Psychiatric care in emergency departments

Background. Psychiatric emergency situations (PES) are frequent in emergency departments (EDs). There are, however, only few investigations that focus on the prevalence of these patients or on diagnostic and therapeutic standards. These PESs in EDs should be treated according to standards comparable to medically disabled patients. Thus it is necessary to learn more about the diagnostic and therapeutic possibilities in EDs, about the procedures and the decision-making process whether these patients are transferred to further outpatient or inpatient treatment. Materials and methods. A survey was conducted in EDs throughout Germany and 1,073 were contacted and asked to participate. The questionnaire consisted of questions concerning the size of the ED and of the hospital (e.g. number of patients and physicians), the prevalence of psychiatric disorders, the diagnostic and therapeutic possibilities, standard procedures for dealing with PES and the method of care in six typical case reports. Results. A total of 74 EDs participated (76% interdisciplinary EDs) with an average of 22,827 +/- 12,303 patients per year in the ED. Psychiatry as a medical discipline was integrated into 10 EDs (14%) and psychiatric competence could be activated in 84% of EDs. Participating EDs reported prevalence rates of 15% mentally disordered patients and 9% of patients who required psychiatric diagnostic and therapeutic procedures. Of the patients 2% presented after suicide attempts and 3% were considered to be aggressive. Approximately 50% of all PESs were related to substance abuse disorders. An average of 2.5 +/- 4.2 (range 0-25)members of the medical and nursing staff were injured during a 1-year period by violent patients. Legal actions against the will of patients were initiated in 81% of EDs. Standardized diagnostic screening instruments or self-rating questionnaires were used in only four EDs. As standard procedures for the diagnostic work-up of psychiatric patients (medical clearance) physical examination, measurement of heart rate and blood pressure and conducting of some laboratory tests (glucose, blood cell count, electrolytes and renal function) were named. Diazepam (91%), lorazepam (88%) and haloperidol (87%) were considered to be indispensable psychopharmacological agents in the ED. Conclusions. In the majority of participating EDs, diagnostic standards for PES were known but were not routinely applied. It has to be assumed that many psychiatric disorders, in particular suicide attempts and suicidal ideation are not discovered. In many EDs psychiatric knowledge was available but a psychiatric consultation was only rarely requested. Physicians in the ED report a high degree of legal uncertainty with psychiatric patients. The use of screening instruments is recommended.