life or serious physical harm, start treatment under common law (in his/her best interests) before psychiatric assessment. Do not wait for a psychiatric opinion

If the person refuses to answer any questions about his/her state of mind, it is reasonable to assume his/her decision making may be impaired as over 70% of people who present with self‐harm have a co‐morbid mental health problem and nearly all will be in a state of distress. The law presumes capacity, but in this particular situation there is a very high probability that the person’s decision making will be impaired

If the patient is deemed not to have capacity to consent to treatment, then staff must act in the person’s best interests. In non‐emergency scenarios, this would involve a ‘best interests’ meeting with all relevant health professionals and the patient’s family or representatives in attendance. In the emergency situation, staff should act to save life or prevent irremediable harm, as this is considered to be the most likely action to be in the patient’s best interests. This may involve sedation, if the patient continues to refuse treatment, so that the necessary medical intervention can be implemented. In most cases, however, the person usually agrees to treatment being implemented if the situation is explained carefully to them by staff.

The role of legal frameworks

If a patient has seriously self‐harmed (e.g. tried to hang themselves or has taken a very serious overdose), and they are attempting to leave the department, there are likely to be grounds to detain them under mental health laws for further assessment of their mental condition. This process, however, usually takes several hours to complete as it requires the attendance of three separate health professionals, so it is rarely feasible or practical to use it as the legal framework for emergency treatment for self‐harm in the ED.

In the setting of an acute medical ward or short stay unit, consent from the patient will not be required for any medical treatment given to them for the mental disorder from which they are suffering, although medical treatment of an unrelated physical condition would not be allowed. Medical treatment may include nasogastric feeding in anorexia nervosa, and although it has not been tested in the courts, it is likely to include life‐saving treatment following self‐harm.

Advance decisions

These are legally binding, prospectively written statements that make provision for individuals to determine the kind of treatment (or no treatment) that they would like to receive in the event they become ill and incapacitous. Individuals need to be capacitous at the time they make the advance decision. Refusals of life‐saving treatment must be expressed in writing, witnessed, and include a statement that the decision stands even if life is at risk.

As the law stands at present, if a patient presents following severe self‐harm and is judged to be incapacitous, but has brought a correctly completed advance decision with them, staff must respect the wishes of the patient, as expressed in the advance decision.

This remains a very difficult and contentious area, as it is still theoretically possible for people to complete advance decisions whilst they are suffering from psychiatric disorder, and this is not appreciated by the witness who signs the advance decision. If staff are in any doubt, they should consult a senior psychiatrist as an advance decision does not preclude the use of legal powers if there are grounds to use them. Legal advice can also often be obtained by NHS Trusts very quickly in an emergency situation.

Multiple or frequent attenders with self‐harm

Some individuals present on multiple occasions with self‐harm. This may be to the same ED or to a variety of departments in a similar geographical area, or to EDs all over the country. The self‐harm behaviour often has low risk of lethality, although this is not always the case, and the self‐harming is often associated with drug or alcohol abuse, unemployment, poor social circumstances and homelessness.

Frequent attendance for self‐harm is associated with a higher risk of suicide and early death following attendance. A history of alcohol abuse and unemployment are also important contributory factors.

The attendance of a patient on three or more occasions within a 12 month period to the ED with self‐harm or requests for psychiatric help should trigger a review of care. This will require a coordinated approach between the ED and community and mental health services. If the person is under mental health services, a care plan should already have been drawn up, which should be reviewed in light of the new episodes of self‐harm or ED attendances. If the person is not under the care of mental health services, they should be offered the option of follow‐up and further assessment from either primary care or secondary care mental health teams. The GP and all other relevant health professionals should be fully involved and informed of these actions. Clinicians should be alert to the possible association of an increased frequency of attendance at the ED and suicide.

Although many of these people have complex psychosocial problems, increased frequency of attendance is often triggered by a recent current stressor. If the person receives help for this, it can reduce ED attendance and the risk of suicide in the short term, even if the underlying problems are very longstanding.

4.9 Summary

Presentations of people who self‐harm are common in the ED. These people should receive integrated physical and mental healthcare, with timely assessment and treatment. People who are at high risk of imminent further self‐harm should be identified at an early stage and appropriate measures put in place to keep them safe, whilst physical and mental health assessments are carried out. People who self‐harm should be involved as much as possible in decisions about their care.

Those people who have self‐harmed and wish to leave the ED, before a full assessment can be completed, require an assessment of their capacity. If there is concern that their decision‐making skills are impaired due to their psychological state, a psychiatric opinion should be sought. If they are deemed to be capacitous their wishes should be respected and they should be allowed to leave.

ED staff should feel confident in their management of both the physical and basic mental health components of care, and work collaboratively with the liaison psychiatry team to provide high‐quality, person‐centred care.

CHAPTER 5
The apparently drunk patient

Learning outcomes

After reading this chapter, you will be able to:

Identify how to rapidly and systematically assess the patient presenting with symptoms and signs of apparent alcohol intoxication using the structured approach

Characterise common co‐morbid problems and mimics of alcohol intoxication

Demonstrate how to work through common, urgent psychiatric scenarios that can accompany intoxication

5.1 Introduction

Alcohol misuse is a major cause of morbidity and mortality in many countries, and as such, is ranked by the World Health Organisation as one of the leading causes of burden of disease. Harmful use of alcohol is associated with 2.5 million deaths per year worldwide.

Europe is the heaviest drinking region in the world, with over 20% of the adult population reporting excess alcohol use. Over 20 million people are treated in emergency departments (EDs) in England each year, with a significant proportion of these visits being related to alcohol misuse at weekends. Over a million hospital admissions per year are associated with alcohol consumption, with a male: female ratio of 2: 1. The cost to the UK National Health Service is estimated at £3.5 billion.

Patients presenting with apparent alcohol intoxication can be a complex and challenging group in terms of assessment and treatment. Acute behavioural disturbance is common, as are co‐morbid injuries, attempted self‐harm and medical conditions that require attention. Common presenting complaints associated with alcohol intoxication have been summarised in Box 5.1 and reflect hospital data reported from Australia, New Zealand, USA and the UK.

Box 5.1 Common presentations associated with alcohol intoxication

Head injury

Falls and collapses

Victim/perpetrator of assault

Possible seizure

Hypoglycaemia

Behavioural disturbance

Acute confusional state/psychosis

Other mental health problems – suicidality, deliberate self‐harm (alcohol often co‐ingested)

Chest pain, suspected cardiomyopathy

Gastrointestinal presentations – gastritis, liver disease, pancreatitis

Key priorities in the apparently intoxicated patient include:

Rapid, systematic assessment for potentially life‐threatening injuries and other physical health issues that require prompt treatment

Confirmation of alcohol intoxication or identification and treatment of the condition resembling it

Screening for mental and physical health complications associated with chronic alcohol use

Offering stabilised patients brief psychological interventions or signposting to suitable services where appropriate. It is possible that first and foremost, de‐escalation techniques and rapid tranquillisation may need to be deployed to enable assessment

5.2 Pathophysiology and measurement of alcohol intoxication

Physiology

Ethyl alcohol (ethanol) is rapidly absorbed across the gastric (20%) and intestinal (80%) mucosa, reaching peak concentrations 20–60 minutes after ingestion. Approximately 10 mL (1 UK unit) of ethanol is metabolised per hour. The rate limiting factor in this process is the enzyme alcohol dehydrogenase, which is affected by the quantity and rate of alcohol consumption and genetic polymorphisms that affect its intrinsic efficiency. Rapid consumption of a large amount of alcohol will saturate the conversion system, resulting in high levels of blood alcohol, but uncomplicated intoxication usually subsides within a matter of hours. Genetic polymorphisms resulting in reduced enzyme efficiency are commoner in Asian populations; severe, rapid intoxication with modest alcohol consumption is common in ALDH2*2 carriers and there is an increased risk of alcohol poisoning.

Alcohol by numbers – percentages, units and levels

Alcohol consumption is often recorded in units. A UK unit of alcohol is equivalent to 8 g/10 mL of ethanol. Cans, bottles and cartons of alcoholic drinks will often display alcohol content as a percentage. A bottle of whisky at 40% strength will contain 40 mL of ethanol per 100 mL. The conversion process from percentage strength to units is outlined in the formula below, but for a quick reference guide, see Table 5.1.

Calculating alcohol consumption in units

Units = percent alcohol (ABV) × volume in mL/1000

Worked example: a 750 mL bottle of wine at 12% strength: 12 × 750/1000 = 9 units

ABV, alcohol by volumeb

Table 5.1 Reference guide for units

Quantity | Strength (typical) | Units
Standard glass of wine = 175 mL | 12% | 2.1
Standard bottle of wine = 750 mL | 12% | 9
Standard box of wine = 3000 mL | 12% | 36
Single measure of spirits = 25 mL | 38–40% | 1
Quarter bottle of spirits = 250 mL | 38–40% | 9.5–10
Large bottle of spirits = 750 mL | 38–40% | 28.5–30
Small bottle of lager = 330 mL | 4–5% | 1.3–1.7
Can of lager = 440 mL | 4% | 2
Pint of bitter = 568 mL | 3.8% | 2.2
Can of super strength lager = 500 mL | 9% | 4.5
Can of strong ‘white’ cider = 500 mL | 7.5% | 3.75
Bottle of normal strength cider = 2000 mL | 5% | 10

Recommended limits (in UK units)

UK: 14 units per week

Ireland: women 14 units, men 21 units per week

USA: women 12 units, men 24.5 units per week

Australia: 2.5 units per day

New Zealand: women 12.5 units, men 19 units per week

5.3 Screening for alcohol intoxication

Clues from the history

Consider how much time has elapsed since the patient was originally picked up (if several hours ago, their presentation should have improved at least in part). From the paramedic notes/collateral history gather as much information as possible – Where was the patient picked up? Was any alcohol found in their possession? Did they smell of alcohol? Was their presentation at that time suggestive of alcohol intoxication? Are there any presenting features on the paramedic history sheet that appear to have resolved or have things got worse (consider peak alcohol levels emerging, withdrawal or an evolving physical health problem)? Is there a history of previous presentations – if so what for? Is there a documented or collateral history of heavy alcohol use or illicit substances? Is there any psychiatric, medical or medication history that might provide clues to an alternative diagnosis or co‐morbidities that should not be overlooked?

Typical characteristics of alcohol intoxication are summarised in sections F1 and F10 of the World Health Organisation’s International Classification of Diseases, 10th edition (ICD‐10) (WHO, 1992). Presenting features include disinhibition, argumentativeness, aggression, mood lability, impaired attention and judgement PLUS one or more of unsteady gait, difficulty in standing, slurred speech, nystagmus, decreased level of consciousness, flushed face and conjunctival injection. Hypotension, hypothermia and hypoglycaemia may also be apparent on examination.

It is clear that features of alcohol intoxication overlap with some of the symptoms and signs suggestive of mental health problems such as mania and schizophrenia, but disturbed level of consciousness and cerebellar motor features are usually absent in the latter conditions. There are other conditions, however, that mimic the behavioural and motor features of alcohol intoxication and these should not be missed. Intoxication with benzodiazepines or opioids can be mistaken for alcohol intoxication or they may have been co‐ingested; it is important to try to confirm this as specific treatments exist that can rapidly reverse life‐threatening features of intoxication. Other conditions that resemble alcohol intoxication are outlined later in this chapter.

Measuring alcohol intoxication

Alcohol levels may be measured by sampling blood, exhaled breath, saliva or urine. Blood and/or breath measurements are most commonly reported. Results may be reported as mcg/L, mcg/100 mL, mg/L or mg/dL but some breathalyser machines convert to estimated blood alcohol percentages. There are also online calculators that convert breath readings to equivalent blood alcohol concentrations (e.g. www.lionlaboratories.com/testing‐for‐alcohol/the‐lion‐units‐converter/, accessed June 2019).

Policies for measuring alcohol levels in patients presenting to EDs vary widely both within and between different countries according to whether measurements are taken and whether blood or breath measurements are preferred. Breath measurements are rapid and efficient estimates but require a degree of cooperation and coordination from the patient. Table 5.2 outlines common symptoms and signs associated with increasing alcohol levels. A degree of variation exists according to age, gender, weight, recent food consumption and, most importantly, how much alcohol is consumed on a regular basis. A regular heavy drinker without liver disease will appear far less intoxicated with a blood alcohol level of 100 mg/100 mL than an occasional drinker and will metabolise any ethanol consumed at a faster rate. Someone who is intoxicated with a blood alcohol level of 20 mg/100 mL is unlikely to be dependent.

Table 5.2 Alcohol levels and associated symptoms and signs

| Alcohol level | Symptoms and signs
No alt text required. | 20 mg/100 mL blood, 0.02%, 9 mcg/100 mL breath | Relaxed, mild euphoria, mild impairment of judgement. Legally impaired to drive in Sweden
No alt text required. | 50 mg/100 mL blood, 0.05%, 22 mcg/100 mL breath | Less inhibited, talkative, impaired concentration. Legally impaired to drive in most European countries and Australia
80 mg/100 mL blood, 0.08%, 35 mcg/100 mL breath | Impaired balance, speech, depth perception and peripheral vision, reaction time and hearing, judgement, reasoning and memory. Impaired judgement and self‐control. Legally impaired to drive in the UK and USA
No alt text required. | 100–120 mg/100 mL, 0.1–0.12%, 44–54 mcg/100 mL breath | Mood swings – anger and tearfulness. Staggering gait, slurred speech, blurred vision, impaired gross motor control and reaction times, vomiting
200 mg/100 mL, 0.2%, 88 mcg/100 mL breath | Confusion and dizziness, requires help to stand and walk, stuporose, impaired gag reflex, possible loss of consciousness
300 mg/100 mL, 0.3%, 132 mcg/100 mL breath | Unconsciousness common, even coma
>450 mg/100 mL, 0.45%, 198 mcg/100 mL breath | Respiratory arrest will occur in most individuals

A common question is whether blood/breath alcohol measurements can help to indicate when someone is ready for psychiatric assessment in the ED. Clinical judgement should be exercised first and foremost according to current risks and the symptoms and signs detailed. If the patient is highly tolerant to alcohol, they may appear sober despite much higher breathalyser readings.

5.4 If it’s not (just) alcohol intoxication, what is it?

The irritable, drowsy patient who smells strongly of alcohol and vomit, with slurred, rambling speech and a broad‐based, unsteady gait will often be correctly diagnosed with uncomplicated alcohol intoxication and may need no further input from the ED, with symptoms and signs resolving in a matter of hours as blood alcohol levels fall. Given the frequency of co‐morbid presentations and conditions that mimic alcohol intoxication, however, it makes sense to work through a checklist of common co‐morbidities and alternative diagnoses.

Co‐morbidities not to miss
Mimics of alcohol intoxication

Head injury, including concussion

Other traumatic injuries (falls, altercations, deliberate self‐harm)

Seizures

Wernicke’s encephalopathy

Hallucinosis

Suicidality

Aspiration and respiratory tract infections

Cardiomyopathy

Gastritis

Pancreatitis

Hepatitis/cirrhosis

Coagulopathy

Ingestion of illicit drugs

Meningitis/encephalitis

Post‐ictal states

Cerebellar or brain‐stem infarct, transient ischaemia attack, bleed, inflammation (cerebellitis/multiple sclerosis)

Encephalopathy (Wernicke’s, hypoxic‐ischaemic, hepatic, uraemic)

Traumatic brain injury – parenchymal damage, subdural or extradural haematoma, raised intracranial pressure, concussion

Hypoglycaemia/diabetic ketoacidosis

Hypo‐/hypernatraemia

Myocardial infarction

Drug overdose – benzodiazepines, phenytoin, carbamazepine, gabapentin, phenobarbital, lithium, amiodarone, ciclosporin

Head injury deserves special consideration as it is a common co‐morbid presentation and sometimes the correct underlying diagnosis in an apparently intoxicated patient. Important questions to ask include the timing and mechanism of injury, duration of any loss of consciousness, presence of seizures, vomiting, retrograde or anterograde amnesia and whether the patient takes anticoagulants. Examination should include Glasgow Coma Scale (GCS) score, cervical spine and neurological examination and inspection of face and scalp for signs of fractures.

In the UK, the National Institute for Health and Care Excellence (NICE) and the Scottish Intercollegiate Guidelines Network (SIGN) have constructed guidelines to assist healthcare professionals making decisions in both pre‐hospital and hospital settings about patients with suspected head injury. This includes guidance on whether a patient requires neuroimaging after head injury and how urgently this should take place (NICE CG176, 2014; SIGN NCG110, 2009).

PUTTING IT ALL TOGETHER – THE STRUCTURED APPROACH TO ASSESSMENT

5.5 Preparation

Establish key concerns at this moment – does current risk exist?

Apparent intoxication and immediate current risk

Agitation and distress

Aggression including attempts to harm self, property or others

Refusing essential medical/nursing input such as observations, investigations and/or treatment

Trying to leave the hospital despite concerns that further assessment should take place

The focus here is diagnosis and acute management of risks.

Apparent intoxication and no immediate identified risk

The patient is accepting care interventions and no immediate risks to self or others have been identified. There are additional or atypical features identified that warrant exploration beyond a working diagnosis of alcohol intoxication. The focus here is achieving diagnostic clarity and contingency planning to manage potential risks including alcohol withdrawal and the acute risk issues highlighted earlier.

Essential background information (where possible)

Age

First language

Recent/relevant medical history (essentials include epilepsy, diabetes, liver disease, hepatitis C status, gastrointestinal bleeds)

History of self‐harm or violence towards others

Alcohol or substance misuse

Disorders associated with psychosis such as schizophrenia and schizoaffective disorder, depression and bipolar affective disorder

Conditions associated with chronic cognitive impairment such as learning difficulties, dementias and acquired brain injury

Forensic history – particularly violence towards others and damage to property

Reason for presentation to ED

Gather any collateral information from paramedics, police or accompanying others (where and when was the patient found, key concerns at the scene including injuries, seizures, persistent vomiting, initial GCS score and physical observations, aggression, suicidality and self‐harm, hallucinations).

If the patient was brought in by the police, establish whether the patient has been detained under police legal powers for their own safety or the safety of others (e.g. section 136 of the Mental Health Act in England and Wales) or whether they are in police custody due to arrest or charges. If the police are present and there is a strong suspicion of violence or other relevant forensic history, they may be able to provide further information that helps to stratify risks to others whilst the patient is in the ED.

Try to quantify the amount and type of alcohol consumed, the timeframe (all at once, over several hours, etc.) and whether this amount is typical for the patient. Establish when the last drink was consumed and whether any other substances were taken.

Top tip

Patients recently released from prison or after a lengthy hospital admission will have markedly reduced tolerance levels to alcohol and illicit substances

There should be a brief review of the latest observations, GCS score and medication chart (blood tests and electrocardiogram (ECG) if readily available).

Based on the above information, check that appropriate support is available to help manage risks (other members of staff, security, police).

5.6 Primary assessment – the unified assessment

ABCD and the AEIO should proceed in parallel during the primary assessment. This enables early identification of serious physical and psychological risks to the patient and others so they can be quickly addressed.

Patient assessment

Is the patient safe to approach? If the patient poses an immediate serious risk to self and others due to severe agitation and is not responding quickly to verbal attempts to calm or reassure, rapid tranquillisation may be necessary to enable further assessment. However, it should be borne in mind that if alcohol has been taken there is a higher chance of sedation and doses should be modified to account for this.

Remember the priorities:

Rapid, systematic assessment for potentially life‐threatening injuries and other physical health issues that require prompt treatment

Rapid identification of significant risk of harm to self and others

Confirmation of alcohol intoxication or identification and treatment of the condition resembling it

Screening for mental and physical health complications associated with chronic alcohol use

Parallel primary assessments – ABCD and AEIO

Is the patient refusing to be assessed? Do they currently have capacity to make an informed decision on this?

Action plan

Capacity assessment and decision whether to proceed according to patient’s best interests

ABCD

A Airway – patency and security

B Breathing – adequacy and effectiveness (rate, effort and symmetry, oxygen saturation, tracheal tug/deviation, percussion and auscultation)

C Circulation – adequacy (peripheral and central capillary refill, pulse, BP, auscultation, any oedema)

D Disability – conscious level and pupils (AVPU/GCS, pupillary responses, fingerprick glucose, obvious lateralising signs)

AEIO

This should follow the structured outlined in Chapter 2.

(A) Agitation/Arousal

Briefly observe the patient and determine whether their level of agitation is low, moderate or high. How does agitation manifest (motor restlessness, distressed or hostile verbal communication, physically threatening or aggressive behaviour or a combination)? Does agitation/arousal escalate or settle when you attempt to talk with the patient?

Action plan

If an assault or significant damage to property has taken place, or if the patient is brandishing a weapon, contact the police

Then ascertain whether there are staff present who are trained in restraint and whether security staff have been called

If necessary, ask nursing staff to locate and prepare oral and intramuscular rapid tranquillisation medication – ensure it is prescribed on the patient’s medication chart

Before tranquillisation, try to create a distance between the individual concerned and other patients. Ask someone to check for previous notes to determine whether there are any alerts for violent behaviour or similar presentations to the ED. What worked?

Verbal de‐escalation should be initially attempted by one person accompanied by 2–3 staff members who are trained in restraint, if possible. Introduce yourself, reassure the patient that you are here to help. Try to establish the patient’s wants and needs, and what triggered the behavioural disturbance. Be vigilant for psychosis and confusion but also look for commonsense factors such as frustration, fear and physical pain. If verbal de‐escalation fails and there is a need to keep the patient in the ED for further assessment of mental and physical health, rapid tranquillisation should be administered. Offer the patient oral medication first, before proceeding to intramuscular injections

(E) Environment

This is the environment in which the patient is being cared for. Refer to the ADELLE checklist in Chapter 2 and decide whether the current environment confers low, moderate or high risks to the patient and/or others.

Can the patient be left alone? If not, why, and how many staff (nursing and/or security) should be present?

