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American Association For Emergency Psychiatry Newsletter Fall Issue 2011

Letter from the President Hello fellow AAEP members, This has been an exciting and very busy year for the AAEP. With 2012 rapidly approaching, it seems a good time to reflect back on an amazing 2011 for our organization. Meetings: January might have brought record snowfalls to the Eastern Seaboard, but that could not prevent President-Elect Dr. Seth Powsner and me from lecturing at the Connecticut Hospital Authority’s special program, “The Care of Psychiatric Patients in Emergency Settings.” AAEP had a booth at the event which resulted in several new memberships.

Scott L. Zeller, MD President 2010-2012

May found the AAEP shaking off the winter doldrums on the beaches of Waikiki for the APA Annual Meeting. AAEP’s course on Emergency Psychiatry, just steps from the ocean, was well-attended and resulted in a nice feature in Psychiatric News. A good-sized group of AAEP members taxied to Queen’s Medical Center for an interesting tour and presentation on Emergency Psychiatry in Paradise, followed by a reception at the RumFire restaurant – where we watched the sun set into the Pacific through the tiki torches as we noshed and networked. October brought the Institute for Psychiatric Services, which was perhaps the most active APA meeting ever for the AAEP. AAEP was involved in four presentations, including an Emergency Psychiatry course, a workshop on patient boarding, and the successful introduction of Project BETA (more on that in this issue). Former AAEP President Dr. Avrim Fishkind was a winner of the APA Gold Award for an innovative telepsychiatrybased PES in Texas. And a busload of AAEP members traveled across the Bay Bridge for a tour of the John George Psychiatric Pavilion, with an afternoon reception afterwards in the East Bay Hills. December led the AAEP to Las Vegas, where members combined with leaders in Emergency Medicine at the dynamic National Update on Behavioral Emergencies Conference. The brainchild of AAEP board member Dr. Leslie Zun, the conference ran for two full days and was very well-received .

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Inside this issue Institute on Psychiatric Services, San Francisco .......................... 3-4 Consult Corner ....................... 5-8


Letter from the President (continued) Members-only Listserv AAEP has recently created a listserv discussion group that is available via invitation to members in good standing only. This is a great opportunity to discuss pressing issues, diagnostic dilemmas and treatment approaches in Emergency Psychiatry, and obtain consultation from your fellow experts on difficult cases. Please accept the invitation and join us today! There is nothing to fear, it will be

Education, Policy and Publications: The AAEP has been involved with multiple educational pursuits this past year. Without question, our biggest undertaking was the year-long Project BETA, the Best Practices in Evaluation and Treatment of Agitation collaboration. Over 35 emergency psychiatrists, emergency medicine docs, and other professionals combined in five workgroups to create guidelines on agitation evaluation and treatment. We are honored to have the entire product published as a six-article special section of the February 2012 issue of the Western Journal of Emergency Medicine. A special thank-you to everyone involved in the long journey to making BETA a success, especially project leader Dr. Bo Holloman for his tireless dedication. But BETA was just one of many educational undertakings. A team of AAEP members have produced a two-article series on protocols for medical clearance for psychiatric patients. Endorsed by the AAEP board, these papers may lead the way in clarifying the age-old controversies in medical clearance. More on those as their publication draws near.

very easy to unsubscribe if you choose to do so at a later time. If you have misplaced or did not received your invitation email, please contact Jacquilyn Davis at: AAEP@EmergencyPsychiatry.org.

The AAEP’s Web Conference series in 2011 may have been our best yet, with solid attendance for a great speaker line-up. The 2012 series is already in the works! The AAEP Journal, Emergency Psychiatry, made its triumphant return in 2011, shepherded by Dr. Seth Powsner. And for those members needing more urgent information and advice, our members-only listserve was active and lively with discussions and questions on a variety of topics in Emergency Psychiatry. The AAEP website’s members-only section was also a useful resource around the clock. Coming in 2012 – even more! The AAEP is continuing its busy ways on into next year. Among the exciting prospects for 2012: A “Centers of Excellence” project to determine standards for the best in Emergency Psychiatry delivery systems (please let us know if you are interested in participating!) Contributing to a French television documentary (for “the Parisian 60 Minutes” newsmagazine) on Emergency Psychiatry in the USA Collaboration on a project to improve Emergency Psychiatry-Partial Hospitalization Program relationships Collaboration on a project to increase peer participation in Emergency Psychiatry Involvement in group projects with other specialty organizations, both in psychiatry and emergency medicine And these are just what we know about now – by next month it wouldn’t surprise me if this list triples. There has never been a better time to be a member of the AAEP, and we have had a huge influx of new members this year. We hope you are enjoying and utilizing your membership. Please tell your colleagues about us, so we may continue to grow and expand the Voice of Emergency Psychiatry. All the best for a happy and healthy holiday season and a joyful new year,

To contribute to future editions of Emergency Psychiatry, send your submissions to: AAEP@EmergencyPsychaitry.org

