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24. Key GF. A comparison of
calcium gluconate and
methocarbamol (Robaxin) in
the treatment of latrodectism
(black widow spider
envenomation). Am
J Trop Med Hyg. 1981;30:
273–277.
25. Clark RF. The safety and
efficacy of antivenin
Latrodectus mactans.
J Toxicol Clin Toxicol.
2001;39:125–127.
26. Alberts BM, Shalit M, LoGalbo
F. Suction for venomous
snakebite: a study of "mock
venom" extraction in a human
model. Ann Emerg Med.
2004;43:181–186.
27. Bush SP, Hegewald KG, Green
SM, et al. Effects of a negative
pressure venom extraction
device (Extractor) on local
tissue injury after artificial
rattlesnake envenomation in a
porcine model. Wild Environ
Med. 2000;11:180–188.
28. McCollough N, Gennaro J.
Evaluation of venomous
snakebite in the southern
United States. J Fla Med Assoc.
1963;49:959–967.
Toxicology
063
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Subpart
IVP
Clinical – Psychosocial
Editor’s Comments on Medical Clearance
In the “typical” observation unit (OU), which includes chest pain and other types of stable,
“low-maintenance” patients, psychiatric patients or patients undergoing medical clearance are
generally excluded from the OU. Psychiatric patients or patients being medically cleared are
“high-maintenance” patients who require additional personnel and resources. Moreover,
placing an unruly, out-of-control, disruptive individual who is intoxicated from drugs and/or
alcohol or high on PCP or a schizophrenic, perhaps, screaming or crying, next to a chest pain
patient in the OU for a rule out presents a myriad of challenges. Therefore, the majority of OUs
exclude psychiatric patients and/or out-of-control intoxicated patients.
1,2
However, in view of the extended emergency department (ED) length of stay (LOS) for
most psychiatric patients and the increasing numbers of psychiatric patients in the ED, the
concept of a ED psychiatric OU has emerged and the presence of ED Psychiatric OUs is likely
to increase in the future. Thus, this chapter is intended to address the concept of psychiatric
OUs and the medical clearance of ED patients, and is not intended to advocate for the
inclusion of these patients into a general or chest pain OU.
References
1. Mace SE, Graff L, Mikhail M, et al. A national survey of observation units in the United
States. Am J Emerg Med 2003; 21:529–533.
2. Mace SE. Clinical Protocols. (Chapter 82)
331
at 064
16:08:18 available
Subpart IVP
Chapter
60
Clinical – Psychosocial
Psychiatric Patients
Jonathan Glauser, MD, FACEP
Introduction
Although patients with primarily psychiatric
complaints have not traditionally filled observation units (OUs) in the United States, it is reasonable to think that this tradition will change. It is
not uncommon for psychiatric patients to remain
in the emergency department (ED) for protracted
periods of time awaiting consultation, with disposition dependent upon “medical clearance.”
Even in settings of over 90% rates of insurance
coverage, over 8% of adult psychiatric patients
may stay in the ED for over 24 hours.
1
Homelessness, transfer to another hospital, public insurance, and use of restraints or sitters all are
associated with prolonged ED stays, and it is
unlikely that any of these factors will abate in
the foreseeable future. This makes it highly probable that OUs for medical clearance and psychiatric evaluation will play an enhanced role in the
health care system. This discussion assum es the
capability for monitoring patients with sitters and
security as needed.
Aside from protecting a psychiatric patient
from him or herself and others, making the decision as to whether or not the patient is “medically
clear” is often the principal task in the accurate
triage of patients in the ED and subsequently
in the OU. A patient may present with severe
depression, suicidal or homicidal ideations,
psychotic disturbances, or altered mental state
that may ultimately lead to admission. It is essential that potentially life-threatening illnesses be
detected before a patient is admitted to a setting
where resources for diagnosis and treatment are
suboptimal. Suicide screening tends to be performed largely on patients with chief complaints
of a psychiatric nature, and approximately onethird of these patients in one report had documentation of alcohol abuse, with another third
noted to have prescription drug misuse or intentional illegal drug use.