(I) Intent

The intent of the individual must be assessed (remember this refers to current thoughts).

Risk of harm to self

Is the patient actively expressing plans to harm themself? What are the nature, frequency and severity of these thoughts – how likely are they to act on or resist these thoughts in the next few hours? Is there evidence of recent self‐harm? Are there any concerns that current presentation is associated with a self‐harm attempt (e.g. toxic effects of overdose, hypoxic insult from ligature)?

Action plan

Remove access to means where possible, consider one‐to‐one observation and brief the ED staff and security on physical description and flight risks

Risk of harm to others

Has the patient harmed others? Clarify the nature of the assault/s. Are they actively expressing verbal or physical threats to others? What are the nature, frequency and severity of these thoughts – how likely are they to act on or resist these thoughts in the next few hours? Are these general or do they involve specific individuals? Are any of these individuals in the immediate environment? Is there any concern that the patient might be carrying a weapon (request assistance from police if necessary)? Has the patient damaged property – what and how badly?

Action plan

Consider de‐escalation techniques, rapid tranquillisation and securing assistance from hospital security staff and/or the police

Psychotic experiences

These are common in delirium tremens and alcohol related hallucinosis.

Does the patient appear to be responding to non‐apparent stimuli (looking at, gesturing towards or talking to unseen people/creatures/objects)? Do they appear unduly agitated, suspicious or frightened? Do you have any concerns that the risks identified above or desire to leave the department are driven by psychotic symptoms such as command hallucinations or paranoid delusional beliefs?

Action plan

This will be based on specific identified risks (to self, others or risk of leaving the department). The mainstay of treatment at this stage is providing support and monitoring from members of nursing staff, sedative medication as and when required if unduly agitated and distressed, and highlighting psychosis to the ED team as it may inform further investigation in patients without an established prior history of psychosis

Desire to leave

Is the patient willing to stay to have investigations and/or treatment? Is there a risk of wandering and inadvertent absconsion (common in confused patients)? Is there a risk of falls?

Action plan

One‐to‐one observation, brief the ED and security staff – physical description of patient and details of potential flight risk

(O) Objects

These are objects that the patient has in their possession, which may be used to harm themself or others.

Action plan

If there is reasonable belief that the patient is carrying a weapon or object that could be used as such and is refusing to surrender it or to be searched, it is reasonable to contact the police to discuss receiving assistance to minimise risks to the patient and to others

5.7 Unified assessment and immediate treatment

Relevant perspectives from ED staff and the assessing mental health team should be rapidly and effectively communicated so that each team member is aware of the seriousness of identified physical and psychological risks and proposed plans for further investigations/treatment. Immediate, life‐threatening risks should be dealt with and opinion on capacity should be formalised at this stage. When the necessary steps have been taken to stabilise the patient and contain risk, secondary assessment should take place to obtain further detail on the clinical presentation.

5.8 Secondary assessment

After immediate, life‐threatening injuries and serious risks have been either excluded or addressed, the parallel assessment should proceed towards arriving at a working diagnosis with plans for treating urgent physical and mental health problems. The patient with suspected alcohol intoxication should be breathalysed if possible by a member of staff who is familiar with the necessary equipment.

Focused physical history and secondary examination

Focused history – PHRASED

P Presenting complaint

H History of presenting complaint

R Relevant medical history

A Allergies

S Systems review

E Essential family and social history

D Drugs (medication, illicits)

Secondary examination – guided by focused history

Top‐to‐toe physical examination (including neurological examination – this is essential)

Investigations:

As directed by examination findings: FBC, U+E, creatinine, LFTs, amylase, troponin, glucose, CRP, coagulation screen, blood gas. Drug levels if relevant. Urine dip, urine M,C+S, urine drug screen

ECG, CXR, CT brain

* If confusion is present in a patient with suspected alcohol misuse always give thiamine – do not wait hours to see if the situation resolves

CRP, C‐reactive protein; CT, computed tomography; CXR, chest x‐ray; ECG, electrocardiogram; FBC, full blood count; LFTs, liver function tests; M,C+S, midstream urine, culture and sensitivity; U+E, urea and electrolytes.

Focused conversational psychosocial history and mental state assessment

Is there any suspicion here of self‐harm? If so proceed to the SLIPA risk assessment. If there is no suspicion of self‐harm, proceed to the remainder of the focused psychosocial history.

Get to the MEAT of the problem:

M Mental health history – anxiety disorders and sleep disorders are highly co‐morbid with alcohol dependence and tend to improve with weeks to months of sustained abstinence

E Emotional trauma/adverse life events – has anything led to increased alcohol or substance misuse?

A Alcohol and drugs – establish pattern of alcohol use and whether the patient is dependent using ICD‐10 (Box 5.2)

T Trouble with the police: does this patient have a forensic history and is it associated with alcohol or substance misuse?

Box 5.2 ICD‐10 criteria for alcohol dependence

Craving or feeling of compulsion to consume alcohol

Impaired ability to control initiation, amount consumed and termination of use

Tolerance to the effects of alcohol

Withdrawal symptoms on abstinence

Salience of alcohol above other interests

Persistent use despite harmful consequences

Screen for other symptoms and signs suggestive of primary mental health problems as part of a full mental state examination using the mnemonic ABC SMITH (Chapter 3 gives further detail):

A Appearance – look for signs of self‐neglect and malnourishment. Any obvious bruising, fresh bleeding or dried blood on skin/clothes? Does the patient smell of alcohol? Are they visibly sweating?

B Behaviour – visibly tremulous, restless, agitated, drowsy (encephalopathic or just tired)? Ataxic gait disturbance?

C Cognition – see ‘Significantly confused’ section later in this chapter

S Speech – slurred, word finding difficulties, rapid and difficult to interrupt?

M Mood and affect – depressed, elated, anxious, irritable?

I Insight and capacity – is the patient willing to have further investigations and treatment? Are they capable of making informed decisions regarding these issues?

T Thoughts – clear or muddled thought stream? Perseverative, bizarre content, any preoccupations that resemble delusional beliefs?

H Hallucinations and illusions – which sensory modalities and how complex?

Suicidality and attempted self‐harm (see Chapter 4)

Depressed mood, suicidal thoughts and attempted self‐harm are common co‐morbid features of alcohol‐associated presentations to the ED. Assessment of self‐harm is covered in detail elsewhere, but specific aspects of assessment in the patient presenting with intoxication are given here.

Establish the severity of depression and associated risks. If the patient has ongoing suicidal thoughts and they are thinking of or have recently acted on these thoughts they should be under one‐to‐one observation. Do suicidal thoughts intensify when intoxicated? Have these thoughts ever led to self‐harm – was the patient intoxicated at the time and was self‐harm planned, impulsive or accidental? Does the patient harbour any concern for their own safety when intoxicated (could provide a window of opportunity for intervention)? Is there a temporal relationship between the development of depressed mood/anxiety and alcohol misuse? Try to establish which came first. Is there a history of significant life events that precipitated either low mood or alcohol misuse? Does alcohol help to blot out difficult feelings and memories, quell anxiety or aid sleep? Are mood, appetite and energy levels better when abstinent from alcohol?

Psychosis (see Chapter 6)

Ascertain the severity and range of symptoms and any associated risks to the patient or others. Ask about content of hallucinations and whether the patient has any concerns about being watched, spied on, being harmed or whether they have any concerns about their partner. Morbid jealousy is a recognised complication of chronic, heavy alcohol use and delusions of infidelity can confer significant risk to the patient’s partner and the suspected seducer. Try to establish whether there is an association between heavy drinking and the development or worsening of symptoms or whether the patient has recently become abstinent. Is there a previous history of schizophrenia, schizoaffective disorder, mood disorder with psychosis, drug‐induced psychosis (culprit drug?), alcoholic hallucinosis (worsens with heavy drinking) or delirium tremens? If there is a history of a psychotic disorder, try to establish whether the patient is compliant with their medication regime, whether they find it effective or whether they sometimes use alcohol to reduce the impact of distressing hallucinations and delusional beliefs.

Significantly confused (see Chapter 7)

Is there any history of cognitive impairment? If unable to sit through a formal test (such as the MoCA (Montreal cognitive assessment)), check whether the patient is oriented, can name months of the year backwards and can recall five words immediately (apple, table, yellow, church, rose) and after a 5 minute delay. If confusion is due to alcohol intoxication it should begin to improve within a few hours of abstinence. Serial breathalyser results and a urine drug screen may be helpful in this situation. The major consideration here is Wernicke’s encephalopathy. If you are trained to do so, check eye movements (lateral movements are often impaired due to VI nerve palsy, and nystagmus may also be present), gait (broad based and unsteady) and truncal stability (may be difficult to remain sitting upright without support). This requires immediate treatment with thiamine. Cognitive tests should be repeated in a few hours to check for improvements, plateauing or worsening. If confusion is not resolving, discuss with the ED team and review examination and investigation results so that further options can be explored.

If the patient is seen by the mental health team for one or more of the scenarios discussed above, further useful information can be ascertained after the risks have been addressed:

5.9 Emergency management

Teams should share perspectives if they have assessed in parallel the following:

Physical health – Is there any evidence of physical health problems or toxic/withdrawal states that could explain or be contributing to the current presentation? If so, what is the working diagnosis and plan for further investigations and treatment? Were any mental health concerns picked up during assessment that should be discussed with the mental health team?

Mental health – Have acute mental health concerns been identified and if so how should they be monitored and managed? Are there immediate and ongoing risks to self and others? What is the immediate plan for managing these? Is there a suspicion of co‐ingestion of other substances? Were any physical health concerns picked up during assessment that should be discussed with the ED team?

Everyone – Has the patient’s capacity to consent to or refuse to remain in hospital to have further investigations and treatment been established? If an extremely agitated, unwell patient is refusing further input and lacks capacity, an urgent joint plan can be implemented that enables action in the patient’s best interests. This may involve rapid tranquillisation to reduce distress and agitation and to enable further investigation and treatment. On rare occasions, anaesthetist colleagues may get involved as sedation and ventilation may be required to administer life‐saving treatment.

5.10 Determine disposal/confirm route of care (CROC)

Significant injuries and/or other physical health problems warranting in‐patient admission – patient to remain in a general hospital setting for further investigation and treatment. If mental health problems were also identified, ongoing input from the liaison mental health team is needed to review progress, and to advise on managing risks and discharge planning.

Routine physical examination and investigations are normal but severe, acute mental health problems were identified that confer risks to patient and others – mental health team to determine whether admission to a psychiatry inpatient unit or discharge with intensive support from crisis services in the community is appropriate.

In both of the above scenarios, thiamine replacement is essential and a system for monitoring the development of alcohol withdrawal such as the Clinical Institute Withdrawal Assessment – Alcohol, revised (CIWA‐Ar) system should be in place, with an appropriate treatment plan should symptoms and signs of withdrawal occur. Chlordiazepoxide is commonly used (lorazepam or oxazepam in patients with liver disease).

If routine physical examination and investigations are normal and no acute severe mental health problems were identified beyond alcohol misuse, then arrange for input from the alcohol liaison services if available and if the patient is willing to engage. If not, discharge the patient from the ED with written information about local community‐based alcohol services.

If an individual is significantly abusive and aggressive but no discernible physical or mental health problems beyond alcohol misuse were identified by the assessing teams, perspectives should be shared and joint agreement should be reached on requesting assistance from hospital security and the police to remove the individual from the department and whether assault or criminal damage charges are appropriate.

5.11 Handover

Risks should be reassessed, and essential information regarding presentation, working diagnosis and treatment plan, should be collated for handover to the receiving team.

5.12 Brief interventions in the ED

Brief motivational interventions are recommended as part of an initial assessment of alcohol misuse. These are short (5–20 minutes), structured conversations about alcohol consumption that seek to motivate and support the patient to think about and plan a change in drinking behaviours in order to reduce consumption. Key elements include adopting a persuasive and supportive approach to helping people to recognise problems related to their drinking habits, to resolve ambivalence to change, and to help instil belief in the ability to change.

They are typically structured as an assessment of alcohol intake, determining whether dependence, harmful or hazardous drinking criteria are met. After this assessment, conclusions regarding risk are stated clearly, along with a discussion about readiness for change. Drinking goals are negotiated and a discussion takes place about the prospect of engaging with a specialist service and a mutual self‐help group. The patient is then supported in making self‐referrals or these are completed on the patient’s behalf.

Current evidence suggests that these interventions may be effective for up to 12 months, at which point the intervention could be repeated. They are most effective if delivered within 48 hours of initial presentation. Any member of the ED or mental health team can be trained to deliver these interventions and there are national competency frameworks that can be consulted to ensure effective, relatively standardised delivery of interventions.

5.13 Case example

Case 5.1
Karl is 42 years old. He has been brought into the ED by paramedics and the police. He appeared drowsy and confused at the scene and vomited twice. Witness accounts mention an altercation outside the bar where he was found. Medical and mental health history is unknown at this stage. He is currently aggressive and refuses to be assessed. There are concerns about alcohol withdrawal – he appears sweaty and tremulous.
Photo of Karl, 42 years old, who is brought into the ED by paramedics and the police and appeared drowsy and confused at the scene and vomited twice.

Primary assessment
ABCD
A – Maintaining own airway, RR 24, reluctant to be examined
B – Oxygen saturations 98%, chest clear, good expansion bilaterally
C – Clammy peripheries, HR 102 bpm, BP 162/90, capillary refill 2 seconds, HS I+II+0
D – GCS 12/15, dilated pupils, no focal neurology, apyrexial, fingerprick glucose 2.8 mmol/L
AEIO
A – Currently aggressive (verbally aggressive in ED and possible recent assaultative behaviour)
E – In cubicle, ligature free, single door. Police have left
I – Expressing wish to leave
O – Has a bag of possessions in the cubicle with him. Unsure whether this has been searched for objects that may be a risk

Unified assessment and immediate treatment
Physical health – hypoglycaemia detected and treated promptly. Head wound cleaned and dressed. CT head scan requested
Mental health – consider capacity; observation level; contingency plan for treatment of acute agitation: sedating antipsychotic such as olanzapine 5 mg/haloperidol 2.5–5 mg can be used until more is known
Parallel assessment is required. Karl currently lacks capacity to make informed decisions on investigations and treatment

Secondary assessment

Focused physical history and secondary examination plus investigations
Currently complains of mild headache and some dizziness. Karl confirms diagnosis of type 1 diabetes with frequent episodes of hypoglycaemia. Remainder of systems examination is unremarkable
Routine blood tests confirm hypoglycaemia at time of admission
Urinalysis – glucose and protein
ECG – normal
CT brain – no intracranial injuries or fractures

Focused conversational psychosocial history and mental state examination (MSE)
GCS improves to 14/15 after glucose
Karl has not tried to harm himself
No history of cognitive impairment, major affective or psychotic disorder
No recent life events
Describes a longstanding history of hazardous drinking. Patient confirms he has not taken any illicit substances or overdosed on prescribed medications
Karl admits to getting into a fight with three men and has a history of convictions for assault when intoxicated
MSE
A – Normal
B – Drowsy
C – Some cognitive slowing with residual effect of intoxication and possible concussion
S – Some slurring
M – Normal
I – Has insight; willing to remain in hospital if required for treatment
T – Normal
H – No

Disposal
Admit for overnight observation. Priorities include monitoring confusion to ensure it resolves, serial glucose measurements and prompt review by diabetes specialist nurse or endocrinology registrar
Information given on support offered by local alcohol services

Reassess risks

No concerns about immediate risk to self
Now more settled – risks to others ongoing given history but regarded as currently low
Risks from others – now settled and less provocative, currently low risk
Engagement with care – currently willing to remain in hospital and receive investigations and treatment

Handover
Summarise presentation, key findings and current treatment plan using SBAR

5.14 Summary

As outlined in the chapter, a rapid, systematic assessment of the patient presenting with symptoms and signs of apparent alcohol intoxication is supported by the structured approach. Tools are also presented to provide an approach to considering common comorbid problems and mimics of alcohol intoxication.

CHAPTER 6
The patient behaving strangely

Learning outcomes

After reading this chapter, you will be able to:

Recognise key features of common psychiatric presentations

Explain how to examine the mental state of a patient behaving strangely

Demonstrate how to screen for medical causes of psychiatric presentations

Describe how to form a management plan including risk management

6.1 Introduction

A patient who is referred for assessment with ‘bizarre’ behaviour might seem a scary prospect. You might have concerns about how to communicate with them, about unpredictable behaviour or aggression. It can often be difficult to take a history from these patients, and there may be little collateral information to help you to discover the underlying cause for this behaviour and how best to manage the situation. There are diverse underlying causes of ‘behaving strangely’: some may be related to physical illness, drug and alcohol use; or the behaviour may be part of a normal reaction to stress. In this chapter we will cover the most commonly seen psychiatric presentations and the signs and symptoms related to them. We will review in some detail what you might discover during the mental state examination (although this is not an exhaustive list of all psychiatric phenomena, it covers the most common presentations). Later in the chapter we will review some of the more common physical and psychiatric disorders that may result in strange behaviour and consider how to develop management plans to keep the patient safe either in the emergency department (ED) or on the ward, whilst awaiting further psychiatric assessment.

PUTTING IT ALL TOGETHER – THE STRUCTURED APPROACH TO ASSESSMENT

6.2 Preparation

Once you become aware that a patient is in the ED or the ward presenting with bizarre behaviour, before you even see them, you need to ensure that the patient is safe and is being appropriately monitored until you can assess them. When you come to assess the patient, if time allows and if you are able to access the patient’s previous notes, you should check for previous incidents of self‐harm or aggression. Before you see the patient ensure that the room is set up appropriately and that it is safe to assess the patient. Ensure that you know how to raise the alarm if necessary and use a chaperone where appropriate (especially if the patient is sexually disinhibited). Whilst assessing the patient it is important to remain calm and empathic. Even if someone seems distracted and unable to focus their attention on you, it is important to try and form a rapport and build trust with the patient. Explain who you are and why you have come to see them and the limits of your confidentiality. If the patient appears very overtalkative and difficult to interrupt it can be useful to set out the time that you have to see them at the beginning of the interview, explaining that this may mean that you need to stop or interrupt them at points during the interview in order to ascertain the information that you need to form a diagnosis.

6.3 Primary assessment – the unified assessment

The patient will often be scared and this combined with the psychotic phenomena that they are experiencing may cause them to act unpredictably. This unpredictability means that their risk can be difficult to assess – an AEIO Unified assessment should be undertaken. It may be best to assume until a full assessment has occurred that they are at risk of self‐harm and pose a risk of harm to others and/or absconding.

As outlined in Chapter 2, the primary AEIO Unified assessment should focus on four key areas:

A Agitation/Arousal

E Environment

I Intent

O Objects

Before you see the patient ensure that:

They are in a safe area – preferably a dedicated psychiatric assessment room. If this is not possible then use a calm area that is free of objects that could be used to harm either themselves or others

They are within sight of either nursing or security staff to reduce the risk of absconding or self‐harm

Other appropriate staff (nursing/security/liaison psychiatry) are aware of the situation and that plans are in place should restraint or rapid tranquillisation be required

There is a plan about what to do if the patient tries to leave

6.4 Secondary assessment

Focused physical history and secondary examination

Before deciding that the patient is suffering from a psychiatric disorder you will need to consider whether there is an alternative physical cause for their presentation. There are many physical illnesses that can present as psychiatric illnesses and these are important to keep in mind, especially if this is a first presentation. If the patient has an established diagnosis of a major mental illness then it is less likely that the cause is organic illness but does not rule it out completely. Appendix 6.1 lists organic disorders with psychiatric presentations and Appendix 6.2 lists disorders associated with substance misuse.

As discussed in Chapter 3, all patients should (if they allow) have a basic physical examination. This should include a full neurological assessment including fundoscopy. If you suspect that the patient may be suffering from an infective or endocrine abnormality then they will need relevant blood tests. Depending on the history and physical examination the patient may need a lumbar puncture and radiological screening. It is wise to perform an electrocardiogram (ECG) and some blood tests on all patients who may require rapid tranquillisation. These tests will include urea and electrolytes and calcium, liver function tests, full blood count, glucose, C‐reactive protein and thyroid function. If you suspect illicit substance use then a urine drug screen can be useful and will help guide further management.

Focused conversational psychosocial history and mental state examination

Initially, allow the patient to talk freely to tell you what has been happening to them and what has led to them coming into hospital. Pay attention to the duration of onset, past psychiatric history, any prescribed medication, and illicit substance use or alcohol intake. Explore briefly any physical health complaints: these may require physical examination and further testing later in the assessment. Once you have a basic history you can use the mental state examination as a way of describing the symptoms that the patient is presenting with. The mental state examination comprises both verbal and non‐verbal elements, so even if the patient is unable to give any coherent history or is unwilling to engage in the assessment, by observing the patient you will be able to complete the majority of the sections of the mental state examination.

The mental state examination has been covered in detail in Chapter 3 using the mnemonic ABC SMITH. To reprise in summary:

Appearance

How are they dressed?

Self‐neglect?

Injury?

Do they show signs of underlying neurological illness?

How active are they?

Behaviour

Are they aggressive?

Do they exhibit abnormal movements?

How does the patient relate to you?

Cognition

Are they oriented in time, place and person?

Do they have poor concentration?

Speech

What is the rate of speech?

What is the form of speech?

Do they present as mute? (It is important to clarify that the patient does not communicate via sign language because they are deaf, or only speaks a language other than that spoken locally!)

Mood and affect

Do they appear depressed?

Do they appear elated?

Are they irritable or labile?

Insight and capacity

Do they have an understanding of their symptoms and illness?

Can they understand the treatment or investigations being offered?

Do they have capacity to consent for any admission, examination or treatment that is necessary?

Thoughts

Do they exhibit disorders of thought form?

Do they exhibit disorders of thought content?

Hallucinations and illusions

Are they suffering from illusions? (misinterpretation)

Are they suffering from hallucinations?