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Scott


Institute on Psychiatric Services, San Francisco October 27 - October 30, 2011 Members of the American Association for Emergency Psychiatry joined hundreds of medical professionals in San Francisco, CA, October 27—30, 2011 for the American Psychiatric Association’s 63rd Institute on Psychiatric Services (IPS) Conference. The AAEP held various events during the IPS. Presentations given by members of the AAEP included Patient Boarding Within the Psychiatric Emergency Department: Identifying the Causes and Developing Solutions, Psychiatric Emergency Services: A Contemporary Paradigm of Care (an AAEP Course), and the greatly anticipated Symposium, Project BETA: Best Practices in Evaluation and Treatment of Agitation. Each presentation had an impressive turnout, especially Project BETA, that although was held on the last day of the conference had over 50 professionals in attendance. During the IPS conference, AAEP hosted the fall Social Event for its membership, which included a site visit of John George Psychiatric Pavilion (JGP) in San Leandro , CA and an outdoor reception at the home of President, Dr. Scott Zeller. Beginning in the early afternoon, members met outside of the San Francisco Marriott Marquis Hotel and boarded a mini coach bus provided by Peninsula Tour. Members enjoyed networking on the bus in this comfortable and casual setting while traveling to JGP. The Pavilion is home to Dr. Scott Zeller who is Chief of the Psychiatric Emergency Service. Members were warmly welcomed by JGP staff and were given a tour of the facility and the opportunity to ask a variety of questions about the facility, their policies, and experiences. After an introduction

Dr. Scott Zeller (right) presenting Dr. G.H. Holloman (left) with a certificate in appreciation for his dedication and service to Project BETA.

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AAEP members and staff member, Jacquilyn Davis, posing for a group photo during the Fall Social Event at Dr. Scott Zeller’s home.

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IPS 2011 (continued)

AAEP Members aboard the Peninsula Tour bus during the fall Social Event.

and Q&A session, members were split into two groups to view the PES and the grounds. Following the site visit, members re-boarded the bus and traveled to the home of Dr. Zeller for a casual reception. The conversation of the ride echoed with interest in the practices of JGP and how it compared to others facilities. Upon arrival, John George Pavilion, San Leandro, CA members were greeted by Dr. Zeller and his wife, who graciously provided food, beverage and a beautiful atmosphere for everyone to relax and mingle. During the reception, Dr. G.H. (Bo) Holloman was honored for his hard work and dedication to Project BETA which would be presented the next morning at the final day of the IPS conference. Everyone applauded his efforts and those of the entire group. At the close of the reception members enjoyed the ride back to the hotel, seeing the sunset over looking icons of San Francisco including Treasure Island, Alcatraz, and the Golden Gate bridge. With each Social Event, the number of participants grow. We hope that you will consider joining us in Philadelphia in May 2012 for our next event. Details will be sent to all active members so be sure to pay your dues in January to remain in good standing. All Social Events are free to members of the AAEP and are a valuable experience that should not be missed.

AAEP Members at the reception

Audience members during the Project BETA Symposium

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Project BETA presenters from left to right: Michael Wilson, Janet Richmond, Kimberly Nordstrom, Daryl Knox, Rachel Glick, G.H. Holloman, Scott Zeller, and David Pepper.


Consult Corner: The Safety Talk By: Jon Berlin, MD

Q: I took a job in a psych ED starting when I graduate in June, but my husband thinks I’m crazy. We plan to get pregnant next year and he’s worried about my safety. I’ve never worked in a PES before, but I like a challenge, and my favorite supervisor always said, “A patient is a patient.” Besides, they told me I can work as many or as few hours as I want, and I like being done when I’m done and not taking home a pager. I asked my future medical director about it. She said I’d be fine as long as I was careful. Then she joked, “Just don’t get hit, sued, fined, burned or behind.” She seemed nice, but I was too nervous to ask her to elaborate. Any thoughts? Signed, Nervous in the Service A: Safety is the first and last word of working in an ED. If it’s well run, I agree that you should be fine. It always makes me a little nervous when pregnant staff work up until the end, but it hasn’t been a big issue as long as they’re careful. You might consider waiting a few months on starting a family till you feel you know the ropes. Long hours in the ED may have warped your medical director-to-be’s sense of humor, and I hope she was just being funny, not careless with your concerns. Making you and your husband feel comfortable is part of her job. She sets the tone for the whole service, and a lot depends on her. If you’re really uneasy, you might want to check out what some of the other staff psychiatrists say about her. But if I understand her little quip correctly, I think there’s some wisdom in it. Fleshed out, it’s not a bad orientation to your first day. Taking her five warnings one by one: Personal safety: not only is your personal safety number one for selfish reasons, it’s hard to think straight when you’re feeling unsafe, and your number one job there is to think. Take another look at the service. Reassure yourself that new patients are checked at the door for weapons and contraband and screened right away for emergency conditions by skilled security and triage nurses. Find out where the safest places are for you to evaluate patients. When you begin work, approach agitated, angry, intoxicated or unpredictable individuals from a safe distance, and always know your escape route. Some interviews can only be done with staff standing by for an appropriate show of force. Be particularly careful if you are confronting someone or giving “bad news” at the end of an evaluation, e.g., when telling someone who really wants to go that he has to stay, or telling someone who really wants to stay that he has to go. It’s a rare occurrence to get hit in a well run PES, but these are the times that I’ve seen it happen, and they are avoidable if you don’t underestimate how much power you wield and how much impact your words have on people, especially if they are pathologically energized or disinhibited. You say you like a challenge. That’s good, but don’t ignore fear and discomfort. They’re the signal your antennae give you when someone is dangerous, and you need to trust your intuition. In terms of emotional safety, my only advice is don’t commit to more shifts than you know