2
Therefore, a large percentage
of patients with suicidal ideation or primary psychiatric complaints have confounding substance
use that precludes an accurate assessment of
risk until a certain amount of time elapses. For
example, if a patient metabolizes ethanol at 15–20
mg/dL per hour, many hours may elapse before an
accurate risk assessment can be achieved in an
inebriated patient.
Many psychiatrists view the patient’s initial
presentation to the ED as the only opportu nity
to diagnose an underlying organic process that
would otherwise go undetected and potentially
lead to morbidity or even mortality if missed.
Complaints that appear psychiatric in origin
may be manifestations of underlying medical
conditions.
3
The psychiatric patient population represents
2% to 12% of ED visits and behavioral problems
have been listed as the presenting complaint in 4%
of ED visits.
4,5,6
From 1992 to 2001, there were
reported 53 million psychiatric-related ED visits,
which is an increase from 17.1 to 23.6 per 1000
visits.
6
Distinguishing whether the patient’s signs
and symptoms result from a purely psychiatric
illness, if a medical disease coexists, or if that
disease is the underlying etiology for the patient’s
presentation will be a continuing concern in any
ED and for any ensuing observation stay.
Psychiatric Emergencies: Defined
According to the American Psychiatric A ssociation, a psychiatric emergency is defined as “an
acute disturbance in thought, behavior, mood, or
social relationship, which requires immediate
intervention as defined by the patient, family, or
social unit.”
7
This umbrella classification covers
both functional and organic disease processes,
and it is important to recognize certain disorders
to think of how medical disease may play a role.
Schizophrenia and other psychoses: These
are marked by the presence of delusions (fixed
065
21:22:46
false beliefs that are not amenable to arguments)
and by hallucinations. There is loss of reality
testing; consciousness is clear. Schizophrenia is
characterized by deterioration in functioning,
classically with continuous signs of the disturbance for more than 6 months. Onset is usually
prior to age 40. The disturbance is not attributable
to substance abuse or to a medical disorder. Negative symptoms include social withdrawal, difficulty in functioning in school or at work, lack of
volition, blunting of emotion, flattened affect,
poor abstract thinking, or apathy.
8
Anxiety: This disorder is characterized by
apprehension, fear, and excessive worry. Feelings
of panic or stress might be accompanied by autonomic hyperactivity out of proportion to any real
danger to the integrity of the patient’s health. It is
unlikely that patients would be admitted to an
OU or to a psychiatric service for anxiety alone.
Symptoms can be induced by a wide variety of
legal and illegal substances. Caffeine and nicotine
are prominent, as are phencyclidine and cocaine.
Over-the-counter medications for cough and
colds, including ephedrine and antihistamines,
can induce anxiety, as can withdrawal from alcohol, benzodiazepines, barbiturates, and betablockers. Palpitations and frank arrhythmias can
induce anxiety. Apprehension can be associated
with other significant medical illnesses such as
hyperthyroidism, hypoglycemia, and hypoxemia.
9
Panic disorder: This is an anxiety disorder
characterized by a sudden surge of anxiety and
dread, with changes in autonomic vital signs. Palpitations, tachycardia, chest tightness, shortness
of breath, sweating, trem ulousness, and subjective
dizziness can be present. Organic etiologies, especially entities that may cause cardiac or respiratory compromise, must be ruled out.
Major depression: This diagnosis is characterized by persistent dysphoric mood, or sadness,
present most of the day, lasting longer than 2
weeks. The lifetime risk of suicide in depressed
patients is approximately 15%.
10
Symptoms
should not be attributable to bereavement or to
direct physiologic effects of a substance. Patients
with major depression without suicidal ideation
typically do not meet admission criteria unless the
depression is sever ely limiting the patient’s functioning and activities of daily living.
Bipolar disorder: This disorder is characterized by the occurrence of mania (elation or irritability) and grandiosity. An elevated, expansive,
or irritable mood should be present for at least
1 week to make the diagnosis. Patients can exhibit
a decreased need for sleep , increased activity,
rapid or pressured speech, and racing thoughts.
They tend to be talkative, with flight of ideas and
distractibility. The onset is usually in the third
and fourth decades of life.
To make these diagnoses, the symptoms must
not be caused by a general medical condition or
substance. These medical conditions should be
investigated in the OU prior to disposition.