Once you have reached this stage in the assessment it can be useful to obtain any collateral information available, this may be from friends or relatives, staff in the department who have previous knowledge of the patient or previous medical or psychiatric records. Collateral information can be particularly useful if the patient is unwilling to engage with the assessment.

6.5 Emergency management

Your findings from the history, examination, collateral information and any investigations should now point you towards the likely diagnoses. The most common psychiatric presentations are covered in Appendix 6.3. Depending on the underlying cause, the patient is likely to require further assessment either by the psychiatry team alone or with combined input from both the medical and psychiatric teams. Whilst awaiting input from these services the patient needs to remain in an environment that is safe and appropriate to manage the risk of aggression, self‐harm and absconding. If the patient is agitated or distressed you may wish to consider giving them a small dose of oral lorazepam or haloperidol, the aim is to reduce levels of agitation rather than causing severe sedation. If the patient is severely agitated then they may require rapid tranquillisation as detailed in Chapter 8.

6.6 Case examples

Case 6.1
Tetsuya, a 57‐year‐old man, is brought into the ED by the police. Local supermarket staff contacted the police after members of the public expressed concerns that a man was locked in a toilet cubicle muttering to himself. Since arrival in the department he has been very anxious. It is difficult to follow his conversation, but he seems to be talking about being followed and also appears to be scared of the police officers accompanying him. He constantly asks passing staff if they can keep him safe and, although appropriately dressed, he is carrying a plastic bag which he is unwilling to put down. The police officers state that the bag contains paperwork including his passport.
Photo of Tetsuya, a 57-year-old man, who is brought into the ED by the police after being found by a local supermarket staff, locked in a toilet muttering to himself.

Primary assessment
ABCD
A – Maintaining own airway
B – RR 18, SpO₂ 98%
C – HR 86 bpm, BP 135/85
D – Alert, PERLA, glucose 5.5 mmol/L
AEIO
A – Anxious and aroused, with possible delusional thoughts
E – In safe room. Police present
I – Not expressing any thoughts of wishing to harm himself. Not expressing an active wish to leave
O – No dangerous objects

Unified assessment and immediate treatment
No immediate physical or mental health risk identified; no immediate physical treatment required; no rapid tranquillisation required
Containment plan to include discrete one‐to‐one security presence

Secondary assessment

Focused physical history and secondary examination
A PHRASED physical history reveals no physical complaints except for mild hypertension (he has been non‐compliant with his antihypertensives recently as he has been too worried to pick up his prescription)
Physical examination is unremarkable, as are routine bloods and ECG

Focused conversational psychosocial history and mental state examination (MSE)
Tetsuya believes that the government are following him using cars as well as spying on him with security cameras and electronic devices. He is unsure why they are doing this but believes that they wish to harm him in some way. He feels that he needs protection but is unsure who he can trust
Tetsuya denies a previous psychiatric history, but hospital records reveal he has had a previous admission on section 3 of the Mental Health Act (MHA) and has a diagnosis of schizophrenia. He was previously on a depot antipsychotic but appears to have disengaged from all follow‐up 6 months previously
He drinks 2 pints of lager on Friday, Saturday and Sunday evenings; no illicit substance use
MSE
A – Normal clothes
B – Constantly looking around and asking for protection
C – Distracted and unable to remember facts
S – Normal speech
M – Alert, anxious
I – No insight
T – Paranoid ideation
H – Hears voices warning him of danger

Disposal
Tetsuya will need treatment for his psychotic illness and will require a MHA assessment

Reassess risks
He will need security (one to one) in the department but at a discrete distance. Medications should be offered to help reduce his distress levels in the department although this may be refused. Should he become more aroused and agitated there may be a need for restraint and rapid tranquillisation

Case 6.2
24‐year‐old Naomi has been brought to the ED by her partner Emma after she had an argument with the neighbour. Naomi became uncharacteristically verbally and physically threatening. In the ED she has been complaining loudly about having to wait. Despite being asked to wait in a single interview room she is wandering around the department talking to other patients and at times entering clearly marked staff‐only clinic areas. Emma reports that Naomi hasn’t slept or eaten properly for several days although she is drinking fluids
Photo of Naomi, a 24-year-old woman, who is brought to the ED by her partner Emma after she had an argument with the neighbour.

Primary assessment
ABCD
A – Maintaining own airway
B – RR 14, SpO₂ 99%
C – HR 105, BP 120/75
D – Alert, PERLA, glucose 4.9 mmol/L
AEIO
A – Agitated and wandering
E – Wandering around department and will not remain in safe room
I – Not expressing any thoughts of wishing to harm herself. Disinhibited and irritable and intermittently expressing a wish to leave
O – No dangerous objects

Unified assessment and immediate treatment
No immediate physical health risk identified. No immediate physical treatment required
Will require increased levels of observation to prevent wandering and maintain others’ safety and privacy. Due to levels of arousal would benefit from medication to reduce this. High risk that she may require rapid tranquillisation or restraint, and plans for this and appropriate placement in the department need to be considered

Secondary assessment

Focused physical history and secondary examination
A PHRASED physical history reveals no physical complaints, although cooperation with history taking was poor
Physical examination was only partly completed as Naomi refused to remove any clothing. No gross abnormalities noted

Focused conversational psychosocial history and mental state examination (MSE)
Emma says that Naomi has had reduced sleep and overactivity for 5 days. Today’s argument with the neighbour arose because Naomi was attempting to use the lawnmower at 6 am. Naomi (who is normally quiet and reserved) is wearing revealing clothing and is intrusive of others’ space. She is talking about launching a clothing range as she says she has special artistic talents. When interrupted or challenged she rapidly becomes irritable and threatening
Naomi denies a previous significant psychiatric history but reveals a brief episode of low mood in her late teens. There is a family history of a paternal aunt who has bipolar affective disorder, and of a paternal grandmother who spent time in an asylum but in whom the diagnosis is unknown. No history of excessive alcohol intake or use of illicit substances
MSE
A – Over‐revealing clothes
B – Overtalkative and disinhibited, intrusive of others’ space
C – Poor concentration and compliance with tests
S – Pressured speech
M – Aroused, irritable and emotionally labile
I – Very limited insight, does not feel that she needs to be in hospital or that she needs any medication
T – Grandiose thoughts
H – No hallucinations

Disposal
Naomi will require close observation and needs to be nursed in a safe, low stimulus environment. Once settled she will require physical examination including bloods and ECG. Naomi will need assessment under the Mental Health Act

Reassess risks
Currently high risk to others, risk of self‐neglect and risk of exploitation by others. Due to lack of insight there is a risk of absconding from the ED
Careful planning and communication is required between staff to ensure that a team is available for rapid tranquillisation and restraint if required

6.7 Summary

As outlined in this chapter, a structured approach to a patient who is behaving strangely will assist you in recognising key features, examining their mental state and screening for medical causes of psychiatric presentations. This will enable you to form a management plan including the management of risk to the patient and to others.

Appendix 6.1 Organic disorders with psychiatric presentations

Insidious onset

In some inherited neurological conditions, psychiatric symptoms may be the first presenting sign. Often the onset is insidious over many years and may include significant change in personality. Many of these disorders can lead to delirium as well as specific psychiatric symptoms.

Acromegaly – depression, irritability, apathy or labile mood

Acute confusional state and dementia – see Chapter 7

Addison’s disease – depression, anxiety and irritability

Cerebral tumours – depression or emotional lability. Symptoms may depend on the location of the tumour: occipital may cause visual hallucinations; temporal lobe may cause visual and auditory hallucinations; parietal tumours are associated with tactile and kinaesthetic hallucinations; frontal tumours may cause disinhibition and a variety of hallucinations; diencephalic tumours may present as Korsakoff’s psychosis

Cerebrovascular disorders – delirium, organic psychoses, mood disorders and personality change

Charles Bonnet syndrome – ocular pathology is related to visual hallucinations which are often complex and vivid and tend to occur at times of low light. The patient often has full insight and is undistressed

Cushing’s syndrome – depression, mania and psychosis

Head injury – organic schizophrenia and affective psychoses. Personality change

HIV (human immunodeficiency virus) – dementia

Huntington’s chorea – may present with depression, aggression, psychosis or obsessive compulsive disorder

Hyperparathyroidism – depression

Hyperprolactinaemia – severe depression

Hyperthyroidism – hypomania/mania, psychosis and anxiety

Hypoparathyroidism – may rarely present with psychoses

Hypopituitarism – depression often with irritability and features of dementia

Hypothyroidism – severe depression with or without psychotic symptoms, may present as early dementia

Inherited leucodystrophies (metachromatic leucodystrophy) – psychotic symptoms

Motor neurone disease – emotional lability

Multiple sclerosis – depression, mania and psychosis

Neuroacanthocytosis – depression, anxiety, obsessive compulsive disorder and personality change

Paraneoplastic syndrome – psychoses and affective symptoms

Parkinson’s disease – depression

Peduncular hallucinosis – damage to the midbrain/thalamus causes vivid visual hallucinations often in the evenings

Pellagra – delirium, depression and psychoses

Phaeochromocytoma – chronic anxiety and panic disorder

Polyarteritis nodosa – delirium, mania and paranoia

Spinocerebellar ataxia – personality change, labile mood, aggression or dysexecutive syndrome

Sporadic Creutzfeldt–Jakob disease – rapidly progressive dementia

Syphilis – may present in a variety of ways including dementia, depression and elation or with schizophrenic features

Systemic lupus erythematosus – psychotic symptoms

Variant Creutzfeldt–Jakob disease – depression or anxiety

Wilson’s disease – personality change, mood disturbance, psychosis and cognitive impairment

Acute onset

Acute intermittent porphyria – psychotic symptoms

Carbon monoxide poisoning – may present as Korsakoff’s psychosis

Encephalitis (including anti‐N‐methyl‐D‐aspartate receptor and antivoltage‐gated potassium channel antibody‐associated limbic encephalitis) – psychotic symptoms and delirium

Epilepsy

Temporal lobe epilepsy – hallucinations in all modalities, may appear to have thought blocking, déjà vu, jamais vu and affective symptoms

Per‐ictal, inter‐ictal and post‐ictal psychosis

Complex partial seizure – may lead to epileptic automatism (the patient may perform often simple but at times complex activities while suffering from reduced consciousness)

Fugue – patients may appear drowsy or intoxicated, often undertake complex behaviours and wander large distances waking in an unknown area with no idea how they arrived there. These states may last from hours to rarely weeks at a time

Parietal and occipital lesions – may cause visual phenomena

Transient global amnesia

Head injury – may cause aggressive behaviour, agitation, amnesia and confusional states

Hepatic encephalopathy – delirium

Migraine – depression, anxiety, irritability and complex auditory and visual hallucinations

Appendix 6.2 Strange behaviour associated with drug and alcohol misuse

Alcohol intoxication

The symptoms vary according to the level of intoxication. In moderate intoxication symptoms include unstable gait, slurred speech, and disinhibited behaviour including aggressive behaviour.

Alcohol related

Delirium tremens – occurs in withdrawal from alcohol in patients who have been alcohol dependent for some time and is a medical emergency. It presents with clouding of consciousness including disorientation, recent memory impairment, tremulous hands, hyperhidrosis, severe agitation and insomnia. Patients describe or can be seen interacting with vivid and at times bizarre hallucinations. Often hallucinations are visual or somatic in nature; patients may report seeing or feeling spiders, snakes or even small figures (Lilliputian hallucinations) running around. Patients may also have occupational hallucinations and undertake actions that they would in their day‐to‐day work. There may also be paranoid delusions. Physically, the patients display autonomic dysfunction and dehydration with electrolyte disturbance, especially low potassium and magnesium levels. Symptoms, as with delirium, tend to worsen at night. Delirium tremens typically develops 24 hours after the last drink and lasts for up to 6 days

Wernicke’s encephalopathy – this is due to thiamine deficiency and occurs most commonly in alcoholics but may also occur in other patients with severe nutritional deficiencies. There is an acute onset of acute confusional state, ophthalmoplegia, nystagmus and ataxia. This is a medical emergency and without treatment has a mortality rate of approximately 15%, and 84% will go on to develop Korsakoff’s psychosis

Korsakoff’s psychosis – predominantly an inability to lay down new memories with coexisting retrograde amnesia. Patients confabulate (invent memories) for the episodes of amnesia; the patient believes these memories to be true

Alcoholic dementia and cerebral atrophy

Psychiatric effects of commonly prescribed medication

A variety of medications may give rise to psychotic symptoms and in acute onset be aware that this may be the case and take this into consideration.

Illicit substance use

Often, intoxication with illicit substances leads to the development of psychiatric symptoms, particularly psychotic symptoms. Some of the more commonly encountered substances and effects are listed below, however this is not an exhaustive list and there are frequently newly manufactured drugs and so‐called ‘legal highs’. Many of the newer drugs elicit both mood lability, impulsivity and psychotic symptoms’ refer to TOXBASE for further details.

Novel psychoactive substances (including spice) are associated with unpredictable behaviour including severe aggression and agitation, self‐harm, depression, psychosis and a zombie‐like state.

Amphetamines (including methyl amphetamine) – may present as mania or psychosis. Psychotic symptoms often include delusions of insects being present under the skin with associated tactile hallucinations. Amphetamine‐related psychosis can be expected to have significantly improved within a week of cessation of amphetamine use

Anabolic steroids – mood instability, aggression, depression and paranoia

Cannabis – both acute intoxication and chronic use may be associated with paranoia, psychotic symptoms and mood fluctuations

Cocaine/crack cocaine – initially euphoria followed by a period of dysphoria leading to hallucinosis and psychosis. Similar to amphetamine psychosis there may be delusions of insects under the skin and associated tactile hallucinations. The psychotic symptoms generally resolve within 24–48 hours

Diazepam – generally sedative effects but there may be paradoxical excitement and aggression

Ecstasy – generally feelings of euphoria, however psychotic symptoms have been reported with heavy use

Ketamine – derealisation and depersonalisation, paranoia and psychotic symptoms

Khat – elation and psychotic symptoms when heavily used

Lysergic acid diethylamide (LSD) – labile mood, synaesthesia, vivid hallucinations and illusions which tend to be visual. Altered sense of time and space may be accompanied by distortions of body image. The effects are short lived lasting up to 16 hours, however LSD‐induced psychosis may last several weeks and in some reports years

Magic mushrooms (psylocybin, psilocin) – predominantly hallucinations

Mephedrone – depression with suicidal thoughts and psychosis

Opiates, buprenorphine, methadone – sedative effects and depression. Psychotic symptoms have been reported with buprenorphine and methadone

Phenyclidine (PCP) – psychotic symptoms which can be associated with violent behaviour

Solvent abuse – euphoria, disinhibition and hallucinations

Appendix 6.3 Commonly encountered psychiatric presentations

Schizophrenia

This is a very heterogeneous disorder but the core symptoms according to ICD‐10 must have been present for at least 1 month (any illness fulfilling the criteria but present for less than a month is classed as an acute schizophrenia‐like psychotic disorder). For full diagnostic criteria see ICD‐10 (WHO, 1992). Schizophrenia is a functional psychosis that does not affect the level of consciousness and is characterised by five groups of symptoms:

Delusions and hallucinations

Disorganised speech and behaviour

Deficit symptoms

Depression and anxiety

Excitement and agitation

There may also be subtle but generalised cognitive impairments which are stable over years. These typically produce impairments in performance about 1.5 standard deviations below the norm, without the relatively severe problems with orientation, amnesia or judgement common in dementia.

Drug‐induced psychosis, psychotic episodes and delusional disorders

These disorders all comprise various features of schizophrenia with delusions and/or hallucinations but the symptoms demonstrated would fail to meet the full ICD‐10 criteria for schizophrenia.

Catatonia

The full syndrome is rare, but relatively commonly psychiatric presentations can include some catatonia signs, although these are often missed. The major causes are either organic in nature or related to schizophrenia, although a similar presentation can occur in severe depression. According to the ICD‐10, for a diagnosis of organic catatonia the disorder must be due to a physical cause and the situation resolves once this cause is treated. Features include:

Stupor (diminution or complete absence of spontaneous movement with partial or complete mutism, negativism)

Excitement (gross hypermobility with or without a tendency to assaultiveness)

Both (shifting rapidly and unpredictably from hypo‐ to hyperactivity)

(The ICD‐10 Classification of Mental and Behavioural Disorders; WHO, 1993)

In catatonic schizophrenia the patient must have met the criteria for diagnosis of schizophrenia and they may present with one or more of stupor, excitement, posturing, negativism, rigidity and waxy flexibility and on occasions command automatism, perseveration and ambitendancy.

Bipolar affective disorder

Mania or hypomania commonly presents with overactivity, pressure of speech, flight of ideas and disinhibited behaviour. Patients may present as irritable or aggressive. If delusions and hallucinations are present they are termed as mood congruent, e.g. a belief that the person has special powers such as being able to fly or has God‐like abilities. Patients with full‐blown mania may be easy to spot purely by their appearance – wearing brightly coloured shorts and T‐shirt with sunglasses in the middle of winter. For full criteria see the ICD‐10.

Episodes of depression are discussed next.

Mixed states involve features of both mania and depression, or rapid shifts in affect that can lead to striking shifts in mental state and behaviour.

Depression

The mental states associated with depression often seem ‘understandable’ and are unlikely to seem strange unless in severe depression there is severe retardation and poverty of thought, unless speech is affected by rumination on stereotyped depressive themes, or psychotic features lead to delusions and hallucination. Sometimes severe anxiety (see below) can be a prominent feature.

Intoxication and withdrawal

Intoxication with a range of substances is recognised by the particular syndrome displayed, often including such features as psychosis, lability, sedation or arousal, and the identification of the intoxicant. Withdrawal from physical dependence can also produce dramatic and even fatal disorders and is harder to identify in the absence of substances detectable in urine or breath.

Delirium and dementia

See Chapter 7.

Anxiety

This is likely to be understandable unless severe agitation affects behaviour, or repetitive worries lead patients to behave oddly and have difficulty participating in the assessment process. Patients will often somatise acutely during panic attacks – e.g. person complaining of choking, being hot, breathless or otherwise physically distressed, and sometimes as having isolated symptoms. When such somatisation is part of the history rather than the mental state (i.e. they present after they have recovered), then hypochondriacal ideation or somatisation may be less obvious. This group can sometimes react angrily when they do not see their needs are met and this can lead to confrontations that confuse clinical staff.

Dissociative disorders and PTSD

These occur when patients are unable to use some aspect of their normal automatic central nervous system (CNS) functions, such as movement, sensation, etc. This occurs when patients experience a severe stress, although once they have occurred less severe stresses can precipitate a recurrence – a key to diagnosing these syndromes is to identify the stressor. Dissociative disorders (hysteria in former classifications) such as paralysis, amnesia, anaesthesia, disoriented wandering (fugues), etc. are commoner in various non‐Western cultures, e.g. sub‐Saharan African and South or East Asian, as well as historically in Europe and North America (incidentally, before overdoses and self‐harm became common) and in military psychiatry.

The aetiology is unclear and controversial, although it occurs more often in childhood, and childhood adversity often predisposes adults to develop it, so those who have suffered abuse and have adult personality problems are more likely to suffer. During acute, stress‐induced dissociation patients can often feel ‘numb’ and experience the world as somehow distant – think of the opening scene of the film Saving Private Ryan for a representation of this state. This group can appear to be distant, ‘mechanical’ and have limited attention and difficulty integrating with function. This state may be relieved if patients instead experience a more isolated, specific CNS dysfunction, including paralysis, numbness or amnesia – they may seem oddly unconcerned ‘a belle indifference’.

These states, particularly acute dissociative ‘numbness’, may have some relation to post‐traumatic syndromes such as post‐traumatic stress disorder (PTSD), where states marked by dissociation and numbness alternate with re‐experiences of trauma, including arousal, agitation, lability, dreams and hallucinations. However, those dissociative syndromes such as paralysis, etc. which present without obvious arousal, are maintained (or even exacerbated) by concern and attention by others that is contingent on the impairment (‘secondary gain’).

Personality disorder

These predispose to most other forms of mental disorder, so can lead to strange behaviour by a range of mechanisms. However, those with features of histrionic personality disorder can present with dramatic accounts of and reactions to otherwise typical problems. Those with dissocial or emotionally unstable traits are more likely to malinger or present with factitious and other related disorders. They are often less inhibited than those with normal personalities in causing a range of problems in the ED.

Munchausen’s syndrome, Munchausen’s by proxy and malingering

Whereas other somatoform disorders (hypochondriasis, somatisation disorders, somatoform pain disorder, somatoform autonomic disorders, dissociative disorders) are driven by distress and anxiety and sufferers are not conscious of the processes involved, these syndromes reflect what is, broadly, an intention to deceive. Those with Munchausen’s syndrome present with fictitious complaints that may become increasingly implausible as they see how far they can go. They may interfere with investigations (e.g. dropping blood into urine, etc.), which is sometimes described as ‘factitious disorder’. Mothers with Munchhausen’s by proxy present with complaints and evidence of bodily illness in their children (sometimes induced by poisoning or otherwise injuring their children). This group appears to be rare, almost always personality disordered, and yet distinguishing them from mere failure to diagnose real illness can be fraught with difficulty.

CHAPTER 7
The acutely confused patient

Learning outcomes

After reading this chapter, you will be able to:

Recognise key features of the acute confusional state

Describe how to screen for delirium and consider alternatives

Identify how to investigate reversible causes of delirium

Demonstrate how to implement a comprehensive management plan

7.1 Introduction

Acute confusional states are a common emergency presentation in the emergency department (ED) or general hospital setting. Presentations can be diverse, as are the range of underlying causes. An important early distinction that should be made is whether confusion is part of a primary mental health presentation (such as mania or psychosis) or is associated with a potentially reversible cause (such as electrolyte imbalance or sepsis). There are many cases where the distinction is unclear (examples include acute‐on‐chronic confusional states, effects of illicit drug intoxication/withdrawal and overdoses). The primary focus of this chapter is recognition and management of delirium. This includes assessment of alternative presentations such as affective and psychotic disorders.

