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STAT: 7 tips for the psychiatric ER

Talk to intoxicated patients briefly, get an adequate medical history, ensure their safety, then let them sleep in the ER.

Vol. 7, No. 7 / July 2008

Psychiatric emergency rooms (ERs) often are the first stop for patients experiencing severe psychiatric symptoms. Following these strategies can help as you assess and treat a variety of patients and create a modicum of calm out of the chaos.

‘Heal’ borderlines

Although patients diagnosed with borderline personality disorder often present treatment challenges, a supportive psychotherapeutic approach based on empathic listening often can be helpful. Allowing these patients to feel understood in the midst of an interpersonal crisis may be enough to help them navigate their predicament in a healthier way.

Beware of shift changes

Patients arriving during a staff shift change might not receive the time and attention necessary for a comprehensive psychiatric evaluation. Resist pressure to speed up the workflow, and do not leave patients waiting to be seen by the oncoming shift. Working only by the clock may result in a rushed and inadequate assessment and a suboptimal treatment plan.

Sleeping it off

Patients often arrive intoxicated and might not be able to adequately participate in a psychiatric assessment. Talk to intoxicated patients briefly, get an adequate medical history, ensure their safety and monitoring, and then let them sleep in the ER. Re-evaluation in the morning often yields dramatically different mental status findings.

Be familiar with social services

Although some ERs employ staff members who specialize in coordinating social services, be familiar with available homeless shelters, travelers’ aid societies, halfway houses, and safe homes. Armed with this information, you can refer to appropriate agencies patients with problems that are more social than psychiatric.

Know your staff

Psychiatric ERs are staffed by a variety of mental health professionals, and individual team members’ experience, training, and knowledge can vary greatly. It is your responsibility to be familiar with the strengths and weaknesses of these workers to guard against having to repeat tasks.

Feed your patients

Providing patients with food is a straight-forward way to demonstrate you care about their needs and want to help. Though it is important that patients do not view psychiatric ERs as places to come to get a hot meal, generously dispensing food often helps lay the groundwork for a therapeutic relationship.

Be generous with thiamine

Many ER patients are undernourished or abuse alcohol and therefore are at risk for thiamine deficiency. The sequelae of thiamine deficiency, including Wernicke’s encephalopathy and Korsakoff’s syndrome, are serious and in some cases irreversible.

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