Patients with Altered Mentation
It is necessary to identify which patients have a
correctable cause(s) for their disturbed mental
status. Determining delirium from dementia is
a critical consideration. (Table 60.1)
Delirium: This has also been synonymous with
organic brain syndrome, metabolic encephalopathy,
toxic encephalopathy, and acute confusional
state. It is characterized by global impairment in
cognitive function with clouded consciousness
and impaired attention. Deterioration is acute,
Table 60.1 Characteristics of Delirium, Dementia, and Psychiatric Illness
Characteristic Delirium Dementia Psychiatric Illness
Onset Acute – hours/days Gradual: months/years Acute
Attention Impaired Normal Disorganized
Consciousness Decreased Baseline Alert
Hallucinations Typically visual Absent Typically auditory
Speech Rapid, incoherent, hesitant, slow Inability to find words Typically coherent
Orientation Usually impaired Usually impaired Rarely impaired
Vital signs May be abnormal Usually normal Usually normal
Jonathan Glauser
065
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measured in hours or days – not months. Hallucinations tend to be visual. By definition, delirium
has a medical cause. Changes in cognition and
thinking can fluctuate during the day and tend
to be more pronounced at night.
Dementia: This diagnosis descr ibes a pervasive disturbance in cognitive functioning in
memory, judgment, abstract thinking, personality, and higher cortical functions such as language. Polypharmacy, renal failure, pulmonary
disease, endocrine disorders, normal pressure
hydrocephalus, slowly growing intracranial mass,
hepatic failure, nutritional disease, infectious disease, inflammatory disease, and depression are
possible reversible causes. Consciousness is not
clouded. Ability to carry out motor functions
can be impaired.
11
There is gradual loss of cognitive abilities such as memory or computational
skills.
8
Physicians must always think in terms of the
most lethal diagnoses – those entities they can
least afford to miss when admitting a patient to
a psychiatric ward. The medical entities listed in
Table 60.2 can cause serious morbidity or mortality, can masquerade as psychiatric disease, and
must be ruled out before physicians can “clear”
patients for admiss ion to a psychiatric service.
Many can be ruled out clinically.
A partial list of substances potentially causing
psychosis includes digitalis, corticosteroids, nonsteroidal anti-inflammatory drugs, isoniazid, disulfiram, cyclic antidepressants, anticonvulsants,
benzodiazepines, amphetamines, cocaine, narcotics, barbiturates, methyldopa, levodopa, anticholinergic medications, jimson weed, and
diphenhydramine. Systemic illnesses that can
cause psychosis include systemic lupus erythematosus and tertiary syphilis. Depression can be
caused by narcotics, alcohol, and other sedatives;
by antihypertensive agents and corticosteroids;
and by entities such as thyroid disorders and
Cushing syndrome. In 24-hour stay units, physicians cannot formally test for all of these – the
workup would be too extensive (lumbar puncture,
metabolic evaluation, drug/alcohol screening,
neuroimaging, neurologic consultat ions, endocrine testing). Once the diagnosis of delirium or
alteration in mental status is made, the patient is
not suitable for observation care and warrants full
hospitalization.
A useful mnemonic for discriminating
organic from functional psychoses is the MADFOCS scale seen in Table 60.3.
12
Medical and Psychiatric Illness
Coexist
Historically, medical findings have been described
in significant numbers of psychiatric patients,
including those who were deemed “medically
clear.” Reasons for errors included inadequate
physical examination, failure to obtain indicated
laboratory studies, failure to obtain available history, and failure to address abnormal vital signs.
13
Changes in mental status resulting in psychosis, anxiety or panic, depression, mania, delirium, and dementia have been associated with a
broad base of underlying medical etiologies. Historically, these have been categorized into five
main groupings: metabolic/endocrine, medications, substances, infectious, and central nervous
system (see Table 60.4).