7.2 Acute confusional states

Delirium

Delirium is a complex, organically driven neuropsychiatric presentation characterised by disturbance of multiple cerebral functions. These include level of arousal, attention, perception, motor behaviour (e.g. agitation, retardation, tremor, asterixis, myoclonus), sleep–wake cycle, emotion, and cognitive functions such as memory, language and visuospatial abilities.

Specific patient populations have been highlighted as being particularly susceptible to delirium (Table 7.1). Most studies report data from later life patients (>65 years) but delirium can occur across age groups and may be a pointer of physiological disturbance.

Impact of delirium – the case for early recognition and treatment

Delirium has been shown to adversely affect prognosis, hence timely diagnosis and early treatment are essential. Four mechanisms have been suggested that link delirium to long‐term neural impairment:

Direct neuronal damage as a consequence of delirium

Indirect effects of altered neurotransmitter concentrations and receptor sensitivity

Acceleration or diversion from normal neurophysiological ageing

Exacerbation of pre‐existing impairments

Delirium is associated with an increased risk of secondary infections, falls, prolonged hospital stays, loss of independence (increased rates of discharge to more supportive settings), long‐term cognitive impairment and a threefold increase in 6‐month mortality rates. Delays in diagnosis and treatment of delirium in the intensive care unit (ICU) is associated with increased mortality in this patient group.

Table 7.1 Pooled point prevalence of delirium in different patient populations in the general hospital setting

Population
Frequency

Postoperative
Oncology
General medicine
Acute respiratory failure
Stroke units
Intensive care unit – on admission
Intensive care unit – during admission
Patients with dementia
Presentations to ED
Admissions from ED
35–65%
25–47%
10–35%
37%
2–66%
7–30%
60–80%
18%
8–17%
14–24%

Key points

Delirium is common among acutely unwell patients

It has serious immediate and long‐term implications

It remains underdiagnosed and undertreated

Recognising delirium – key features

A multicentre survey of UK junior doctors highlighted that although most were aware of the high prevalence and potential seriousness of delirium, many found diagnosis and acute management challenging.

Top tip

Although you are less likely to meet them in an acute psychiatric emergency, do not dismiss the patient who is described as ‘pleasantly confused’. Delirium can present as hypo‐ or hyperactive and both represent an acutely unwell patient with a high risk of increased morbidity and mortality

Specific diagnostic criteria can be found in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders 5th edition (APA, 2013) and the World Health Organisation’s International Classification of Diseases 10th edition (WHO, 1992).

The checklist in Box 7.1 is a distillation of both sets of diagnostic criteria.

Box 7.1 Delirium diagnostic checklist

The current presentation should be different to the patient’s baseline, have developed over hours to days (occasionally weeks) and should fluctuate in severity during the course of a day

There should be clouding of consciousness – reduced clarity of awareness of environment (‘spaced out’, drowsy).

Attention is disturbed (directing, focusing, sustaining and shifts of attention). Answers to questions might be frankly irrelevant or more subtle impairments where patients focus initially but quickly become distractible or perseverative. Impaired attention and concentration may prevent adequate assessment of other cognitive functions

There may be additional disturbance of one or more cognitive domains – immediate recall and recent memory and disorientation in time and place are most commonly affected. Other cognitive domains that may be affected include language (appropriate understanding and production), visuospatial ability (e.g. planning and drawing a clock), perception (misinterpretations and hallucinations) or a combination of these. Bedside cognitive tests commonly used include the AMT (abbreviated mental test) and the MoCA (Montreal cognitive assessment, which includes a version for visually impaired patients)

There may be psychomotor disturbance (rapid, unpredictable shifts from hypo‐ to hyperactivity; may also manifest as sustained periods of hyper‐ or hypoactivity)

There may be disturbance of the sleep–wake cycle (insomnia, daytime somnolence, reversal of sleep–wake cycle, nocturnal worsening of symptoms, disturbing dreams that may continue as hallucinations or illusions after waking)

Symptoms should not be better explained by the presence of other pre‐existing or evolving neurocognitive disorders such as learning difficulties or dementia

There might be evidence that physiological disturbance from a general medical condition, intoxicating substance, toxin, medication or a combination of these are directly responsible for the confusional state. An important caveat is that the cause may not be found in up to 15% of patients

Supportive features:

Emotional disturbances (depression, anxiety, fear, irritability, euphoria, apathy or perplexity) are common but not specific for diagnosis

Transient delusions (often persecutory in nature) are sometimes present

Screening tools

There are many rapid screening tools for delirium. The 4AT is a brief and effective screen that focuses on alertness, orientation, attention and fluctuations. One of the most commonly used tools worldwide is the confusion assessment method or CAM. Pooled sensitivity and specificity are generally encouraging (82 and 99%, respectively). Sensitivities are variable across different patient populations however and, as such, a focused clinical assessment remains the gold standard.

Mania and psychosis

Patients with psychiatric conditions such as bipolar affective disorder or psychosis can appear acutely confused during relapse. Although consciousness is not usually impaired and fluctuations are perhaps less acute, patients experiencing manic relapse may sometimes present as stuporose. Important observations to make and questions to ask about mania include euphoric or irritable mood, increased energy levels, racing thoughts, reduced need for sleep and any new projects or plans that seem unrealistic, grandiose and/or paranoid.

Psychosis symptoms include thought interference (feeling as though thoughts are being inserted into or withdrawn from one’s head; experiencing one’s thoughts as being broadcast), passivity phenomena (feeling as though something or someone is making you think, feel or do certain things) and complex or bizarre delusions. Furthermore, visible distress associated with hallucinations and delusions may be intermittent. Hallucinations and paranoid beliefs are also commonly encountered in patients with delirium, so ask additional questions to shore up an alternative psychiatric diagnosis.

Depressive pseudodementia

If a confused patient appears hypoactive, enquire about symptoms of depression, especially depressed mood, feeling unable to enjoy anything, feeling guilty or worthless and thoughts of life being pointless. Note that in depressive pseudodementia, attention and concentration are usually okay, but the patient may require prompting to continue with a task as they may give up early. In each of these conditions, family members may have noticed a gradual deterioration over days to weeks and may recognise the current presentation as a relapse.

Acute exacerbations of chronic condition

Patients with chronic cognitive impairment (developmental disabilities or neurodegenerative disease such as dementia) can also present with acute confusion and behavioural change. This may be related to disease progression – patients with vascular dementia can experience sudden deterioration in cognitive function post‐infarct (note this may represent delirium or disease progression) – or disease fluctuations – dementia with Lewy bodies follows a naturally fluctuating course.

Social and environmental stressors: alterations or more restrictive routines can cause agitation, distress and acute behavioural change. It is also important to consider whether the presentation you see in front of you is an expression of fear and distress. Think about whether there may be safeguarding issues.

Key points

For patients with chronic cognitive impairment:

Acute cognitive and behavioural change may represent natural fluctuations or disease progression but exclude delirium FIRST

This is a vulnerable patient group. Be alert to the possibility of safeguarding issues

Precipitants of acute confusion

Working out the precipitants of acute confusional states can be tricky as often there are multiple contributing factors. The principal aim of the emergency assessment is to screen for potentially life‐threatening reversible causes in addition to gaining an impression of risk of harm to the patient and to others. It is also helpful to think of predisposing risk factors that render a patient susceptible to developing acute confusion (Table 7.2) and what perpetuating factors might hinder recovery (Table 7.3).

Table 7.2 Causes of delirium

Precipitating factors I – general considerations
Precipitating factors II – intoxication, toxicity, withdrawal and deficiency states
Precipitating factors III – primary neurological disease

Trauma
Hypoxia/hypercapnia
Ischaemia
Infection
Electrolyte disturbance
Hyponatraemia
Hypercalcaemia
Hypermagnesaemia
pH disturbance (lactate, ketones, etc.)
Uraemia
Hypoglycaemia
Thyroid or adrenal disease
Constipation and/or urinary retention
Alcohol, sedatives
Illicit substances
Delirogenic drugs
Polypharmacy
Overdose
Exposure to toxic substances
Renal failure
Liver disease (hepatic encephalopathy, hepatitis, liver failure)
Malabsorption and/or malnutrition: vitamin B₁ or B₁₂ deficiency
Head injury
Bleed (subdural haematoma, subarachnoid haemorrhage)
Stroke
Non‐convulsive status epilepticus or post‐ictal state
Meningitis
Viral or autoimmune encephalitis
Vasculitis (e.g. systemic lupus erythematosus)
Primary or secondary malignancy
Raised intracranial pressure

Table 7.3 Factors that increase the risk of delirium and hinder recovery

Perpetuating factors
Predisposing factors

Pain
Dehydration
Constipation
Sensory impairment
Insomnia
No clock or visible daylight
No visits
Noisy, stimulus‐rich ward
Low staff : patient ratio
Advanced age
Vascular risk factors
Cardiac disease
Pulmonary disease
Cognitive impairment
Sensory impairment
Co‐morbidity load
History of alcohol or illicit drug misuse

PUTTING IT ALL TOGETHER – THE STRUCTURED APPROACH TO ASSESSMENT

7.3 Preparation

Establish key concerns at this moment – does current risk exist?

Acute confusion and current risk

The patient has acute cognitive and behavioural change coupled with:

Agitation and distress

Aggression including attempts to harm self or others

Wandering and falls

Bags packed and trying to leave the hospital

Refusing oral intake

Refusing essential medical/nursing input such as observations, investigations and/or treatment

The focus here is diagnosis and acute management of risks.

Acute confusion and no current risk

The patient has acute cognitive and behavioural change and is accepting care interventions; no immediate risks to self or others have been identified. The focus here is diagnosis and contingency planning to manage potential risks.

Essential background information (where possible)

Age

First language

Recent/relevant medical history

Disorders associated with psychosis such as schizophrenia and schizoaffective disorder, depression and bipolar affective disorder

Conditions associated with chronic cognitive impairment such as learning difficulties, dementias and acquired brain injury

History of self‐harm or violence towards others

Alcohol or substance misuse

Forensic history – particularly violence towards others and damage to property

Reason for presentation to ED

Gather any collateral information from paramedics, police or accompanying others (where was the patient found, who called the ambulance, duration of confusion):

Acute departure from patient’s usual baseline

Any physical health symptoms or signs

Initial Glasgow coma scale (GCS) score

Physical observations

Any associated features including aggression or refusal to come into hospital

There should be a brief review of the latest observations and medication chart (blood tests and electrocardiogram (ECG) if readily available).

Top tip: medication review

Beware drugs with sedative properties (antihistaminergic, GABAergic, opioids), high anticholinergic load or those with toxicity syndromes. Common culprits include: tricyclic antidepressants, bladder stabilisers, digoxin, carbamazepine, antiparkinsonian medications, opiates and non‐selective β‐blockers

Based on the above information – check that appropriate support is available to help manage risks (other members of staff, security, police).

7.4 Primary assessment – the unified assessment

ABCD and the AEIO should proceed in parallel during the primary assessment. This enables early identification of serious physical and psychological risks to the patient and others so they can be quickly addressed.

Patient assessment

Is the patient safe to approach? If the patient poses an immediate serious risk to self and others due to severe agitation and is not responding to verbal attempts to calm or reassure (de‐escalation – Box 7.2) administer rapid tranquillisation (see Chapter 8) to enable further assessment. Where immediate serious risk has not been identified, spend a little time trying to engage the patient then proceed to assessment of the confusional state.

Box 7.2 Engaging the acutely confused patient

Think about sensory impairments and language barriers

Introduce yourself and explain why you are here using clear, simple language

Express concern and reassure you are here to help

Adopt a friendly, polite, concerned approach

Try to make eye contact (shift position if necessary to make this easier) but do not stare – this can be intimidating

A light touch on the arm or shoulder can help a confused patient to focus and engage but can also irritate or startle a suspicious agitated patient – use your judgement and consider your personal safety

Deal with risks first but spending a few seconds acknowledging the patient’s fear/irritation/upset can open a window of communication and ultimately negotiation regarding further assessment, taking bloods, etc.

When a patient wanders from topic, use the patient’s first name, re‐establish eye contact and use a polite segue back to your question/topic, e.g. ‘Jack, I just want to ask about …/Can you tell me if you are …’

Parallel primary assessments – ABCD and AEIO

The patient refuses to be examined/to have tests – do they have capacity to make an informed decision on this? Should they be assessed anyway in their best interest?

ABCD

A Airway – patency and security

B Breathing – adequacy and effectiveness (rate, effort and symmetry, oxygen saturation, tracheal tug/deviation, percussion and auscultation)

C Circulation – adequacy (peripheral and central capillary refill, pulse, BP, auscultation, any oedema)

D Disability – conscious level and pupils (AVPU/GCS, pupillary responses, fingerprick glucose, obvious lateralising signs)

Think

Airway obstruction

Hypoxia

Shock

Hypoglycaemia

Meningism

Reduced GCS

Pupillary signs

Focal neurological signs

Rash

Trauma or bleed

Sepsis

AEIO

This should follow the structure outlined in Chapter 2.

(A) Agitation/Arousal

Briefly observe the patient and determine whether their level of agitation is low, moderate or high. How does agitation manifest (motor restlessness, distressed or hostile verbal communication, physically threatening or aggressive behaviour or a combination)? Does agitation/arousal escalate or settle when you attempt to talk with the patient?

Action plan

Consider the number of staff that should be present to support the assessment and monitor the patient afterwards. Is rapid tranquillisation required at this point?

(E) Environment

This is the environment in which the patient is being cared for. Refer to the ADELLE checklist in Chapter 2 and decide whether the current environment confers low, moderate or high risks to the patient and/or others.

Can the patient be left alone? If not, why, and how many staff (nursing and/or security) should be present?

(I) Intent

The intent of the individual must be assessed (remember this refers to current thoughts).

Risk of harm to self

Is the patient actively expressing plans to harm themself? What are the nature, frequency and severity of these thoughts – how likely are they to act on or resist these thoughts in the next few hours? Is there evidence of recent self‐harm? Are there any concerns that current presentation is associated with a self‐harm attempt (e.g. toxic effects of overdose, hypoxic insult from ligature)?

Action plan

Remove access to means where possible, consider one‐to‐one observation and brief the ED staff and security on physical description and flight risks

Risk of harm to others

Is the patient actively expressing verbal or physical threats to others? What are the nature, frequency and severity of these thoughts – how likely are they to act on or resist these thoughts in the next few hours? Are these general or do they involve specific individuals? Are any of these individuals in the immediate environment? Is there any concern that the patient might be carrying a weapon (request assistance from police if necessary)?

Action plan

Consider de‐escalation techniques, rapid tranquillisation and securing assistance from hospital security staff and/or the police

Psychotic experiences

These are common in delirium.

Does the patient appear to be responding to non‐apparent stimuli (looking at, gesturing towards or talking to unseen people/creatures/objects)? Do they appear unduly agitated, suspicious or frightened? Do you have any concerns that the risks identified above or desire to leave the department are driven by psychotic symptoms such as command hallucinations or paranoid delusional beliefs?

Action plan

This will be based on specific identified risks (to self, others or risk of leaving the department). The mainstay of treatment at this stage is providing support and monitoring from members of nursing staff, sedative medication as and when required if unduly agitated and distressed, and highlighting psychosis to the ED team as it may inform further investigation in patients without an established prior history of psychosis

Desire to leave

Is the patient willing to stay to have investigations and/or treatment? Is there a risk of wandering and inadvertent absconsion (common in confused patients)? Is there a risk of falls?

Action plan

Observation, brief the ED and security staff – physical description of patient and details of potential flight risk

(O) Objects

These are objects that the patient has in their possession, which may be used to harm themself or others.

Action plan

If there is reasonable belief that the patient is carrying a weapon or object that could be used as such and is refusing to surrender it or to be searched, it is reasonable to contact the police to discuss receiving assistance to minimise risks to the patient and to others

7.5 Unified assessment and immediate treatment

Relevant perspectives from ED staff and the assessing mental health team should be rapidly and effectively communicated so that each team member is aware of the seriousness of identified physical and psychological risks and proposed plans for further investigations/treatment. Immediate, life‐threatening risks should be dealt with and opinion on capacity should be formalised at this stage. When the necessary steps have been taken to stabilise the patient and contain risk, secondary assessment should take place to obtain further detail on the clinical presentation.

7.6 Secondary assessment

After immediate, life‐threatening injuries and serious risks have been either excluded or addressed, the parallel assessment should proceed towards arriving at a working diagnosis with plans for treating urgent physical and mental health problems.

Focused physical history and secondary examination

Focused history – PHRASED

P Presenting complaint

H History of presenting complaint

R Relevant medical history

A Allergies

S Systems review

E Essential family and social history

D Drugs (medication, illicits)

Secondary examination – guided by focused history

Top‐to‐toe physical examination (including neurological examination – this is essential)

Investigations:

IV access and bloods (bold indicates commonly used): blood gas – get an initial venous gas if arterial is not possible – FBC, U+E, calcium, creatinine, TFTs, LFTs and PT, troponin, glucose, B₁₂, folate, CRP. Urine dip, urine M,C+S, urine drug screen

ECG, CXR, EEG, CT/MRI brain

Consider: drug levels, amylase, LDH, creatinine kinase, NH₄⁺, blood cultures, HIV, syphilis and Lyme serology, antibodies (VGKC, NMDA, GAD, TPO, ANA, cardiolipin), lumbar puncture

ANA, antinuclear antibody; CRP, C‐reactive protein; CT, computed tomography; CXR, chest x‐ray; ECG, electrocardiogram; EEG, electroencephalogram; FBC, full blood count; GAD, glutamic acid decarboxylase; HIV, human immunoglobulin virus; IV, intravenous; LDH, lactate dehydrogenase; LFTs, liver function tests; M, C+S, midstream urine, culture and sensitivity; MRI, magnetic resonance imaging; NMDA, N‐methyl‐D‐aspartate; PT, prothrombin time; U+E, urea and electrolytes; TFT, thyroid function tests; TPO, thyroid peroxidase; VGKC, voltage‐gated potassium channel.

Focused conversational psychosocial history and mental state examination

See Box 7.1 (delirium diagnostic checklist).

Is there any suspicion here of self‐harm? If so, proceed to the SLIPA risk assessment. If there is no suspicion of self‐harm, proceed to the remainder of the focused psychosocial history.

Screen for other symptoms and signs suggestive of psychosis or an affective disorder as part of a full mental state examination (see Chapter 3).

Undertake a clinical assessment for delirium: History from staff relatives/notes to set the presentation in context. Key symptoms? Confusion developed over hours–days–weeks–months? Different to baseline? Fluctuates during the course of the day? Disturbed sleep–wake cycle? History of cognitive impairment – diagnosis? History of mental health problems? Alcohol excess – any sweating/tremor over the last few days? Illicit drug misuse?

Assessment – COMA CHAMP

C Conscious level – hyperaroused, drowsy, fluctuating? Record AVPU or GCS score

O Orientation – building, floor, town, county, country/day, date, month, year, season

M Memory – try three word repetition (e.g. orange, pencil, book) and then test recall after testing attention or try an address (Peter Jones, 50 Windermere Road, Taunton, Somerset)

A Attention – two of: months of the year backwards, spell WORLD backwards, subtract serial 7s from 100 five times – 93, 86, 79, 72, 65 (try serial 5s if this is too difficult). Able to remain focused on the task? Able to shift attention appropriately or is there perseveration or wandering off topic?

C Cognitive testing: if able, try more formal tests such as the AMT, MoCA or Addenbrooke’s cognitive examination (ACE; longest and most detailed)

H Hallucinations – which sensory modalities? Distressing? Any insight?

A Affective disturbance – anxiety, irritability, distress

M Motor disturbance – restless, agitated, pacing, wandering, disinhibited or conversely very little spontaneous movement. Look out for other motor signs such as tremor, myoclonus and ataxia

P Paranoia – common themes include theft of belongings, poisoned food, hearing derogatory remarks

7.7 Emergency management

Teams should share perspectives if they have assessed in parallel the following:

Physical health – Is there any evidence of a physical health problem or toxic/withdrawal state that could explain the current presentation? If so, what is the working diagnosis and plan for further investigations and treatment?

Mental health – Is delirium the most likely explanation for the confusional presentation? Are there any psychiatric co‐morbidities to consider? Are substance misuse or alcohol dependency contributing to/likely to impact on this presentation? What risks to self and others have been identified? What is the immediate plan for managing these?

Everyone – Has the patient’s capacity to consent to or refuse to remain in hospital to have further investigations and treatment been established? If an extremely agitated, unwell patient is refusing further input and lacks capacity, an urgent joint plan can be implemented that enables action in the patient’s best interests. This commonly involves rapid tranquillisation to reduce distress and agitation and to enable further investigation and treatment. On rare occasions, colleagues from intensive care may get involved as intubation and ventilation may be required to administer life‐saving treatment.

7.8 Determine disposal

Delirium most likely and examination and investigations point to a probable cause – admit to a general hospital setting for further investigation and treatment. Ongoing input from liaison psychiatry is needed to review progress, and to advise on managing risks and discharge planning.

Delirium most likely cause and examination and investigations are normal – admit to a general hospital setting to commence further investigations. Ongoing input from liaison psychiatry is needed in terms of suggesting/further discussion of relevant investigations, management and review of progress.

Delirium unlikely and examination and investigations are normal – arrange transfer to a mental health setting or discharge with intensive support if risks are low and the patient assents to further assessment and treatment.

7.9 Handover

Risks should be reassessed, and essential information regarding presentation, working diagnosis and treatment plan should be collated for handover to the receiving team.

The following pharmacological and non‐pharmacological strategies may be helpful when formulating care plans.

Management of symptoms and signs of delirium

Pharmacological measures

Treating persistent, severe agitation and/or distress associated with hallucinations and delusions. Try on an as required basis first. If beneficial, consider writing up regular doses once or twice daily but ensure this is reviewed frequently.

Haloperidol (0.25–1 mg PO if >65 years; 2–10 mg PO for younger adults). If not effective, repeat at 60 minute intervals and consider increasing the dose. Can be used IM (0.5–1 mg 2 hourly if >65 years; 1–3 mg 1–2 hourly for younger adults). Doses greater than 2 mg are rarely required, even in significantly agitated patients

Olanzapine 5–10 mg PO. Can be used IM. There MUST be a gap of at least 60 minutes between IM olanzapine and benzodiazepines

Risperidone 2–4 mg PO (0.5–1 mg if >65 years). Doses greater than 2 mg are rarely required

Quetiapine 12.5–50 mg PO (evidence weak but it is widely used; it is the ONLY antipsychotic that should be used in patients with known or suspected Parkinson’s, Lewy body disease or N‐methyl‐D‐aspartate (NMDA) encephalitis)

Try to avoid benzodiazepines unless delirium was precipitated by drug or alcohol withdrawal. Chlordiazepoxide, oxazepam and diazepam are typically used in these patients. If it becomes necessary in other patient groups (concerns arise about using antipsychotics, etc. or they are not available in an urgent situation) use a short‐acting version such as lorazepam 1–2 mg.

Regulation of sleep–wake cycle.

Melatonin 2 mg an hour before bedtime. Can be increased in 2 mg increments. Benefits are rarely observed at doses higher than 8 mg. Trazodone 50 mg nocte is a useful adjunct or may be used as monotherapy but tolerance can eventually occur

Non‐pharmacological measures

Nurse in a moderately lit room if possible and try to provide a day/night light cycle. A night light can be helpful as it allows sleep but helps the patient reorient more quickly if they do not wake to complete darkness. Try to avoid room changes.

Depending on the level of agitation and distress and associated risks to self and others, one‐to‐one support may be required. The member of staff doing this should take a proactive approach to reorient the patient several times a day (day, month and year, time, location, reason for being in hospital, name of key member of staff), engage in conversation, reassure, monitor input and output and check the patient is comfortable. Daily brief screens can also be carried out such as the CAM or 4AT.

Calendars, signs and clocks can help orientation. Correct sensory impairment where possible (glasses, dentures and hearing aids are often mislaid).

Early mobilisation has also been shown to hasten recovery from delirium. Non‐ambulatory patients should be referred to physiotherapy for help with maintaining muscle and joint integrity.

Monitor hydration and pain levels. Check for and tackle urinary retention and constipation.

Involve relatives and carers and explain what is going on. It is important to mention that delirium can take time to resolve – often days to weeks but occasionally months.

7.10 Case example

Case 7.1
A 66‐year‐old woman, Lyla, has been brought into the ED by paramedics. She was found semi‐clothed in her garden and appeared confused and distressed. She is a heavy smoker and has a history of type 2 diabetes, chronic kidney disease stage 3 and previous myocardial infarction. There is also a previous history of depression.
Photo of Lyla, a 66-year-old woman, who is brought into the ED by paramedics after found semi-clothed in her garden and appeared confused and distressed.

Primary assessment
ABCD
A – Maintaining own airway
B – RR 29, oxygen saturations 88% room air, crepitations right lower and middle lung zones
C – HR 105 bpm, normotensive
D – Pyrexial 38°C, fingerprick glucose 9 mmol/L, no focal neurology
AEIO
A – Not currently agitated or aggressive. No concerns currently regarding active plans to self‐harm or harm others
E – Wandering
I – Refusing care
O – No dangerous objects

Unified assessment and immediate treatment
Physical health – oxygen (fluids, antibiotics, antipyretics)
Mental health – consider capacity, observation level, contingency plan for treatment of acute agitation
Both – agree on preliminary working diagnosis: delirium secondary to respiratory tract infection

Secondary assessment:

Focused physical history and secondary examination plus investigations
7‐day history of lethargy, increasing shortness of breath, right‐sided pleuritic chest pain and cough with green sputum. GCVS 14/15
Routine bloods and blood cultures sent
CXR – right side consolidation lower and mid zones
Urine dip – protein ++
Allergic to penicillin – clarithromycin given instead

Focused conversational psychosocial history and mental state examination (MSE)
There are no obvious symptoms or signs suggestive of hallucinations or paranoia at this time
MSE
A – Now in hospital gown. History of inappropriate clothing
B – Disoriented, confused and restless
C – Lacks capacity to make an informed decision
S – Quiet
M – Agitated and emotionally labile
I – No insight regarding need for treatment and remaining in hospital
T – Disordered
H – No hallucinations

Disposal
Admit to general hospital under care of physicians with mental health liaison team support

Reassess risks

Risks as in primary assessment (unchanged)

Handover
Summarise presentation, key findings and current treatment plan using SBAR

7.11 Summary

Acute confusion is common and may represent a warning flag for an acute medical or psychiatric emergency.

Exclude delirium first and foremost.

A collaborative approach between ED/ward staff and the mental health liaison team is essential for rapid identification and effective management.

CHAPTER 8
The aggressive patient

Learning outcomes

After reading this chapter, you will be able to:

Characterise the risk factors for aggression in hospital settings

Demonstrate how to assess for aggression/violence

Identify how to manage aggression/violence

Identify the early signs of the patient who is becoming angry or violent

Recognise how to approach and communicate with the patient

Recognise how to de‐escalate a potential aggressive situation

8.1 Introduction

Circumstances leading to violence and aggression can occur in any hospital or clinical setting for a variety of reasons. Violent incidents in hospitals are reported to be increasing, especially in the emergency department (ED), with most acute hospital assaults taking place in the ED. A 2004 study indicated that ED nurses experienced some form of violence or aggression on a weekly basis. It is essential, therefore, that a practitioner knows how to recognise early signs of violence, is able to assess the situation, de‐escalate any aggression that occurs and then be able to lead on a reflective exercise for themselves, the team and the patient.

It is imperative that early signs of behavioural change are taken seriously, attention drawn to them and appropriate steps taken. While staff in psychiatric hospitals may have training in understanding changes in others – allowing them to pre‐empt aggression – those staff working within general hospital settings may lack this experience. This can result in a situation escalating, or a staff member becoming unknowingly drawn into a potentially violent situation. Professionals with experience and training in the recognition and prevention of aggression should therefore aid and assist those who do not have this training.

8.2 Principles in assessing aggression and violence

The Royal College of Psychiatry in Prevention and Management of Violence: Guidance for Mental Healthcare Professionals (Khwaja and Beer, 2013) make a number of overarching recommendations about assessing violence (Box 8.1).

What is aggression?

Aggression refers to harmful physical or verbal behaviour or threats towards persons or objects, with violence the resultant action. Although aggression is a common presentation that the health professional is frequently called to assess, evaluate and treat (either as a main concern or secondary to the presenting complaint) it should never be thought of as relating only to patients. Aggression can originate from any person in the ED, including staff, visitors or other professionals. The causes of aggression presenting in an emergency setting are often multifactorial and complex – resulting from biological, social, cultural and medical factors. Although there is a perception that mental illness is associated with aggression, the link between psychiatric illness and aggression is contentious and disputed. Furthermore, the perception that poor mental health is automatically associated with violence can reinforce stigma for vulnerable distressed patients, leading to exclusion or lack of appropriate care.

Box 8.1 Recommendations about assessing violence

Zero tolerance against violence

Risk assessment is an integral component of psychiatric practice

The risk of violence should be assessed in a structured clinical judgement approach

Effective communication is an essential part of any risk management plan

Assessment of the risk of violence is meaningless without a plan for subsequent action or management

The risk of violence cannot be removed, only minimised, and it is not always desirable to eliminate all risks. Responsible clinical risk taking should be encouraged and benefit and harm weighed up

Risks to children must be explicitly considered

The contribution of alcohol and substance misuse to risk must be recognised, and treatment signposted

By law, all hospitals in England are responsible for ensuring the care and treatment they provide meets government standards of quality and safety. In relation to the management of violence, the core elements of training and education, audit, research and development, openness, risk management and information management can be applied

In addition, transparency in reporting incidents and the duty of candour should always be considered

Theories of aggression

The determinates and causes of aggression and violence are not well understood. However, an understanding of the main theories of aggression can be used to help predict situations where aggression may occur and will allow management and ultimately prevention.

Association between aggression and mental illness

Violence as a result of mental illness remains rare. Currently, it is understood that severe psychopathology can be a cause of aggression and violence, with risk deemed highest the closer the proximity is to the first psychotic episode – especially if this is associated with delusions. This is therefore an important consideration when going to assess a person with a newly suggested diagnosis of psychosis. However, the MacArthur Violence Risk Assessment Study (MVRAS) indicates that delusions do not predict violence. It needs to be stressed that patients who are mentally ill are more likely to be victims of violence than perpetrators, and that they experience violence outcomes at higher rates than the general population.

Use of substances and their relationship with aggression and violence

Substance misuse has been shown consistently to be a risk factor for aggression and violence. The results of the National Epidemiologic Survey on Alcohol and Related Conditions indicated that violence was higher for people with severe mental illness, but only significantly so in those with co‐morbid substance misuse. Furthermore, substance misuse increases the risk of psychotic symptoms and medication non‐adherence, which in turn may lead to worsening of symptoms, greater impulsivity and a corresponding increased risk of violence. Intoxication with alcohol can also increase the risk of violence and aggression.

Location and environment and the risk of aggression

Environments that are busy, disorganised and chaotic elevate stress levels for all concerned, increasing the risk of misunderstanding and aggression. Any patient being admitted to a hospital who finds themselves disorientated, without privacy and unable to leave, is at a potentially higher risk of becoming frustrated and angry. Further, if a patient has attended for a specific purpose and these concerns are not listened to and addressed, this can lead to frustration leading to aggression. Guidelines by the Royal College of Physicians suggested that hospitals should be ‘comfortable, safe, private and homely’.

Staff variables associated with aggression and violence

Repeated studies have demonstrated that poor communication (or lack of communication) is central to escalating aggressive incidents. Whilst increasing emphasis is placed on improving communication, the increased pressure on staff and resources means there may be limits and constraints to their ability to be able to communicate properly. Negative staff attitudes to certain patients can also result in aggression. Studies have found that certain staff are more prone to being assaulted, indicating problematic relationships and an ongoing lack of communication skills. Communication skills are an important aspect of the structured approach. Good communication between doctor and patient can reduce psychological anxiety, and ‘improve a patient’s perception of the medical encounter regardless of treatment outcome’ (Pfeiffer et al., 1998). However, poor communication can ‘thwart the goal of understanding patient expectations of treatment or involving the patient in treatment planning’ (Baile et al., 2000).

The causes of aggression related to psychiatric disorders (from studies by Foley, 2005 and Bjørkly, 1995) are outlined in Box 8.2.

Box 8.2 Causes of aggression related to psychiatric disorders

Co‐morbid substance misuse

Non‐adherence to medication

History of childhood abuse

Involuntary admission status

Lack of insight

Previous history of violence

Younger age

Male sex

Organic brain disorders

Learning disability

8.3 Risk formulation

The Royal College of Psychiatrists’ report Assessment and Management of Risk to Others (RCPsych, 2016) outlines that risk formulation encapsulates an understanding of personality, mental state, environment, potential causes, protective factors and any corresponding changes to these. Aim to answer the following questions:

How serious is the risk?

How immediate is the risk?

Is the risk specific or general?

How volatile is the risk?

What are the signs of increasing risk?

Which specific treatment and/or management plan can reduce the risk?

Risk and confidentiality

When assessing risk, consent to risk assessment should be sought and an explanation of the risks and benefits of the process given. Patients should be made aware of confidentiality and the situations when information may be shared without their consent.

The General Medical Council (GMC, 2017) outlines four situations when information can be disclosed:

The patient has given consent

The disclosure is of overall benefit to a patient who lacks the capacity to consent

The disclosure is required by law

The disclosure can be justified in the public interest

8.4 Managing potential aggression and violence

The risk of aggression and violence should be considered in the assessment of any patient and all professionals should take adequate steps to reduce the risks and remain aware of signs of aggression or frustration. Hospital, patient and staff variables can all contribute to aggression, therefore each of these will be addressed in turn. It must be stressed that in numerous studies no clear definitive indicator has been proven to predict the risks and therefore a global approach aiming to reduce risk across multiple domains should be advocated.

Hospital variables

It is essential that the environment for the patient assessment is appropriate.

Steps to reduce risk should be taken, including:

All interview rooms should have a panic alarm system and multiple doors allowing access and exits

Items that could be used as potential weapons should not be available

Steps should be taken to ensure that patients are not interviewed on overlooked corridors or in ill‐lit areas

The interviewer must always alert another professional about their whereabouts and a system must be in place to ensure that someone can be contacted immediately

If a patient is intoxicated or under the influence of substances steps should be taken to allow both the patient and attending staff to be kept safe until such a time as an interview is possible

The patient should be asked about possessing either weapons or substances on their person

Steps to improve engagement and rapport should also be taken:

The patient should be interviewed in an appropriate setting with adequate privacy

The patient should be orientated as to where there are, why they are there and who they are talking to. The patient should also be aware of who to contact to be able to obtain further information

The patient should not be made to feel overwhelmed or trapped

Provision should be made for breaks, food and fluids

Waiting times should be addressed. If there is a delay then clear communication of the expected wait must be made

Patient variables

Certain characteristics amongst patients and their experiences indicate a higher risk of violence and aggression. If possible, these should be identified prior to interview from records, collateral history and other professional sources and assessed. If collateral history cannot be obtained issues should be explored tactfully during the consultation.

Assessment should include a patient’s narrative of their own risk. The patient’s agenda and needs are listened to and as far as possible addressed

Gender: men are more likely than women to commit violence with a higher possibility of this resulting in the victim requiring medical treatment and the arrest of the perpetrator

Age: young patients are more likely to be aggressive. However, a subgroup of elderly patients with organic disorders (dementia, delirium) are also at higher risk of committing physical violence to others

Previous violence: previous violence is a predictor of future violence; therefore the patient’s forensic history should be checked prior to assessment with collateral information obtained if possible

Childhood experiences: abuse as a child (physical or neglect) is an indicator of future violence. Furthermore, a parental figure who misused substances or has a forensic history increases the risk of a child perpetrating violence in the future

Diagnosis: a substance misuse diagnosis is strongly indicative of a risk of aggression and violence. A personality disorder diagnosis carries a higher risk of violence than a diagnosis of schizophrenia

Psychopathy: a diagnosis of antisocial personality disorder is strongly indicative of a risk of violence

Delusions: the presence of delusions alone are not predictive of violence. However, if the content of those delusions are persecutory the risk of aggression increases

Hallucinations: specific command hallucinations instructing a violent act are associated with increased risk of violence

Thoughts: ruminating on persistent violent thoughts increased the risk of aggression

Anger: the more anger displayed by the patient, the higher the risk of violence towards others

Staff variables

Staff must be alert to the early risk signs of aggression

Staff should be appropriately trained in de‐escalation

Staff who are rigid and authoritarian in their manner are at increased risk of violence. Furthermore, staff who expect violence are found to be at higher risk

Junior staff must have the support of seniors, and should not be left to deal with escalating situations alone (care assistants and student nurses are found to be those most assaulted in studies)

Reduced staff turnover improves the relationship between staff and patients

Handover and meal times are noted to have higher levels of violent incidents

8.5 Assessment, prevention and management of risk

Assessment

A risk assessment should be carried out including a review of the patient’s history, forensic history, the characteristics of the current admission and the current mental state of the patient. McAllister and Patel (2012) define risk assessment as ‘the systematic collection of information from all sources to estimate the degree to which harm (to self or others) is likely at some point in time’. It is a dynamic process and can change at any time.

Within the structured approach (see Chapter 1), risk should be a consideration at all stages, with risk assessment a key component of the unified assessment and handover segments.

As outlined in Chapter 2, the person who is acutely disturbed should have a primary assessment that is designed to identify and manage any immediate risk to safety. This involves an AEIO Unified assessment alongside (where appropriate) a rapid assessment of airway, breathing, circulation, disability (neurological status) and exposure – ABCD. A full discussion of this approach is covered in Chapter 2.

Prevention

Preventing the escalation of risk can be divided into three stages: primary prevention, secondary prevention and tertiary prevention (Figure 8.1).

Primary prevention

This involves identifying and controlling (as far as possible) the hospital variables, patient variables and staff variables outlined earlier.

Figure 8.1 Assessment and prevention

Secondary prevention

This involves employing measures at the ‘pre‐violent stage’. At this stage aggression is increasing and the patient is potentially at higher risk of violence. Variables outlined in primary intervention may no longer be able to be addressed.

Early recognition of this escalation and prompt de‐escalation are essential.

Agitation can escalate at any time due to patient, staff and environmental factors.

De‐escalation

The most effective use of de‐escalation is the completion of pre‐emptive steps prior to and during the interview so that agitation is minimised. The skilled practitioner will be aware of factors that may contribute to escalation, with the emphasis on risk reduction.

If agitation does increase despite initial attempts at reducing risk, then the principle of a non‐coercive approach should be at the forefront of any actions taken and the competent practitioner will be ready to step back and utilise de‐escalation techniques.

Putting together a composed interview requires the environment to be considered, the behaviour of all parties to be continuously monitored and assessed (Box 8.3), and a verbal approach that is engaged and collaborative (Box 8.4).

Box 8.3 Behavioural and environmental approach to de‐escalation

Use a room that is well lit, quiet, offers a calm environment and that is not isolated. If a suitable room is not available use a well‐lit, open space

Intense triggers should be removed or reduced (this may include other people)

Panic alarms, personal alarms and security contacts should be accessible

A protocol should be available outlining how to deal with the aggressive client, with a code of conduct and a code of violence

When approaching the patient maintain an appropriate distance, do not approach from behind or in a perceived aggressive or authoritarian manner

Body language and posture is important. Do not stand over the client or adopt an aggressive stance. Maintain a neutral facial expression, mirror the patient’s posture and maintain intermittent (non‐staring) eye contact

Offer information to both the patient and relatives

Box 8.4 Verbal approach to de‐escalation

Introduce yourself clearly, explaining why you are present. Ask the patient why they are there and their aims and intentions. Outline your own objectives, emphasise the positive but do not hide potential difficulties

Help the patient to orientate to the situation. Clocks, newspapers and media can be used to aid this process

Use easy words, short sentences and a calm manner

Establish limits, for example the possible duration of the interview

Set limits of acceptable behaviour and explain these ‘ground rules’ in advance. Explain that violence is not acceptable

Use active listening, summarise and reflect back what the patient is saying

Involve the patient in a collaborative dialogue with shared problem solving

Encourage the expression of feelings and emotions

Discourage acting out and importantly do not be drawn into punitive reactions

When communicating a decision explain clearly and simply with space for reflection and questions. Be optimistic and provide hope

Return to patient and staff goals and assess if they have been addressed

Price and Baker (2012) noted certain skills when de‐escalation is successful: staff are perceived to be open, honest, supportive, self‐aware and non‐judgemental. They can maintain self‐control even in situations of high anxiety (allowing the patient to feel secure), and they are aware of verbal and non‐verbal cues.

If de‐escalation is required first consider verbal de‐escalation.

Richmond et al. (2012) outline a number of reasons why verbal de‐escalation should be considered prior to the use of medication or physical restraint:

If staff members utilise physical restraint it may reinforce to both patient and staff that force or violence is a necessary step to resolve agitation

Patients physically restrained are more likely to be admitted to a psychiatric ward and have, on average, longer periods of in‐patient stay

If verbal de‐escalation is utilised then patients and staff are less likely to be harmed

At the point of de‐escalation the practitioner should allow themselves to step back from the interview. This can be done either metaphorically during the interview or by having a physical ‘time out’ for all parties.

Firstly, the practitioner should attempt to identify if any part of their interview style is contributing to the escalation. Medical interviews can sometimes take on paternal or domineering tone. If recognised this can be addressed by asking the patient again for their views or goals, directing the interview back to a collaborative approach.

Secondly, goals for all parties should be regularly addressed throughout the interview. A patient may be becoming agitated if they feel they are not receiving an outcome to their reason for attending the ED. Equally, the interviewer may become terse or display less empathy if they are worried about time pressure or the call of their bleep. A relative may feel they are being prevented from either returning home or to work.

Thirdly, instead of viewing a patient as ‘difficult’ or ‘uncooperative’, staff should utilise a degree of empathy and recognise they may be doing as well as possible under the circumstances and their behaviour is a reinforced response to previous difficult ED encounters. If recognised, this will reduce the chances of this situation playing out in the same negative way as previous interviews.

Fourthly, patients should be offered alternatives to aggression or violence allowing them to ‘save face’. If a patient’s normal reaction to stress is aggression they should be praised, and shown a degree of respect, for remaining non‐violent, allowing positive reinforcement of an alternative behaviour and reducing the perceived threat of lost dignity (Gertz, 1980).

When using verbal de‐escalation, it is better to approach it as a loop, rather than a straight line. It may be necessary to return to basic principles at many points during the interview, for example checking the patient is aware of exactly who you are and why you are present, re‐establishing goals and reinforcing orientation (important if the patient has been waiting for a number of hours).

Tertiary prevention

Tertiary approaches involve planning for, and management of, violence

If the patient remains aggressive despite attempts at de‐escalation and communication then alternative approaches may be necessary.

If a patient with a mental health problem becomes aggressive or violent, do not exclude them from the ED

Within the ED attempt not to use seclusion

Physical intervention

An unwell patient may require the presence of security to protect themselves and others

Any manual restraint should be undertaken by staff who work together closely as a team with an understanding of roles and clearly defined team lead:

Manual restraint should never be used that interferes with a patient’s airway, breathing or circulation

Alternatives to manual restraint should be considered regarding pharmacological medication

A well member of the public who becomes violent or agitated can be excluded from the ED and the police contacted

Pharmacological intervention

Medication can be offered in an oral form to an agitated patient to help calm anxiety and prevent escalation to physical intervention:

A small dose of a benzodiazepine can be offered orally

Any use of intramuscular medication needs to take into account:

Alternative methods of de‐escalation

Coexisting physical issues

Patient’s advance wishes and directives

Current use of medication or substances

Previous reaction to medication

Rapid tranquillisation is dealt with in the Appendix 8.1 at the end of this chapter.