5,14
History of Present Illness
If the patient is unable to provide a thorough
history, it may be obtained from family, police,
witnesses, or other health care providers. Focused
questioning should determine if the patient has a
history of psychiatric or medical disease, if there
Table 60.2 “Can’t Miss” Medical Illnesses Simulating
Psychiatric Disease
Meningitis/ encephalitis
Other infections: sepsis, UTI, pneumonia
Diabetic emergencies: hypoglycemia, DKA
Hypoxia or hypercapnia
Encephalopathies (hypertensive, Wernicke,
hepatic, uremic)
Head injury
Intracranial hemorrhages
Poisoning
Drug withdrawal (benzodiazepines, barbiturates,
ethanol)
Seizures
Neuroleptic malignant syndrome
Serotonin syndrome
Thyroid disturbances
Gross electrolyte abnormalities
Psychiatric Patients
065
21:22:46
are any new medications, an estimate of the
patient’s baseline level of alertness and ability to
perform activities of daily living, the acuity of
onset, and if any substances are involved. Clues
suggesting medical illness rather than a primarily
psychiatric are listed in Table 60.5.
Physical Examination
The physical examination must note the vital
signs. Abnormal vital signs should automatically
raise the suspicion that a medical component is
playing a role in the patient’s presentation.
A complete neurological examination should also
be performed including cranial nerves, muscle
strength, sensation, reflexes, cerebellar function,
and orientation assessment prior to observation
admission.
Impaired mental status can be the manifestation of a wide range of medical conditions that
warrant hospitalization on a medical ward. The
Quick Confusion Scale (QCS) has been touted as
preferable to the Mini-Mental State Examination
for emergency use, because it does not require
pencil and paper and is quicker to administer.
15
The QCS may also be useful in determining alteration of cognition:
16,17
Table 60.3 MADFOCS: Mnemonic for Discriminating Organic from Functional Psychosis
Organic Functional
M – Memory deficit Recent impairment Remote impairment
A – Activity Hyperactive, hypoactive, tremor, ataxia Repetitive activity, rocking
D – Distortions Visual hallucinations Auditory hallucinations
F – Feelings Emotional lability Flat affect
O – Orientation Disoriented Oriented
C – Cognition Lucid thoughts, perceives/attends/
focuses occasionally
No lucid thoughts, unfiltered
perceptions, unable to attend/focus
S – Some other findings Age > 40
Sudden onset
Physical exam abnormal
Vital signs abnormal
Social immodesty
Aphasia
Consciousness impaired
Age < 40
Gradual onset
Physical exam normal
Vitals normal
Social modesty
Intelligible speech
Awake/alert
Table 60.4 Medical Conditions with Behavioral Symptoms
Metabolic/
Endocrine
High or low thyroid, blood sugar,
parathyroid, cortisol levels
Medications SSRIs, benzodiazepines, opiates,
corticosteroids, anticholinergics,
digitalis, others
Substances Alcohol, amphetamines,
benzodiazepines, phencyclidine,
LSD, other hallucinogens
Infectious Meningitis, encephalitis, urinary
tract infections, pneumonia,
sepsis
Central
Nervous
System
Seizures, cerebral tumors, CVAs,
post-ictal, hydrocephalus,
migraines
Table 60.5 Clues Suggesting Organic Medical Illness
- No previous history of psychiatric disorder
- Sudden onset
- Age < 12 or > 40 years at onset
- Disorientation
- Depressed level of consciousness
- Abnormal vital signs
- Focal neurologic deficits
- Visual or tactile hallucinations (not auditory)
- Evidence of exposure to toxins or suspected
ingestion
Jonathan Glauser
065
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If substance abuse or withdrawal is implicated,
it should be temporally related to the disturbance.
The physical examination should be a head-to-toe
assessment looking for evidence of trauma, funduscopic exam looking for papilledema, evidence
of prior craniotomy or shunts, enlarged thyroid,
meningismus, pneumonia, asterixis, track marks,
or other findings.
Routine Testing
Psychiatric consultants may request a myriad of
specific tests, although a period of observation
may prove more valuable, since toxins in general
metabolize and require 4–6 hours of supportive
care in an ED or observation setting. The American College of Emergency Physicians (ACEP)
suggests that “Focused Medical Assessment”
better suits the process of determining if a medical disease is the cause of the patient’s symptoms
or needs to be acutely treated.