After use of a restrictive intervention, a post‐incident debrief should ideally be conducted and this should involve multidisciplinary staff, including security.

Factors leading to the incident should be investigated

The current status of the incident should be addressed

Plans should be made to reduce the chance of a similar incident occurring in the future and strategies to maintain reduced aggression should be formulated

The patient should be given an opportunity to discuss the incident

Necessary documentation should be completed

8.6 Case examples

Case 8.1
Gemma, a 26‐year‐old woman, is brought to the ED by her husband. She had given birth to a boy 7 days ago via a difficult, painful, forceps delivery. She is currently presenting in the department as highly agitated and dressed in mismatched clothing. When approached by staff (especially females) she is abusive and not making any sense. Her husband states he is now exhausted trying to look after his wife and child. She states she has to leave the department to carry out God’s work.
Photo of Gemma, a 26-year-old woman, who is brought to the ED by her husband after she had given birth to a boy 7 days ago via a difficult, painful, and forceps delivery.

Primary assessment
ABCD
A – Maintaining own airway
B – RR 20, oxygen saturations 96%
C – HR 98 bpm, BP 120/80
D – No neurological deficit, PERLA, apyrexial
AEIO
A – Agitated, irritable and delusional thoughts. Risk to others including specifically her own infant
E – In mental health room
I – Wishes to leave but not actively attempting to do so
O – No dangerous objects

Unified assessment and immediate treatment
Physical health – infection and other physical complications need to be excluded
Mental health – consider capacity, immediate medication, whether observations are needed (or security) and a contingency plan for treatment of a new mother who is also an agitated patient
Both – agree on preliminary diagnosis of puerperal psychosis and the importance of considering safeguarding issues for child

Secondary assessment

Focused physical history and secondary examination
Physical health – assessed by on‐call obstetrician and no acute concerns identified on examination. Blood tests, urinalysis and swabs later returned as within normal limits

Focused conversational psychosocial history and mental state examination (MSE)
Although initially bonding well in the first 24 hours postpartum, over the following 3 days the patient has become withdrawn and isolated, not sleeping, leaving most of the childcare to her husband and telling him he is the better parent. However in the last 48 hours her presentation has seriously worried her partner as she is now agitated, irritable and stating bizarre beliefs that she has been chosen by God as an instrument to tell mothers around the UK how to give birth. Her husband has had to stop her leaving the house semi‐naked on two occasions. She tried to take her child on one occasion saying ‘he is the instrument to show’
MSE
A – Wearing mismatched clothing; tired and dishevelled
B – Bizarre and unpredictable
C – Lacks capacity
S – Intermittent, high volume speech
M – Agitated and threatening to leave
I – No insight
T – Delusional religious beliefs
H – None admitted to but seems to be reacting to unheard voices

Disposal
The patient requires immediate treatment for her severe mental illness. She will need security (one to one) in the department and plans for a Mental Health Act assessment. Consideration should be made for admission to a mother and baby unit. Medications should be considered to help immediately calm her distress and to treat her. Involvement of perinatal psychiatry is essential as well as discussions with her mental health midwife and health visitor. A discussion should take place about safeguarding

Reassess risks
The overall risk profile in this case is high to both client and child as this patient has a likely puerperal psychosis which may involve delusional beliefs about her son. There is a high risk of harm to either the client or child via direct or indirect means

Handover
Summarise presentation, key findings and current treatment plan using SBAR

Case 8.2
A 29‐year‐old man, Kieran, presents to the ED. He is demanding that he is given a prescription of methadone. He tells reception that he received his usual dose of 40 mg methadone yesterday but the chemist was shut today and then he lost his prescription. Reception tell him he will have to wait to be seen at which point he becomes quite abusive telling her that he feels like he is going to die and can’t stop sweating and shaking.

Primary assessment
ABCD
A – Maintaining own airway
B – RR 22, oxygen saturations 95%
C – HR 105 bpm, BP 130/09
D – No neurological deficit, pupils moderately dilated, apyrexial
AEIO
A – Becoming agitated when he has to wait
E – In the ED waiting room
I – Not expressing intent to self‐harm. Threatening to leave if he is not seen quickly
O – Has not been searched

Unified assessment and immediate treatment
Physical health – judged not to be immediately withdrawing. Can wait for assessment by clinician

Mental health – judged to be angry but not an immediate risk to self or others

This patient requires de‐escalation of anger and aggression

Secondary assessment

Focused physical history and secondary examination
Known drug dependence on methadone support. Physically patient is presenting with early signs of drug withdrawal consistent with missed dose of methadone. Demanding immediate dose of opiate to overcome withdrawal

Plan to confirm previous dose and dispensing history with named pharmacy and to re‐establish current regime. In the meantime he can be given symptomatic medication

Focused conversational psychosocial history and mental state examination
Known to community drug services and confirmed as being on a methadone support programme after years of intravenous heroin use. Presents as angry and demanding without thought for others

MSE
A – Normal
B – Angry and demanding
C – Has capacity
S – Normal
M – Agitated
I – Has insight
T – Normal
H – None

Disposal
Arrange immediate support for his drug withdrawal with a plan for ongoing community biopsychosocial support for his dependency

8.7 Summary

Aggression and violence can be anticipated in any hospital situation, from any source (patient, professional, staff or family). Therefore all staff working in a hospital should have an awareness of this risk.

Each hospital should have a protocol to allow staff to assess aggression and violence in a structured clinical judgement approach. Assessment is meaningless unless there are clear instructions for action and management.

Risk cannot be eliminated, and this is not a desirable aim of any protocol as it may lead to inflexible and rigid practice. Responsible clinical risk taking (weighing up potential benefits and harms) should be encouraged.

Primary intervention can focus on the environment, patient and staff to attempt to identify areas at risk of violence and implement means to reduce and prevent this.

Secondary intervention can focus on de‐escalating a potentially aggressive situation via communication skills (verbal and non‐verbal), education and training. Effective communication is an essential part of any risk management plan.

Tertiary intervention can focus on the management of the aggressive patient including physical and pharmacological means. This should also incorporate a reflection and debriefing stage for both patient and staff.

Appendix 8.1 Rapid tranquillisation

What is rapid tranquillisation and when should it be used?

Rapid tranquillisation refers to the use of medication in patients presenting with agitated, disturbed and potentially dangerous behaviour in order to calm the patient and prevent injury to themselves or others. Rapid tranquillisation is used when both psychological techniques and environmental management have failed to be effective. It is important to note that, while the term rapid tranquillisation conjures up picture of restrained patients being given intramuscular injections, where possible all medication should be offered orally first and should be given with the patient’s consent.

The guide here applies to adult patients. There are certain patient groups where particular care must be taken. These include the elderly, frail patients, those patients with coexisting physical illness or who are intoxicated, pregnant women and those with learning disability. Physical illnesses that are most relevant include: head injuries, hypoglycaemia, drug overdose or respiratory failure (where tolerance may be reduced and signs of toxicity missed) and liver failure (where metabolism is reduced). In all such cases there are many variables which would alter the choice and dose of medication as well as the post tranquillisation monitoring regime.

Before prescribing medication for rapid tranquillisation you should consider where the patient will be placed for monitoring of both mental and physical health as well as the frequency of this monitoring. You should ensure that there are adequate resuscitation facilities. As most of the drugs that are used are short acting you will need to plan how the patient will be managed in the longer term. This may include prescribing regular medication and moving the patient to a more appropriate setting. It is also wise to plan for the possibility that the patient may require restraint or further sedation, and to make sure that staff are available should this be required.

It is vital that at all times the patient’s dignity is respected. Even if the patient appears not to be able to take in information an explanation of what is happening should be given throughout. Afterwards, when the patient is calm, it is often helpful for a member of staff to talk through what has happened with the patient.

As far as possible it is important to take into account the wishes of the patient when prescribing. If there is an advance directive or clear preference for a particular medication expressed by the patient then use this if it is safe to do so and it is appropriate to the situation. Rapid tranquillisation can be given when justified using the legal frameworks surrounding capacity, common law and the power to provide medical treatment in particular circumstances. In situations where patients lack capacity to make decisions themselves, it is the duty of all doctors to be competent to assess whether patients have capacity in regard to this particular important decision. Although this is not the place to describe these terms in detail, it is worth pointing out that doctors should assess and record a patient’s capacity at this point and indicate how they are acting in the patient’s best interests if this is the case.

Note that if the patient is likely to need further regular medication such as antipsychotics to manage their psychiatric condition, and they are not consenting to this, then they will need assessment and detention under legal powers before this can be administered. On the other hand, when patients retain capacity and are not detained using legal powers then rapid tranquillisation may be appropriate but can only be given with their consent.

Prescribing for rapid tranquillisation

Some years ago common practice in rapid tranquillisation was the intramuscular administration of both haloperidol (5 mg) and lorazepam (2 mg), even in neuroleptic naïve patients. This often resulted in oversedation, extrapyramidal side effects and even sudden death. Nowadays the aim of rapid tranquillisation is not to ‘flatten’ the patient but to mildly sedate (in fact, tranquillise) them to a state where they are calmer, more reasonable and less distressed. If a patient requires IM medication as they are refusing oral it is always worth taking both the injection and the tablets to the patient as many, when faced with the reality that one or the other is going to be given, will agree to take the medication orally despite the cognitive difficulties they are experiencing. If an injection is required, always ensure that you expose the injection site rather than injecting through clothing – there have been many occasions where the restraining staff have been accidentally injected rather than the patient.

It is recommended that lorazepam is used initially, and this should be used alone where:

There is limited information about the patient

The patient is antipsychotic naïve

The patient suffers from cardiovascular disease and/or prolonged QT

No electrocardiogram (ECG) has been completed

If there is a partial response then consider a further dose of lorazepam. Lorazepam reaches maximum plasma concentration in 60–90 minutes and has a plasma half‐life of 12–16 hours. It is recommended to wait at least 30 minutes before repeating either IM or oral doses. In patients taking valproate, plasma concentrations may be raised and there may be reduced clearance so dosage should be reduced by 50% (especially if repeated). Caution should also be exercised in patients on clozapine who may become rapidly oversedated and hypotensive. In adults, paradoxical reactions of excitement are rare but do occur especially in the elderly.

If lorazepam is ineffective then the use of IM haloperidol combined with IM promethazine should be considered. Although this combination of medication is in the National Institute for Health and Care Excellence (NICE) guidance it should be noted that in the TREC trials in Brazil and India, where this combination was compared to various benzodiazepines or antipsychotics, the primary outcomes were sleep or tranquillisation. Haloperidol and promethazine were slightly more efficacious (number needed to treat = 6) and had fewer dystonic effects than haloperidol alone and were approximately as efficacious as other alternatives, but required less frequent further injection than lorazepam or olanzapine. In theory, haloperidol will reduce levels of arousal due to α‐adrenoreceptor blockade and has a tranquillising and antipsychotic effect due to dopamine blockade. The promethazine (used off licence) is sedating and may reduce the chance of a dystonic reaction due to its antimuscarinic effects.

If there is only a partial response to the initial dose then you may wish to consider a further dose after an hour. If after lorazepam the patient is calmer but is still presenting with psychotic symptoms and is willing to take oral medication, then consider either an extra stat dose of their usual medication or, if you require a medication with rapid onset or the patient is not on a regular antipsychotic, consider risperidone liquid or oro‐dispersible quicklets. Olanzapine, asenapine, aripiprazole and risperidone all have oro‐dispersible formulations; the generic ones may well not disperse in the same way as the branded versions. When considering doses you need to take into account any regular antipsychotic that the patient is taking, previous reactions to antipsychotics, age, others substances consumed and medication interactions. If the patient is neuroleptic naïve, elderly or has a learning disability, you would need to start at a low dose, e.g. a half dose as a rule of thumb.

Adverse effects and monitoring

Following the administration of IM medication all patients should be monitored regularly until such time that the level of consciousness is stable, blood pressure, respiratory rate and pulse are normal, and the patient is complaining of no severe adverse effects such as dizziness on standing or dystonia.

The following should be monitored:

Pulse

Blood pressure

Respiratory rate

Temperature

Level of hydration

Level of consciousness

Monitoring should occur at least every hour until there are no further concerns about the service user’s physical health status.

Check the above every 15 minutes (more frequently, if deemed necessary) if the British National Formulary maximum dose has been exceeded or the patient appears to be asleep or sedated, has taken illicit drugs or alcohol, has a pre‐existing physical health problem, has experienced any harm as a result of any restrictive intervention, or is high risk, such as in pregnancy or elderly patients.

Benzodiazepines can cause respiratory depression. If necessary, the agonist flumazenil can reverse the effects but is contraindicated in those with a history of seizures or benzodiazepine dependence. If the respiratory rate falls below 10/min after the administration of a benzodiazepine, administer initially flumazenil 200 mcg IV over 15 seconds; if an improved level of consciousness is not achieved after 60 seconds then subsequent doses of 100 mcg every 60 seconds can be given up to a maximum of 1 mg in 24 hours. Flumazenil has a relatively short half‐life.

Prior to the administration of haloperidol patients must have had a recent, normal ECG to exclude pre‐existing prolonged QTc, due to the risk of haloperidol prolonging QTc and/or sudden cardiac death due to torsades des pointes (without an ECG the drug is being used off licence). Sudden cardiac death can occur without the increased risk due to pre‐existing QTc prolongation: the groups at risk of long QTc seem broadly the same as those at risk of torsades for other reasons. These include older patients, females, those with electrolyte disturbances, pre‐existing cardiac conditions, intoxicated with illicit drugs such as amphetamine and cocaine, or alcohol or after self‐poisoning and those already taking cardiotoxic medications, including many of the psychotropic medications and especially in combination. Abnormal electrolytes will also increase the risk of cardiac arrhythmias, even with a normal ECG, so if this is suspected then also check blood electrolytes (including Mg²⁺).

There will, of course, be occasions where it is impossible to obtain an ECG or blood investigations or when the patient has risk factors. In these situations, you will need to balance the risks of tranquillisation with the risks of continuing to suffer a disturbed and agitated state that may prevent appropriate treatment for the underlying cause or lead the patient to act violently and recklessly. Junior doctors should obtain senior advice. Ensure that you document fully the reasons for your decision either to administer or not to administer medication and ensure that an appropriate monitoring plan is in place and that resuscitation equipment is available. There are alternative IM antipsychotic medications available but these are rarely available outside psychiatric facilities.

All antipsychotic medications reduce the seizure threshold to varying degrees. There are also low risks of severe reactions like neuroleptic malignant syndrome. Some antipsychotics can drop blood pressure substantially more than others. Again, first generation antipsychotics are more likely to cause dystonias or Parkinsonian effects (hence the adjuvant use of drugs such as promethazine or procyclidine with antimuscarinic effects). Haloperidol, risperidone and (to a lesser extent) olanzapine can cause akathisia which might be hard to distinguish from continued agitation in too high doses. Olanzapine IM can cause potentially fatal respiratory depression if given at or around the same time as IM lorazepam.

Pregnancy

During pregnancy you need to consider carefully both risks to the mother and foetus. During any restraint the standard procedures will need to be modified to avoid harm to the foetus. There will need to be close collaboration with the obstetric team and, in later pregnancy, the paediatric team. When choosing medication (both antipsychotic and benzodiazepine), drugs with a short half‐life are likely to be preferable. The minimum effective dose should be used. No antipsychotic or benzodiazepine is classed as ‘safe’ during pregnancy. When used close to the birth of the infant, then benzodiazepines may cause ‘floppy baby syndrome’ and antipsychotics may cause neonatal extrapyramidal symptoms. When rapid tranquillisation is used, then the obstetric team should be involved to assess what foetal monitoring will be required.

Other approaches

A range of other agents have been suggested for rapid tranquillisation, e.g. oral antipsychotics (especially sedative ones such as quetiapine, chlorpromazine or sublingual asenapine) or other benzodiazepines given buccally (midazolam), orally or intramuscularly. Asenapine is notable in being somewhat sedative, tranquillising and having a very high first pass metabolism (96%) unless delivered parenterally. Other medications that can be injected intramuscularly include aripiprazole, olanzapine and zuclopenthixol decanoate. Aripiprazole is relatively unlikely to cause cardiac arrhythmias, catastrophic hypotension or extrapyramidal effects, but as a partial dopamine and 5‐hydroxytryptamine 1A (5HT1A) agonist can cause agitation and nausea and often requires additional benzodiazepines or other sedatives for sleep later. Olanzapine IM injection (not the long‐acting palmitate derivative) can cause severe respiratory depression with lorazepam and has some potential for hypotension. Zuclopenthixol decanoate (Acuphase) is not a rapid tranquillisation agent: its peak levels are hours after injection and its effect continues for days.

Loxapine is an antipsychotic delivered as a nasal spray, which is little used in the UK, or as an injection, which is unlicensed in the EU.

Refractory agitation is a difficult and often dangerous situation requiring specialist skills from the multidisciplinary team. A range of the above techniques can be used, as well as rarities like paraldehyde IM, IV barbiturates or, more realistically, IV midazolam.

Medication regimes

Titrate doses where possible (start doses for the elderly may need to be very low).

Use combinations of drugs rationally to treat target symptoms

Use the safest routes of administration

Institute a regime of treatment following rapid tranquillisation (Table 8.1)

The manufacturers of IM olanzapine advise NOT to give intramuscular lorazepam within 1 hour of intramuscular olanzapine. The maximum combined oral and IM daily dose is 20 mg. A minimum of 2 hours should elapse between the first and second injections of IM olanzapine, with a maximum of three injections daily for 3 days.

Table 8.1 Recommended drugs and doses in adults (elderly or debilitated should be started on lower minimum doses)

Single dose
Peak
24 hour maximum
(total dose of oral and IM)

Antipsychotic (oral)

Haloperidol*
2–10 mg
3–6 hours
20 mg

Olanzapine
5–20 mg
5–8 hours
20 mg

Risperidone
2–4 mg
1–2 hours
16 mg

Parenteral (intramuscular)

Haloperidol
2–5 mg
<1 hour
12 mg

Olanzapine
5–10 mg
<1 hour
20 mg

Aripiprazole
5.25–15 mg
<1 hour
30 mg

Benzodiazepines (oral and intramuscular)

Lorazepam
1–2 mg (4 mg exceptionally)
2 hours
4 mg (maximum daily dose can increase up to 12 mg if deemed clinically necessary)

* Haloperidol should be prescribed with an anticholinergic drug (procyclidine 5 mg bid initially to a maximum of 10 mg tds), except in the elderly if anticholinergic effects are considered to be a greater risk than extrapyramidal symptoms or where they are contraindicated.

Summary

In the context of psychological de‐escalation and engagement techniques it may be necessary to prescribe medication intended to rapidly produce a state of tranquilllity and mild sedation. This reduces the risk of inadvertent harm, violence or inability to cooperate with vital assessment and treatment. This should be with consent where meaningful and should be explained and negotiated as far as possible in any case.

Rapid tranquillisation may be administered orally – this can have almost as rapid an onset of action as an IM injection and is less likely to cause antagonism, indignity and toxicity. If this is impossible, then a sequence of 1–2 mg lorazepam, repeated if necessary, then haloperidol (e.g. 2.5 or 5 mg IM) and promethazine (e.g. 25–50 mg IM) should be used (Figure 8.2). If possible, haloperidol should be preceded by a recent ECG and perhaps electrolytes. A range of other agents is available that may be more appropriate in certain circumstances.

Figure 8.2 Rapid tranquillisation

CHAPTER 9
Legal aspects of emergency psychiatry

Learning outcomes

After reading this chapter, you will be able to:

List the major legal issues that arise in the assessment and management of psychiatric emergencies

Describe the key components of each relevant legal issue

Know where to find a more detailed and specific description of the legal frameworks in the jurisdiction where you work

Identify the principles of maintaining patient confidentiality and the legal context

Describe the importance of accurate and robust clinical documentation

9.1 Introduction

This chapter outlines the principles involved in the law as it pertains to psychiatric emergencies. The specifics of the legal frameworks for particular jurisdictions are available online at www.alsg.org/legal if the APEx course is delivered in that jurisdiction. If the course is not delivered in the jurisdiction in which you work, then other summaries of the relevant law as it relates to the issues outlined in this chapter should be sought.

The following sections outline the issues that are important when assessing and treating patients with a recognised mental disorder who are at risk to themselves or others.

9.2 Determining mental capacity

Mental capacity is a term that describes an individual’s capability to make their own choices and decisions. Laws in different jurisdictions may vary but the general principles are that an individual has capacity to decide if they are capable of:

Understanding the information relating to a particular decision (including risks and benefits)

Retaining that information long enough to make a decision

Weighing up the information involved in making a decision

Communicating their decision

Understanding decisions

Retaining the memory of decisions

If there is any doubt about whether the individual lacks capacity then an urgent second opinion should be sought. If doubt still remains, then an assumption should be made that they do have capacity and proceed on that basis. This means taking all reasonable steps to help them make their own decision.

The law may make a distinction between those who lack capacity as a result of a defect of mind and those who lack capacity as a result of a mental illness.

The flowchart shown in Figure 9.1 outlines the key steps at this point in your decision making.

Figure 9.1 The approach to a patient who refuses treatment or care

9.3 Treating a patient who does not have mental capacity

If you determine that someone lacks the capacity to decide about their treatment then the law may give you the opportunity to consider their best interests and act on this basis. Deciding on their best interests should lead you to consider:

Whether the decision can wait until they regain capacity

What the person has wanted in the past, and their relevant values and beliefs

What their family and close friends say

If you can involve the incapacitated person in the decision making

The flowchart shown in Figure 9.2 outlines the key steps at this point in your decision making.

Deprivation of liberty

In many jurisdictions a person’s freedom of movement cannot be limited without a court order, even if they lack capacity. In others, restrictions on movement can be authorised by other statutory organisations such as a local authority or a healthcare provider. Such restrictions are often limited in time and place.

Figure 9.2 The patient who refuses treatment or care and does not have capacity

Advance decisions and mental health

Some jurisdictions allow advance decisions to be made. An advance decision is a statement of directions about what medical and healthcare treatment a patient wants to allow or refuse at a future time and the circumstances in which the decision will apply. Advance decisions may be stored with the patient’s medical record and should be referred to if the patient has lost the capacity to make these decisions. The advance decisions must be made when the patient has capacity and should be witnessed and signed. The patient must be an adult when making the advance decision.

Doctors may be able to override the advance decision if the patient is detained under mental health law, but this may only be for certain treatments, or where it is necessary to save life or prevent serious deterioration. Advance decisions about physical health treatments may remain valid even if the patient is detained under the law.

An advance statement is not a legal document but it provides information from the patient about their preferences on many matters, for example who to contact if they become unwell, who they would like to be kept informed, and their preferences for treatment and medication. It does not have to be witnessed. You should take this into account when treating the patient, but it can be overridden, for example, if there is a risk to the patient or others.

In the case of advance decisions and advance statements, if the patient has named an attorney under the law, and given them the power to make the same decisions or refusals, then they will make the decisions or refusals on the patient’s behalf.

Detention for personal or public safety whilst in the community

If a person in the community is suspected of having a mental disorder and is thought to be in need of immediate care or treatment, or is thought to represent a risk to the safety of themselves or others, then it may be possible for them to be detained immediately under mental health laws. These powers may sit with the police (as powers of a police officer), with community health or mental health staff or with others. Generally these powers will be powers of detention and will be limited in time and place (particularly making a distinction between a public and private space) and will be limited in what they allow to happen.

Following emergency detention it will be specified what further legal routes may need to be pursued for ongoing detention (see following).

Stopping someone with a known or suspected mental health condition who is at risk of harm to self or others leaving the emergency department

The law will indicate whether or not you can take immediate steps to prevent someone lacking capacity leaving prior to a full assessment. Generally any powers that are granted will be given to particular professionals, will be limited in time and must be proportionate.

If you think that the patient has a mental disorder and that their decision making is impaired because of this, that they need urgent investigations and treatment and/or they are a risk to themselves or others, then you will need to pursue legal routes to detain them in the department if they still wish to leave. These legal routes differ in each jurisdiction and it is important to understand what actions you are able to take with each of these.

Sometimes, in an emergency situation, there is not enough time to seek judicial review. The law will be clear about who is empowered to prevent someone suspected of having severe mental illness from leaving before assessment, about how much force (if any) is allowed and about how long someone can be detained without formal assessment under mental health law.

Detention for diagnosis of psychiatric conditions in the emergency department under mental health laws

Although the law differs in different jurisdictions, emergency detention routes may only allow for assessment to decide if treatment is needed for a mental disorder. The patient would still need to consent to any treatment. If they patient refuses consent then other detention routes should be considered.

Detention for treatment of psychiatric conditions in the emergency department under mental health laws

If treatment of the psychiatric condition is considered necessary and the patient refuses the treatment, then each jurisdiction will have detention options that permit the patient to be treated with or without their consent. Patients will have a right of appeal.

Detention for diagnosis of psychiatric conditions on the wards under mental health laws

There are generally legal powers that allow detention for diagnosis and, if necessary, treatment of psychiatric patients. These are different from the emergency powers. They may be differentiated by whether the patient has ever been assessed in hospital, has not been assessed in hospital for some time or if they are well known to mental health teams and therefore further assessment is not required. Patients detained in this way will usually have the right to appeal.

Physical treatment of a patient detained under mental health laws

The law may differ in the area of consent depending on whether the proposed treatment is for mental or physical health needs. Laws under mental health acts often only apply to treatment for mental disorder. They may not apply to the treatment of physical disorders unless it is reasonable to say that the physical disorder is a symptom or an underlying cause of a mental disorder.

As previously mentioned, in some jurisdictions doctors and nurses have the right to use holding powers where treatment for either a psychiatric or physical condition is deemed necessary and when a voluntary or informal patient (that is a patient not currently detained under mental health laws) is wishing to leave. Generally, they must show that the patient must be immediately stopped from leaving for their own health or safety or for the protection of others. They must also show that the use of more formal legal routes would not be possible in the timeframe required. It is important to understand how this works within your own jurisdiction to ensure that you take the appropriate steps to work within the law.

9.4 Treating a patient who has mental capacity

The flowchart shown in Figure 9.3 outlines the key steps at this point in your decision making if the patient has mental capacity but refuses treatment.

Figure 9.3 The patient who refuses treatment or care and has capacity

9.5 Consent

In general terms, if a patient has the capacity to consent, then their consent should be obtained prior to providing treatment. This consent should be informed consent and as outlined earlier you will need to assess the capacity of the patient to give this. Check the legal framework in your jurisdiction for details of express, implied or presumed consent and ensure that you fulfil the requirements with regard to obtaining this and documenting it.

Top tip

For consent to be valid:

It must be given voluntarily

There should be no duress

The patient must have capacity

Any information regarding risks, benefits, side effects and alternatives must be presented so that the patient can make an informed decision, and

The patient must be able to communicate their choice

9.6 Confidentiality

All healthcare practitioners have both a professional and a legal duty of confidentiality to their patients.

Guidance and frameworks are produced by relevant professional bodies, employers and data protection legislation.

These apply to all forms of records, not just those stored on computer media.

Consider confidentiality when providing a handover in the emergency department – never verbally present confidential information in the presence of relatives or anyone else without the patient’s consent. Be particularly vigilant when passing information to colleagues via telephone, and remember that a curtain around a hospital bed does not prevent others hearing what is being said either to a patient or to colleagues.

When considering confidentiality, you should:

Take all reasonable steps to keep a patient’s information safe

Obtain the patient’s informed consent if you are passing on their information

Only disclose identifiable information if it is absolutely necessary, and, when it is necessary, only disclose the minimum amount necessary

Tell patients when you have disclosed their information

Source: Adapted from HCPC (2018).

9.7 Documentation

It is important to reinforce the essentialness of accurate and robust clinical documentation. After any patient consultation, which may be either face‐to‐face, over the telephone or even when providing advice to a colleague, a record should be made either in writing or electronically in the patient’s notes. It is also important to make accurate, signed, dated and timed records of discussions about the use of mental health legislation. There may well be particular procedures to follow and forms to be completed. Failure to make accurate records of these matters is not only potentially detrimental to patient care, but may also render any deprivation of liberty illegal.

The most important factor is not when the notes were written, but what was recorded. Always strive to maintain the highest level of clinical documentation, as this supports safe and effective patient care. This is not only a requirement of professional registration, but it may also help in your defence against complaint or allegation of poor practice.

Clinical documentation should:

Be written in a clear, accurate and legible manner

Record whether consent was obtained or not

Detail all clinical findings, decisions made and actions taken

Record the information given to patients

Record any drugs prescribed or other investigation or treatment

Identify whether confidential information has been shared

Always contain details of who is making the record and when

9.8 Summary

The legal and professional frameworks covering consent, capacity, detention, confidentiality and documentation are an essential element in the management of patients. Clinicians should understand the principles of what these can achieve and the detail of the legal and professional frameworks within their own jurisdiction.

CHAPTER 10
Human factors

Learning outcomes

After reading this chapter, you will be able to:

Describe how human factors affect the performance of individuals and teams in the healthcare environment

Describe styles and structures for communication with patients

Describe a structured approach to communicating with colleagues

10.1 Introduction

The emphasis on the management of a psychiatric emergency has traditionally concentrated on the knowledge of the treatment process. An often overlooked element is how in these high‐pressure situations individuals from a variety of different professional and specialty backgrounds come together to form an effective team that works actively to prevent adverse events.

This chapter provides a brief introduction to some of the human factors that can affect the performance of individuals and teams in the healthcare environment. The study of human factors, also referred to as ergonomics, is an established scientific discipline; clinical human factors have been described as:

Enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture and organisation on human behaviour and abilities and application of that knowledge in clinical settings.

(Catchpole, 2010)

10.2 Extent of healthcare error

In 2000 an influential report entitled To Err is Human: Building a Safer Health System (Kohn et al., 2000) suggested that across the United States somewhere between 44 000 to 98 000 deaths each year could be attributed to medical error. A pilot study in the UK demonstrated that approximately one in 10 patients admitted to healthcare experienced an adverse event.

Healthcare has been able to learn from a number of other high‐risk industries including the nuclear, petrochemical, space exploration, military and aviation industries about how team issues have been managed, and these lessons have been slowly adopted and translated to healthcare.

10.3 Causes of healthcare error

Consider this example of an adverse event:

A patient is brought to the emergency department with a self‐inflicted wound. Three hours later the patient is found cyanosed with a neck ligature tied round a coat hook, in one of the assessment rooms. What are the potential causes of this situation? (Table 10.1)

Table 10.1 Potential causes of our example error

Initial assessment delay | The triage nurse was very busy and did not complete a risk assessment
Environmental error | The room used was inappropriately designed with non‐collapsible hooks
Policy error | The emergency department policy did not stipulate that any self‐harm should receive immediate parallel mental health risk assessment
Supervision error | The unit was short staffed and there was no nurse overseeing that area
Assessment error | The emergency department doctor who assessed the patient did not ask any questions about future intent
Equipment error | The ligature cutter was not always kept in the same place, and could not be found
Communication error | None of the individuals involved so far had shared information about risk concerns
Management plan failure | No‐one had written an observation plan for this patient

Q. What one thing links all of these errors?

A. The humans involved – these are all examples of human errors.

No‐one comes to work to harm patients. Humans make mistakes. No amount of checks and procedures will mitigate this fact. In fact, the only way to completely remove human errors is to remove all the humans involved. It is vital therefore that we look to work in a way that, wherever possible, minimises the occurrence of mistakes and ensures that when they do occur this minimises the chance of it resulting in an adverse event.

10.4 Human error

It has been suggested that these human errors can be further categorised into those that occur at the sharp end of care by the treating team and individuals and those at a blunt or organisational level typically through the policies, procedures, staffing and culture.

These errors can be further subdivided as shown in Table 10.2.

Table 10.2 Types of errors

|  | Explanation | Example
Sharp errors that occur with the team/individuals treating the patient | Mistake | Lack or misapplication of knowledge | Not knowing the correct drug to prescribe
Slip or lapse | Skills‐based mistake | Knowing the correct drug but writing another one
Violation | Deliberate action that may be routine or exceptional | Not attempting to get a drug second checked as there is never staff available
Blunt/organisational errors |  | Policies, procedures, infrastructure and building layout that has errors embedded | Different drugs used by different specialities and departments for same condition

It is typically found that the latent/organisational issues often coexist with the sharp errors; in fact it is rare for an isolated error to occur, often there is a chain of events that results in the adverse event. The Swiss cheese model demonstrates how apparently random, unconnected events and organisational decisions can all make errors more likely (Figure 10.1). Conversely, a standardised system with good defences can capture these errors and prevent adverse events.

Figure 10.1 The Swiss cheese model

Each of the slices of Swiss cheese represents barriers which, under ideal circumstances, would prevent or detect the error. The holes represent weaknesses in these barriers; if the holes align, the error passes through undetected.

Reconsider the earlier example using the Swiss cheese model.

The first slice is the hospital’s policies and procedures, and the structural design of the emergency department (ED). The second slice is the staffing levels, and the resourcing of the department. The third slice is the availability of mental health expertise in the department. The fourth slice is the risk assessment skills of the individuals involved. The final slice is compliance oversight of standard procedures, such as where to keep safety equipment.

In this example, there were larger holes in each slice, and some slices were missing altogether. The end result was that multiple defences were weakened or removed and error was more likely, and the error was more likely to cause harm.

It is important to be aware of the different types of error with potential gaps in knowledge, a latent/organisational error (no effective policy and possibly an issue with nurse staffing) and a routine violation.

10.5 Communication

Communicating well with colleagues

Communication failure is the leading cause of adverse events. This is not surprising; to have an effective team there needs to be good communication. The leader needs to communicate with the followers, and followers communicate with leaders and other followers. Communication is not just saying something – it is ensuring that information is accurately passed and received. We all want to ensure effective communication at all times. Remember there are multiple components to effective communication (Table 10.3).

Table 10.3 Elements of communication

Sender | Sender | Transmitted | Receiver | Receiver
Thinks of what to say | Says message | Through air, over phone, via email | Hears it | Thinks about it and acts

When communicating face‐to‐face a lot of the information is transmitted non‐verbally, which can make telephone or email conversations more challenging. Communication can be more difficult when talking across professional, specialty or hierarchal barriers as we do not always talk the same technical language, have the same levels of understanding, or even have a full awareness of the other person’s role.

Psychiatric emergencies are often unfamiliar or frightening – for the patient, other patients in the department and for the staff involved. Whether the situation is a very urgent one, such as rapid tranquillisation, or less immediate, such as the scenario earlier in the chapter, good communication is essential for a positive outcome.

There is a variety of similar tools to aid communication, one such as SBAR (situation, background, assessment and recommendation). Find out what your organisation uses and practise using it; look out for other staff using it too. SBAR is designed for acute clinical communications. It facilitates the sender to plan and organise the message, make it succinct and focused, and provide it in a logical and expected order. It is also an empowerment tool allowing the sender (who may be more junior) to request an action from a more senior individual.

While these tools are useful they tend to be reserved for certain situations where we want to establish effective communication as the routine not the exception. One method to routinely improve communication is to incorporate a feedback loop.

Effective communication with a feedback loop

Errors can occur at any level or multiple levels. Consider the busy clinical situation where the patient has presented following self‐harm, as described earlier. The triage nurse moved the patient into a room, and assumed that the staff in that area would continue the care from there. Whose job was it to ensure communication had happened? Consider how much better the outcome would have been if the following simple communication and feedback loop had occurred:

Triage nurse to supervising nurse: ‘I’ve just put Mr X into the blue room. He is at high risk of further self‐harm, so I think he needs to have someone with him at all times’

Supervising nurse to triage nurse: ‘OK – Mr X is in the blue room. I’ll arrange for him to have someone with him at all times, and I’ll ask the mental health team to assess him straight away’

We now know that the message has been transmitted and received correctly. For this process to work, both parties (the sender and receiver) need to understand and expect it – again demonstrating the need to practise and train together.

Communicating well with patients

In psychiatric emergencies much of the assessment is carried out by communicating with the patient or those accompanying them; there are generally few physical tests to carry out, or signs to elicit. In many cases there will be barriers to communication, such as language, cultural norms or disturbed behaviour. Preconceptions of what is, and is not ‘normal’ may affect the assessment, leading to bias at best, and poor care with prejudice at worst. To avoid these consider the following:

Do:

Seek as much information from those around you as possible, especially before they leave the department

Identify if there is anyone around immediately who can help with communication difficulties

Check available records to see if they supplement the information available

Escalate concerns about communication as soon as possible

Do not:

Pigeonhole patients into characteristic groups

Delay decision making in emergency situations

Overreact – many situations can wait until more information is available, especially when communication is difficult

10.6 Team working, leadership and followership

At a basic level a team is a group of individuals with a common cause. Historically, we have tended to train individually or in professional silos, the risk here is that we are making a ‘team of experts’ rather than an ‘expert team’. Often within healthcare our teams form at short notice and often arrive at different times. Much emphasis has previously been given to the role of the leader, but a leader cannot be a team on their own – as much emphasis should be given to developing the other team members, the active followers. A good leader will be able to swap from the role of leader to follower as more senior staff arrive and agree to take over.

The leader

The leader’s role is multifaceted and includes directing the team, assigning tasks and assessing performance, motivating and encouraging the team to work together, and planning and organising.

All leadership skills and behaviours need to be developed and practised. There are different leadership styles and the leader needs to choose an appropriate style for that situation. Effective communication is key and should be reviewed and reflected upon regularly. Constructive feedback should both be given and sought in order to facilitate continuously improving performance.

Who is the leader?

It is vitally important to have a clearly identified leader. There can be times when people come and go, or different specialties arrive, creating a situation where the leader may not be clear. In some situations or institutions, individuals will wear tabards or other forms of identification to mitigate against this uncertainty. If there is a scribe recording events they should record who is leading and any changes to the leader.

Physical position of the leader

As soon as the leader becomes hands on, and task focused, they are primarily concentrating on the task at hand. This becomes the focus of their thoughts and they lose situation awareness – their objective overview of the situation (see later). The leader should be standing in an optimal position where they can gather all the information and ideally view the patient, the team members, and the monitoring and diagnostic equipment. This enables them to recognise when a member is struggling with a task or procedure and to support them appropriately.

Clear roles

Ideally the team should meet before the event and have the opportunity to introduce each other, and clarify roles and actions in emergencies. Sometimes this can be facilitated at the beginning of a shift but at other times it is impossible to predict or arrange. It is important, therefore, that individuals identify themselves to the leader as they arrive and roles are agreed, allocated and understood. A lot of the time their role may be determined purely in relation to the specific specialty knowledge that the individual possesses, but it is important that team members are flexible, e.g. if three airway providers are first on scene then they would also need to undertake the other necessary tasks.

Followership

The followers have roles that are as important as the leader. Followers are expected to work within their scope of practice and take initiative. It is important to think about the level of communication required between the leader and followers. If it is obvious we are doing a task this does not need to be communicated. There is a risk that followers can overwhelm the leader with verbal communications when, in fact, the key is to communicate concerns or abnormal things. In the Formula One pit lane during a tyre change the crew communicate (visually) as tasks are completed; they also signal if they have a problem – they do not communicate every expected step.

Hierarchy

Within the team there needs to be a hierarchy. This is the power gradient; the leader is at the top of this as the person coordinating, directing and making the decisions. However, this should not be absolute. There is much discussion in the literature about the degree of the hierarchical gradient. If it is too steep the leader has a massive position of power, their decisions are unquestionable and the followers blindly follow their orders. This is not safe because leaders are humans too and also make errors, their team is their safety net.

Safe practice is achieved where the followers feel they can raise concerns or question instructions. This must always be understood by the leaders as much as the followers. One way to reduce the hierarchy is for the leader to invite the team’s thoughts and concerns particularly around patient safety issues. It is also important for the follower to learn how to raise concerns appropriately.

One method that is sometimes used to raise concerns appropriately is PACE (probing, alerting, challenging or declaring an emergency). The probing question allows diplomacy and maintenance of the hierarchy whilst raising a point.

Stage | Level of concern
P Probe | I think you need to know what is happening
A Alert | I think something bad might happen
C Challenge | I know something bad will happen
E Emergency | I will not let it happen

These stages are described, with examples:

Consider the situation below, involving one of the healthcare assistants (HCAs) in the ED who has noticed Mr X in a side room, on his own. How would the patient’s outcome been altered if the HCA carried out the PACE protocol?

| The HCA thinks | The HCA says to the nurse in charge
Probe – this is used where a person notices something they think might be a problem. They verbalise the issue, often as a question | That person seems distressed | ‘Have you noticed that Mr X seems quite upset?’
Alert – the observer strengthens and directs their statement and suggests a course of action | Mr X seems to have found some tubigrip | ‘Mr X has found some tubigrip. I don’t think that room is safe, and I think he needs observation’
Challenge – the situation requires urgent attention. One of the key protagonists needs to be directly engaged. If possible the speaker places themselves into the eye line of the person they wish to communicate with | Mr X is on his own, in an unsafe room, with a ligature | ‘You must go in to see Mr X now – I am worried for his safety’
Emergency – this is used where all else has failed and/or the observer perceives a critical event is about to occur. Where possible a physical signal or physical barrier should be employed together with clear verbalisation | No one is doing anything | ‘I am taking control of this situation. I have asked Bill to sit in with Mr X, until the situation is made safe’

The PACE structure can be commenced at any appropriate level and escalated until a satisfactory response is gained. If an adverse event is imminent then it may be relevant to start at the ‘declaring emergency’ stage, whereas a much lower level of concern may well start at a ‘probing’ question.

Some industries have also additionally adopted organisation‐wide critical phrases that convey the importance of the situation, e.g. ‘I am concerned’, ‘I am uncomfortable’ or ‘I am scared’.

10.7 Situation awareness

A key element of good team working and leadership is to be fully aware of what is happening; this is termed situation awareness. It not only involves seeing what is happening but also captures how this is interpreted and how to understand what is seen, how decisions are made and ultimately to plan ahead.

Typically three levels of situation awareness are described:

Level 1 – What is going on?

Level 2 – So what?

Level 3 – Now what?

Level 1

In psychiatry, what we see and what we hear are the key ways in which we gather information. However, both are prone to significant errors – what we think we saw or heard may not be correct, and our senses may have let us down. Whereas most of us are familiar with popular ‘visual illusions’, fewer know of auditory illusions, particularly when there is a mismatch between visual and auditory signals (for example, the McGurk effect). The risk is that we perceive what is expected to be seen or heard, rather than what is there. Figure 10.2 shows the similar package design of two different medications, making errors more likely.

Figure 10.2 Similar package design of two different medications

It is important to really concentrate on seeing what is actually there.

Distraction

Within healthcare distractions become the norm to such an extent individuals are often not even aware of them. The risk is that mistakes are made and information is missed. It is important to try to challenge interruptions when doing critical tasks and when they do occur to restart the task from the beginning, rather than where it is considered the interruption occurred. In a psychiatric setting, distraction may alter the flow of a structured risk assessment, leading to missed components, and an incorrect conclusion. Some organisations try to have specific quiet areas for critical tasks. Whatever the local set up, the key is to develop and maintain everyone’s awareness of how distraction greatly increases the chance of error.