18
Medical clearance generally entails three
components:
1. No physical illness is found in the patient
2. Coexisting medical problems are determined
not to be the primary cause of the acute
psychiatric symptoms
3. An acute medical condition was stabilized
Laboratory testing may vary depending on each
facility, department, and personal practices of the
physician and should have input from the
psychiatric service. The history and physical
examination is clearly important in medical clearance, while unfocused routine laboratory testing
is unnecessary. Pregnancy testing in female
patients over the age of 16 should be performed.
19
The presence of an established psychiatric diagnosis coupled with a lack of a specific medical
complaint, negative physical findings, and stable
vital signs appears to identify a subgroup of
patients for whom laboratory testing is not
necessary.
20,21
That said, a recent survey found that such
testing was required of 35% of a sample of emergency physicians ran domly selected through
ACEP membership rolls. Of those required to
perform routine testing, 84% were required by
the psychiatric service or referral institute. The
most commonly required tests were serum alcohol and urine toxicology.
4
If the patient is taking
lithium, specific levels may be warranted due to
neurologic sequelae, including seizures.
Other commonly requested tests include:
complete blood count (CBC); bedside glucose;
electrolytes; BUN/creatinine; blood alcohol; pregnancy testing; serum and urine for cocaine, phencyclidine, and amphetamine; urine analysis and
culture; arterial blood gases; calcium; creatine
phosphokinase (CPK); thyroid function testing;
liver function tests; ECG for evaluation of QT
interval; and cranial computed tomography.
Testing shou ld be directed by the clinical
Quick Confusion Scale
Question Response Weight Score (product)
What year is it? 0 or 1 (0 if incorrect, 1 if correct) x 2
What month is it? 0 or 1 (0 if incorrect, 1 if correct) x 2
Give memory phrase John Brown, 42 Market Street, New York
(no score given for repetition of phrase)
What time is it? 0 or 1
(1 if within 1 hour, 0 if not)
x2
Count backward from 20 to 1 0, 1, or 2
(2 if no errors, 1 if one error, 0 if two or more)
x1
Say the months in reverse 0, 1, or 2
(2 if no errors, 1 if one error, 0 if two or more)
x1
Repeat the phrase 0, 1, 2, 3, 4, 5
(score each portion remembered as 1 point)
x1
For each response count the number of errors and multiply by the weight to determine the total. The possible score ranges from 0 to 15.
A score of less than 12 suggests a need for further evaluation and a score of 7 indicates almost certain cognitive impairment.
Psychiatric Patients
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presentation rather than by protocol. Patients
with altered mentation may not be appropriate
for observation care.
Recent evidence indicates that patient selfreporting is quite accurate regarding drug and
ethanol use.
20,21
Testing does increase both cost
and time, and patients with straightforward psychiatric complaints have been medically cleared
without a urine toxicology screen.
22
A patient cannot be medically cleared if
impaired by alcohol. However, there remains no
evidence-based literature supporting the notion
that there is a specific blood alcohol concentration
where patients regain decision-making capacity or
when psychiatric symptoms become more apparent without the confounding influence of alcohol.
Cognitive function should be assessed on a caseby-case basis if alcohol is involved. Protocols aside,
urine drug screening has seldom proven helpful
either in treatment or in influencing disposition.
Imaging and Medical Clearance
One study of healthy military recruits with new
onset psychosis revealed no clinically significant
findings on head computed tomography (CT)
scan.
23
A more recent study of 397 patients with
psychiatric complaints and no focal neurological
findings indicated that 95% of the head CT scans
showed no abnormality. Abnormalities seen in
the other 5% were all deemed to be unrelated to
the patient’s condition. In all, the probability of
any relevant abnormality was not greater than
finding one in the general population.
24
Head
CTs should generally be reserved for patients
with HIV, a history of trauma or cancer, focal
neurologic findings, or altered behavior or mental
status changes. If a head CT is truly indicated, the
patient should probably not be primarily managed on a psychiatric service.
It has been suggested that there are groups
of patients who are at high risk of medical illness:
(1) the elderly, (2) patients with a history of substance abuse, (3) patients without a psychiatric
history, (4) patients with preexisting medical disorders, and (5) patients from a lower socioeconomic level.
25
The threshold for testing might be
lowered in these individuals.
Summary
Patients with alterations in mental status must
receive an appropriate medical diagnostic workup.
Any abnormal vital signs must be addressed and
should normalize within a 24-hour stay if due to
anxiety. History and physical examination is critical, including medication history. Testing should
be guided by the history and physical examination
findings. No single battery of tests will pick up
every metabolic or structural abnormality that
might affect patient behavior. Universal laboratory
and toxicologic screening of all patients with psychiatric complaints has a low yield and generally
does not affect care. It is desirable to coordinate
protocols for screening with the desires and needs
of one’s psychiatric service. Finally, it is notable
that the term “medical clearance,” cannot ensure
that a patient is indeed clear of all medical
conditions.
References
1. Chang G, Weiss A, Kosowky
JM, et al. Characteristics of
adult psychiatric patients with
stays of 24 hours or more in the
emergency department.
Psychiatr Serv 2012 Mar 1; 63
(3): 283–286.
2. Ting SA, Sullivan AF, Miller
JA, et al. Multicenter study of
predictors of suicide screening
in emergency departments.
Acad Emerg Med 2012 Feb; 19
(2): 239–243.
3. Riba M, Hale M. Medical
clearance: fact or fiction in the
hospital emergency room.
Psychosomatics 1990;31
(4):400–404.
4. Broderick KB, Lerner EB,
McCourt JD, et al. Emergency
physician practices and
requirements regarding the
medical screening examination
of psychiatric patients. Acad
Emerg Med 2002;9(1):88–92.
5. Williams ER, Shepherd SM.
Medical clearance of psychiatric
patients. Emerg Med Clin North
Am 2000;18(2):185–198.
6. Larkin GL, Claassen CA,
Emond JA, et al. Trends in U.S.
emergency department visits
for mental health conditions,
1992 to 2001. Psychiatr Serv
2005;56:671–677.
7. Allen MH, Forster P, Zealberg
J, et al. APA Task Force on
Psychiatric Emergency Services:
Report and Recommendations
regarding Psychiatric
Emergency and Crisis Services.
American Psychiatric
Association, 2002.
8. Broder JS, Olshaker JS. Medical
clearance of psychiatric
patients. Crit Decis Emerg Med
2001;16(4):7–11.
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9. Dorsey ST. Medical conditions
that mimic psychiatric disease:
a systematic approach for
evaluation of patients who
present with psychiatric
symptomatology. Emerg Med
Rep 2002;23(20):233–245.
10. Blumenthal SJ, Kupfer DJ. eds.
Suicide over the Life Cycle: Risk
Factors, Assessment, and
Treatment of Suicidal Patients.
Washington, DC: American
Psychiatric Association, 1990.
11. American Psychiatric
Association. Diagnostic and
Statistical Manual of Mental
Disorders. 4th ed. Washington,
DC: American Psychiatric
Association, 1994.
12. Frame DS, Kercher EE. Acute
psychosis. Functional versus
organic. Emerg Med Clin North
Am 1991;9(1):123–136.
13. Reeves RR, Pendarvis EJ,
Kimble R. Unrecognized
medical emergencies admitted
to psychiatric units. Am J Emerg
Med 2000;18(4):390–393.
14. O’Brien RF, Kifuji K,
Summergrad P. Medical
conditions with psychiatric
manifestations. Adolesc Med
Clin 2006;17:49–77.
15. Folstein MF, Folstein SE,
McHugh PR. “Mini-mental
state.” A practical method for
grading the cognitive state of
patients for the clinician.
J Psychiatr Res 1975;12(3):
189–198.
16. Stair TO, Morrissey J, Jaradeh
I, et al. Validation of the quick
confusion scale for mental
status screening in the
emergency department.
Intern Emerg Med
2007;2:130–132.
17. Irons MJ, Farace E, Brady WJ,
et al. Mental status screening of
emergency department
patients: Normative study of
the quick confusion scale.
Acad Emerg Med 2002;9:
989–994.
18. Lukens TW, Wolf SJ, Edlow JA,
et al. Clinical policy: critical
issues in the diagnosis and
management of the adult
psychiatric patient in the
emergency department. Ann
Emerg Med 2006;47:79–99.
19. Korn CS, Currier GW,
Herdersen SO. “Medical
clearance” of psychiatric
patients without medical
complaints in the emergency
department. J Emerg Med
2000;18(2):173–176.