Level 2

Level 2 captures how what has been seen is processed into an ‘understanding’ of the situation. To minimise level 2 errors it is necessary to consider how the human brain works, how it recognises things and how it makes decisions and choices. This level of detail is beyond the scope of this introductory chapter, and therefore this section will focus on a part of this, the decision making that leads into level 3.

On the face of it the practice of decision making is familiar to everyone. However, to understand those things that can compromise this process it is important to understand the factors that will influence the decision made. To make a good decision a person needs to assess all aspects of a problem, identify the possible responses to the problem, consider the consequences of each of those responses and then weigh up the advantages and disadvantages. Having completed this process they then need to communicate their decision to their team.

Good situation awareness is a basic prerequisite. To achieve this, the decision maker must ensure they have all of the key information. The whole team should be on the alert for ambiguities or conflicting information. Any inconsistent facts should be treated as a potential marker for faulty situation awareness. They should never be brushed off as unimportant anomalies in the absence of evidence to support such a decision.

In many clinical situations there can be a significant pressure of time. Where this is not the case then no decision‐making process should be concluded until the team is satisfied they have all of the information and have considered all of the options. Where time is a pressure, a certain amount of pragmatism must be employed. There is plenty of evidence to confirm that practise and experience can mitigate some of the negative effects of abbreviating a decision‐making process. Those making decisions under such circumstances need to remain aware of the short‐cuts they have taken. They should be ready to receive feedback from their team, particularly if any member of the team has significant concerns about the proposed course of action.

Level 3

Having seen and understood we can now plan forward and communicate this with the team.

Team situation awareness

The individuals in the team may have a differing awareness of the situation depending on their previous experiences, specialty, physical position, etc. The team’s situation awareness will often be greater than any individual’s, however this can only be exploited if the individual elements are effectively communicated. The leader should actively encourage this.

In the example shown in Figure 10.3, the situation awareness of each member of the team is increased by being in the team, and by communicating with each other.

Figure 10.3 Team situation awareness

10.8 Improving team and individual performance

In addition to effective communication, team working, situation awareness, leadership and followership skills, there are a number of other ways that team and individual performance can be further developed and improved.

Prebriefing

It is important for emergency medicine and psychiatry colleagues involved in the care of patients with acute psychiatric emergencies to plan in advance of a patient consultation. All members of the team should be briefed so that everyone understands their roles, the approach to the patient and how to keep everyone safe.

Awareness of situations when errors are more likely

If we are aware that an error is more likely we can be more proactive in detecting them. Two common situations that make errors more likely are stress and fatigue. Stress is not only a source of error when we are overworked and overstimulated, but also at the other end of the spectrum when we are understimulated we become inattentive.

The acronym HALT has been used to describe situations when error is more likely:

H Hungry

A Angry

L Late

T Tired

I’M SAFE has been used as a checklist in the aviation industry asking whether the individual may be affected by:

I Illness

M Medication

S Stress

A Alcohol

F Fatigue

E Eating

Ideally, individuals who are potentially compromised need to be supported appropriately, allowed time to recover and the team made aware. How this can be achieved in the middle of a night shift though can be problematic.

Red flags

There are at least a dozen situations that are early warnings (red flags) of the early stages of an error chain. These include:

Broken or difficult communications

Ambiguities or inconsistencies

Deviation from standard operating policies or guidelines

Unexpected change of plan

Taking short cuts or missing steps out

Getting fixated or preoccupied on one task

Getting side‐tracked

Physical alarm bells going off

Confusion or uncertainty

Inaction

Irritability

Staff ‘pulling rank’

If you notice a red flag – speak up. ‘Time flies’ in high‐pressure situations, and it may be later than you think.

Awareness of error traps

A common trap that people fall into is only seeing or registering the information that fits in with their current mental model. This is known as a confirmation bias. When this occurs people favour information that confirms their preconceptions or hypotheses regardless of whether the information is true. This may be observed within the healthcare setting during the process of a referral or handover.

An example of this might be a clinician receiving a phone call requesting them to attend the ward to review an acutely deteriorating patient. The clinician is advised that the patient is a known asthmatic. On their way to the ward the clinician builds up a series of preconceived expectations around what they will find upon their arrival. They may even formulate a management plan whilst travelling to the scene, based upon their expectations. Once this mindset is established it can be difficult to shift.

On arrival, the clinician examines the systems affected by the presumed diagnosis. They seek to confirm their expectation by focusing on an auscultation of the chest at the expense of a thorough assessment. Upon hearing bilateral wheeze their preconceived ideas are confirmed and the remainder of the assessment is completed without due attention and more as a rehearsed exercise rather than an open minded exploration. They fail to notice that the patient also has a soft stridor and is hypotensive. In this case, the eventual diagnosis of anaphylaxis becomes at best a very late consideration, or at worst a situation that requires an objective newcomer to the team to point out the obvious.

Cognitive aids: checklists, guidelines and protocols

Cognitive aids such as guidelines are made available because the human memory is not infallible. They also confer team understanding through the use of a standardised response. This reduces stress. This is especially true where an uncommon emergency event occurs. The team may be unfamiliar with one another and each member will be trying to remember what to do, what treatments are required and in what order. A good team leader will use the available cognitive aids as a prompt and the members of the team can use it as a resource so that they can plan ahead. Safe practice is promoted through the use of these tools in an emergency rather than relying on memory.

Calling for help early

Trainee staff are often reluctant to call for senior help, partly due to not recognising the severity of the situation and also due to concerns about wasting the time of seniors. With all emergency events, escalation and appropriate help should be summoned as soon as possible. Remember help will not arrive instantly.

Using all available resources

Team resources include staff, observations, equipment, cognitive aids and the facilities in the local area. The team leader should continually consider the appropriateness of utilising available, untasked staff or equipment to optimise the patient’s care and prevent a bottleneck in the treatment pathway.

Debriefing

Wherever possible a debriefing should be facilitated, even briefly, following clinical events. Ideally this should be normal procedure, rather than being reserved for catastrophic events. The aim of a debrief is to summarise any particular issues or problems that the team had, and reflect on how the team performed. Some organisations have set templates to facilitate this. It gives the opportunity for individuals, teams and organisations to continually develop.

10.9 Summary

This chapter has given a brief introduction to the human factors that can lead to poor team working, patient harm and adverse events. It is really important to use every opportunity to reflect and develop your own performance and influence the development of others and the team. Appropriate debriefing is included in the APEx course which may be used to inform incorporation of this process into your own clinical practice.

CHAPTER 11
The patient experience

Learning outcomes

After reading this chapter, you will be able to:

Recognise the experience of attending the emergency department with a mental health crisis from the perspective of a patient

Identify potential improvements to optimise the patient experience

11.1 Introduction

This chapter is based on an interview with a patient who has had experience of personal mental health crises and of mental health crises within her family.

The themes that emerged during the interview are:

Emotional safety

Balance of care between physical and mental health

Attitudes and responses of staff

Privacy and confidentiality

Communication with patient, parent and carer

Environmental issues

Each of these is covered in more detail below.

11.2 Aspects of a patient’s experience

Emotional safety

Emotional safety is often ignored with a focus purely on physical safety. Emergency medicine staff can improve emotional safety by talking to the patient and providing a ‘reassuring touch’. Once physical safety is assured, emotional safety should be the focus, with attention paid to making sure that the environment does not feel hostile in any way. Attention to the areas covered elsewhere within this chapter such as attitudes and responses of staff, balance of care and communication can support this.

Balance of care

The balance between physical and emotional care for those with a mental health crisis can be variable. In some situations, mental health patients present with a combination of physical and mental health issues; in others, the presentation requires no physical treatment. It is important in the emergency medicine setting to consider the point at which the emergency medicine team care of the patient begins and ends. Just dealing with the physical issue and not focusing on emotional safety may result in the underlying problem being ignored. The patient may then reattend repeatedly seeking the emotional support that they need.

Even in situations where there is a decision taken that further support is required from the psychiatry team, experience has shown that there is a tendency for the emergency medicine staff to ‘step back’ while waiting for the psychiatry team to arrive. Verbal interactions, in addition to physical monitoring checks, could make a difference in this situation, with the patient then feeling supported during the transition from the care of the emergency medicine to the psychiatry team. This is also the case where someone is detained in the department but no physical health checks are required, when some level of interaction would make patients not feel ‘abandoned’ by the emergency medicine team.

A better balance between the questions asked by the emergency medicine team and the psychiatry team can reduce distressing repetition. Consider what it is essential to know now and what can wait until the full psychosocial assessment.

The wait for the psychosocial assessment can be distressing for the patient and their family. This is particularly so if this involves lengthy waits in the emergency department (ED) or admission overnight into a hospital bed.

Attitudes and responses of staff

The attitude of staff can make attendance in the department a daunting experience for mental health patients. Experience of ‘eye‐rolling’ and comments such as ‘Oh it’s you again’ can make patients feel less deserving of care. Comments like ‘It’s not as bad as last time’ while intended to be reassuring can have unexpected consequences on someone who is a repeat attendee with self‐harm. One one occasion a comment like that resulted in the patient ‘going into the hospital toilet and making the cut bigger’ so that she ‘deserved’ the care she needed.

It only needs one person to be perceived as having this attitude to lead to a ‘negative pathway’. It can, potentially, prompt someone to leave the department before a full psychosocial assessment.

Comments which were in all likelihood not intended to be negative or derogatory, e.g. ‘Why do you keep doing this to your beautiful arms’, can be taken as such in someone who is vulnerable with low self‐esteem, low self‐confidence and low self‐worth. They hear: ‘You’re a rubbish person, you’re thoughtless’.

Comments that dismiss the level of distress someone is in, such as ‘You’re not going to be silly again are you’; may be heard in a different way than intended. Patients hear: ‘You are behaving badly’ and ‘You may be punished’.

Privacy and confidentiality

In cubicles, in particular, privacy can be an issue with only the curtain separating the patient from other patients and ‘common’ areas. The sensitive nature of conversations about mental health issues should be considered. Concerns that they may be overheard may make the patient reluctant to be open and this can then be a barrier to their ongoing treatment.

In addition, consideration should be given to the impact on the patient of physical signals that make their situation less private, e.g. being flanked by police officers or security guards whilst walking through a hospital if they are being detained for their own safety. Consideration of their safety, but also other approaches to this, may mean that the escort is less obvious. Provision of a side room whilst waiting for admission to a ward, rather than waiting with the escort in public areas, may also make their situation more private.

Communication

Regular communication with the patient themselves and, in the case of children, with them and their parent/carer can often be forgotten if the patient has been ‘handed over’ to the psychiatry team and the ED staff are waiting for them to arrive. The delays can often be considerable and during this period regular updates are important to provide support and reassurance.

Often families are not aware of the steps involved in arranging a psychosocial assessment, and an explanation of this and what the assessment will involve can make the situation feel more controlled. Briefing the family, where confidentiality permits, before they see their loved one, can prepare them and make the initial meeting more manageable and less stressful for them and the patient.

The patient themselves can be ‘scared’, ‘distressed’ and ‘anxious’ about what is happening to them and about what the reactions of their family will be when they arrive. This can further heighten their feelings and emotions and communicating with them regularly and reassuring them can help alleviate this.

Being honest and open about timeframes can also mean that family members can go for food, drink and respite breaks.

Environmental issues

In the ED, guideline changes over recent years have resulted in improvements to the physical environment for mental health patients. From an emotional perspective, however, it is often not the best environment. A cubicle with a surrounding curtain can be ‘claustrophobic and scary’ and voices can be heard from all around which can be ‘disorientating’. For someone who is intent on self‐harm, these environments may be safer, but they are not completely safe and regular checks should be made and can help to make the patient calmer and emotionally safer.

Rooms that are set‐up for the physical safety of someone who is being detained for their own safety can be like ‘goldfish bowls’ with the patient feeling watched. Also, with nothing available that can be a risk to the patient they can be ‘boring’ with nothing to keep patients occupied during their wait.

Other environmental issues to consider during a wait for the psychiatry team are food, drink, toilet and, in some cases, cigarette breaks. Again, this supports calmer and emotionally safer patient experiences.

11.3 Summary

From a patient perspective, there are many small, but essential, changes that can be made that would improve their experience of attending an ED with a mental health crisis and would support their ongoing emotional safety.

Index

Page numbers in italic refer to figures

4AT 65

ABC SMITH mnemonic 15, 45

ABCD assessment 2, 5, 7

acute confusional states 68

alcohol intoxication 42

activity level 15

Acuphase 88

acute confusional states see confusional states, acute

ADELLE acronym 9

advance decision 93

self‐harm 35–6

advance statement 93

adverse factors

self‐harm 26

AEIO assessment 2, 5, 7, 8

acute confusional states 68

agitation/arousal 8

alcohol intoxication 42

environment 8

intent 9–10

objects 10

self‐harm 20, 22

strange behaviour 52

affect 16

aggression 15, 75–85

assessment 76, 79

case examples 83–4

causes, psychiatric disorders and 77

confidentiality and risk 77

de‐escalation 80

behavioural and environmental approach 80

verbal approach 80, 81

definiton 75–6

location and environment 76

mental illness association 76

pharmacological intervention 82

physical intervention 81

prevention

primary 79

secondary 80–1

tertiary 81–2

risk, management of 78

hospital variables 78

patient variables 78

staff variables 79

risk formulation 77

staff variables 77

substance misuse and 76

theories of 76

agitation/arousal 8

alcohol intoxication 43

psychomotor 15

refractory 88

akathisia 15

alarm, access to 6

alcohol intoxication 37–49

background information 41

brief interventions in ED 47

case example 48

characteristics 39

common presentations 37

co‐morbidities 40–1

confirm route of care (CROC) 47

cost to NHS of 37

determine disposal 47

emergency management 46

extent of 37

handover 47

history 39

measurement 39

pathophysiology 38

primary assessment 42–4

priorities 38

reason for presentation to ED 41–2

risk 41

screening 39–40

secondary assessment 44–6

self‐harm and 28

strange behaviour 58–9

symptoms and signs 40

unified assessment and immediate treatment 44

units of consumption 38–9

alcohol misuse see alcohol intoxication

alcohol withdrawal 47

antipsychotics 88

anxiety 60

apparently drunk patient see alcohol intoxication

appearance 15

aripiprazole 88

arousal see agitation/arousal

asenapine 88

attitudes, staff 108

balance of care 107–8

behaviour 15–16

see also behaviour, strange

behaviour, strange 51–5

case examples 54–5

drug and alcohol misuse 58–9

emergency management 53

organic disorders and 57–6

structured approach to assessment 51–3

preparation 51

primary assessment 52

secondary assessment 52–3

bipolar affective disorder 60

capacity 17

in self‐harm 33–5

catatonia 59

chlordiazepoxide 47

chronic cognitive impairment 65

Clinical Institute Withdrawal Assessment – Alcohol, revised (CIWA‐Ar) system 47

cognition 16

cognitive aids 106

collateral information 18

COMA CHAMP mnemonic 71

communication 2

element of 99

with colleagues 99–100

with feedback loop 100

with patients 100, 108–9

co‐morbid mental illness, self‐harm and 27

confidentiality 96, 108

aggression and 77

confirm route of care (CROC) 47

confirmation bias 106

confusion assessment method (CAM) 65

confusional states, acute 63–74

alcohol intoxication 46

case example 73

disposal determination 71–2

emergency management 71–2

mental health 71

physical health 71

handover 72

precipitants of 66

secondary assessment 70–1

structured approach to assessment 67–70

background information 67

engagement 68

environment 69

intent 69

objects 70

preparation 67

primary assessment 68–70

reason for presentation to ED 67

unified assessment and immediate treatment 70

consent 2

legal aspects 95

self‐harm 33

debriefing 106

delirium 16, 69, 71

causes of 66

diagnostic checklist 64–5

impact 63–4

key features 64

management of symptoms and signs 72

non‐pharmacological 72

pharmacological 72

prevalence in hospital setting 64

risk of 66

screening tools 65

delirium tremens 44, 58

delusional disorders 59

dementia 65–6

depression 33, 60

symptoms 27

depressive pseudodementia 65

desire to leave 10

acute confusional state 69

alcohol intoxication 44

detention

for diagnosis in ED 94

for diagnosis on wards 94

for personal/public safety in community 94

for physical treatment 94–5

for treatment in ED 94

dissociative disorders 60

documentation 96

drug‐induced psychosis 59

drug misuse

self‐harm and 28

strange behaviour 58–9

drunkeness see alcohol intoxication

duty of care 2

emergency management

acute confusional states 71–2

self‐harm 32

strange behaviour 53

emotional safety 107

environment 109

alcohol intoxication 43

risk assessment 9

error

healthcare 97–8

human 98–9

Swiss cheese model of 99

error traps, awareness of 106

flight risk 24

focused conversational psychosocial history see psychosocial history, focused conversational

focused physical history see physical history and examination, focused

followership 100–2

Glasgow Coma Scale (GCS) 41

hallucinosis 18, 53

alcohol related 44

haloperidol 11

HALT acronym 105

handover 47, 72

harm to others, risk of 6, 8

acute confusional state 69

alcohol intoxication 43

current thoughts of 9

legal aspects 94

head injury

alcohol intoxication vs 40–1

guidelines 41

healthcare error

causes 98

extent 97

help, calling for 106

hierarchy, team 101–2

human error 98–9

ICD‐10 criteria for alcohol dependence 45

illusions 18

I'M SAFE acronym 105

information

collateral 18

shared 5–6

insight 17

intent 9–10

alcohol intoxication 43–4

assessment 10

self‐harm 26

intoxication 60

see also alcohol intoxication

Korsakoff's psychosis 58

leadership 100–2

legal aspects 12, 91–6

confidentiality 96

consent 95

documentation 96

mental capacity determination 91–5

self‐harm 35

treatment of patient with mental capacity 95

lethality of self‐harm episode 26

liberty, deprivation of 92

lorazepam 11, 47, 89

loxapine 88

malingering 61

Manchester Triage System 22, 23

mania 65

MEAT mnemonic 44

mental capacity

determination 91–2

lack of, treatment 92–5

self‐harm 35

mental state examination

acutely confused patient 71

alcohol intoxication 44

appearance 52–3

behaviour 53

cognition 53

hallucinations and illusions 53

insight and capacity 53

mood and affect 53

speech 53

thoughts 53

mood 16

movement, abnormal 16

Munchausen's by proxy 61

Munchausen's syndrome 61

mute patients 16

objects 10

alcohol intoxication 44

risk from 10

observation, self‐harm 32

olanzapine 88, 89

oxazepam 47

PACE (probing, alerting, challenging or declaring an emergency) method 102

patient experience 107–9

performance improvement 105–6

person‐centred care 12

personality disorder 61

PHRASED approach

acute confusional states 70

alcohol intoxication 44

mnenomic 14

physical history taking 14

psychosocial history 14

physical environment 109

physical examination, focused 13–14

physical health problems, co‐morbid, suicide risk 28

physical history and examination, focused 13–14

acute confusional states 70

alcohol intoxication 44, 45

strange behaviour 52

place of safety suites 8

post‐traumatic stress disorder (PTSD) 60–1

prebriefing 105

preparation for assessment 1, 5–6

acute confusional state 67

alcohol intoxication 41–2

self‐harm 20, 21–2

primary assessment 2, 5, 6–7, 6

alcohol intoxication 42–4

physical risk 7

psychiatric risk 8

self‐harm 22

strange behaviour 52

privacy 108

promethazine 11

protective factors, self‐harm 26

pseudodementia, depressive 65

psychomotor agitation 15

psychomotor retardation 15

psychosis 65

alcohol intoxication 46

drug‐induced 59

Korsakoff's 58

psychosocial history, focused conversational 14–15

acute confusional states 71

alcohol intoxication 45

self‐harm 24–5

strange behaviour 52

psychotic episodes 59

psychotic experiences 9–10, 17

acute confusional state 69

alcohol intoxication 44

rapport 15

red flags 105

refractory agitation 88

refusal of treatment 92, 93, 93

self‐harm 32–6, 34

responses, staff 108

resuscitation 7

rights, people's 12

risk of harm see harm to others, risk of; self‐harm; self‐harm, risk of

safety, staff 11–12

SBAR (situation, background, assessment and recommendation) 100

schizophrenia 59

secondary assessment 2, 12, 13

acute confusional state 70

alcohol intoxication 44–6

physical and psychosocial illness 13–18

self‐harm 24–9

secondary psychosocial (mental state) examination 15–18

self‐harm 19–36

alcohol intoxication 45–6

case examples 29–31

current thoughts of 9

emergency management 32

general principles 20

multiple attenders 36

preparation 20, 21–2

primary assessment 22–4

reasons for 25

secondary assessment 24–9

see also self‐harm, risk of; suicide, risk of

self‐harm, risk of 69

alcohol intoxication 43

legal aspects 94

risk profile 28, 28

self‐poisoning 24

situation awareness 102–4

SLIPA mnemonic 25–6

speech 16

staff

number of, for safe containment 11

safety 11–12

stress, performance and 105

structured approach to assessment 2, 3, 5–6, 13

acute confusional state 67–72

alcohol intoxication 41–6

strange behaviour 51–3

self‐harm 20–2

stupor 15

substance misuse, aggression and 76

see also alcohol intoxication; drug misuse

suicide, risk of 19

alcohol intoxication 45–6

demographic/historical risk factors 26, 27

self‐harm 25

triage 22

Swiss cheese model of error 99

team

performance, improving 105–6

situation awareness 102–4

teamwork 2, 100–2

thoughts 17–18

disorders of 17

top‐to‐toe physical examination 45

tranquillisation

adverse effects and monitoring 87–8

agents 88

medication regimens 89

pregnancy 88

rapid 11, 86–7, 90

unified (U) assessment 2, 3, 6–7, 10–11

acutely confused patient 68–70

aggressive patient 79

apparently drunk 42–4

behaving strangely 52

self‐harm 23–4

Wernicke's encephalopathy 46, 58

withdrawal, alcohol/substance 41, 46, 47, 58, 60

zuclopenthixol decanoate (Acuphase) 88