20. Olshaker JS, Browne B, Jerrard
DA, et al. Medical clearance
and screening of psychiatric
patients in the emergency
department. Acad Emerg Med
1997;4(2):124–128.
21. Shihabuddin B, Hack C, Sivitz
A. Role of urine drug screening
in medical clearance of
psychiatric pediatric patients: is
there one? Ann of Emerg Med
2010;56(3):144.
22. Fortu JM. Psychiatric patients
in the pediatric emergency
department undergoing
routine urine toxicology
screens for medical clearance:
results and use. Pediatr
Emerg Care 2009;25
(6):387–392.
23. Bain BK. CT scans of firstbreak psychotic patients in
good general health.
Psychiatr Serv
1998;49:234–235.
24. Agzarian MJ. Use of routine
computed tomography brain
scanning of psychiatry patients.
Australas Radiol 2006;
50(1):27–28.
25. Gregory, RJ, Nihalani ND,
Rodriguez E. Medical screening
in the emergency department
for psychiatric admission: a
procedural analysis. Gen
Hosp Psychiatry 2004;26:
405–410.
Psychiatric Patients
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Subpart IVQ
Chapter
61
Clinical – Disasters
Disasters
Constance J. Doyle, MD
Introduction
A disaster is defined as occurring when needs
outstrip resources, and is dependent on circumstances, as well as on community and mutual aid
resources. Preservation of the medical infrastructure and doing the greatest good for the greatest
number are the goals of medical surge. Altered
standards of care or “crisis standards of care”
allows equitable sharing of scarce resources to
provide the best possible care for the maximum
number of patients. When the local medical infrastructure is overwhelmed during a disaster and
hospital capacity is overextended, there must be a
plan for allowing hospitals alternate ways of
caring for increased numbers of patients and for
alternative ways of staffing for these increased
needs. The use of observation beds both in the
hospital and outside the hospital can provide
some of the needed additional bed capacity.
In-Hospital and Inter-Hospital Surge
When hospital beds are full, patients may be
accommodated in units within the hospital that
would be underutilized in a disaster including
elective diagnostic testing units with recovery
beds, such as gastroenterology procedural suites
for endoscopy and colonoscopy, and outpatient
elective ambulatory surgery units. If the disaster is
taxing hospital resources, elective surgeries may
be cancelled and post anesthesia care unit
(PACU) beds would have some capability as well.
Community and regional planning among hospitals may allow some movement between hospitals to transfer sicker or more injured patients
to hospitals with greater tertiary type capability
and to allow the movement of general care floor
patients to be “ downloaded” to general hospitals.
The Joint Commission requires that hospitals
participate in community planning with community partners: emergency management, public
health, emergency medical systems (EMS), their
medical staffs, and other hospitals.
1,2,3
When hospitals have exceeded capacity, sometimes defined
by surge plans as an amount over normal
capacity,
4,5,6
then the transfer of patient care to
outside resources beyond the local/regional hospital infrastructure may be needed. Regional and
state disaster plans will help to define how this
patient surge is to occur, as well as identifying
transportation resources. A secure, well-integrated
patient tracking system is essential to locate and
relocate patients, for integrated record keeping,
and to allow family access, if needed.
Alternate Care Facilities
Under the grants from the Health Resources
Service Administration (HRSA), which is now the
Assistant Secretary for Preparedness and Response
(ASPR),
7
states have been tasked with the planning
and coordination of multiple levels of medical care
and the surge of medical care and resources in
disasters.
8
This would include expansion of services
that can be considered observation, and ward care
facilities as well as facilities for triage, prophylaxis,
education, and expansion of home care services.
Regional Medical Coordination Centers (MCCs)
may be activated for the organization and coordination of hospital and regional resources. Medical coordination and hospital coordination allow
sharing of resources and responses and are coordinated by a regional MCC, a regional Emergency Operations Center (EOC) health division or by county
medical or public health jurisdictions. Public health
is the coordination point in some plans. Regional
MCCs then coordinate with the state’smedical
branch of operations under a state’sEOC.State
coordination of intra- and interstate resources is part
of the National Response Framework.
8
Interstate
coordination with federal and state partners occurs
at the federal level.
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