Do you have a question for Dr. Berlin? Email: jberlinmd@gmail.com and your question may appear in the next issue.

Interested in writing for the Newsletter? All members of AAEP are invited to submit articles for publication the Newsletter. We welcome articles relevant to the field of Emergency Psychiatry from all perspectives: psychiatrists working in a PES, social workers, nurses, students, or physicians in the field. Newsletters are sent to the Membership electronically on a quarterly basis. For deadlines and additional information on how you can contribute to the Newsletter, please contact Jacquilyn Davis at 888-945-5430 or email AAEP@EmergencyPsychiatry.org.

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Consult Corner (continued) you can handle. After you get the feel of the place, think about how long-term you’d like to work there and pace yourself accordingly. It’s great work, but it can be grueling and you’ll get burned out if you overdo it.

“...whether a patient is admitted to an inpatient unit or is treated and released, the goal is to turn an acute patient into an outpatient.”

Medicolegal safety: Bad feelings plus bad outcomes are what lead to lawsuits. It’s inevitable that at times you’ll be making some patients or their families unhappy. Don’t announce an adverse disposition to a patient and then walk away. Give him some time to react and help him express his displeasure appropriately. Correct any misconceptions or misperceptions he might have and reassure him that your decision is based on concern for his welfare. Repeat this as many times as necessary until he hears you. This mitigates bad feelings. (It also increases personal safety of everyone in the area.) The other way to mitigate bad outcomes, besides practicing good medicine, is to have really good documentation. PES’s and ED’s are usually experts at releasing people who are safe but who still have significant risk factors, but they’re not good at writing out their rationale. Be sure to chart the protective factors, what you’ve done to mitigate the risk factors and, most importantly, what your medical decision-making was. This is what they’ll ask of you if there’s ever a bad outcome and someone wants a deposition. “What were you thinking?” If your charting is good, they really don’t have a case. For example, if one of your discharges has a bad outcome, you’ll hope you’ll have written such things as: “Protective factors in this case carry more weight than risk factors”; “Patient is not a high, short-term risk to himself or others”; “Patient collaborated in aftercare planning and prefers non-hospital treatment”; “Patient declines hospitalization, and the risks of coercive care (damaged therapeutic alliance, interference with work and relationships, increased stigma) outweigh the benefits (increased immediate safety, more concentrated evaluation and treatment, more data to support decision to release).” If there’s a bad outcome and you’ve discharged the individual because he seemed to be exaggerating his risk, you’ll hope you’ll have written such things as: “Chronic self-destructive potential is not responding to hospitalization”; “Acceptance of risk is the price of outpatient care”; “Hospitalization might worsen a problem with dependency”; “Contingent suicidality: Patients who threaten suicide if discharged are typically not high risk”; “In unguarded moments, patient does not appear to be in as much crisis as he or she reports.” In general, collateral contacts, second opinions, referrals, safety plans, and cautionary warning (e.g., avoid guns and alcohol) are particularly important to document. Statutory safety: Don’t get fined for an EMTALA violation. The Emergency Medical Treatment and Active Labor Act is the federal law passed in 1986 enforcing ethical practices in the ED/PES. Inspection for compliance is mainly complaint-driven, but violations may incur, for you and your hospital, multi-thousand dollar penalties, not to mention a lot of grief. First, EMTALA says all patients presenting to an ED must be screened for Emergency Medical Conditions. Emergency psychiatric conditions are included in the definition and ED’s must stabilize emergency conditions to the best of their ability. Don’t fall into traps that people may set for you. For example, a new nurse tells you that there’s a minor alone at the door asking for a Ritalin refill, so they’re telling him to leave and see his regular doctor. You’re uneasy about this but the nurse says you’d get in trouble for seeing the patient without guardian consent and “this is how we’ve always handled these.” What do you do? Answer: Obey EMTALA. Screen the teenager for emergency medical and psychiatric conditions. (Continued on page 7)

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Consult Corner (continued) Federal law trumps all other law: city, county and state. Period. EMTALA also regulates transfers between hospitals. The sending hospital must get acceptance from the receiving hospital before initiating a transfer. The receiving hospital can decide who will be its accepting person. Some hospitals require it to be an attending. Some let residents or intake coordinators accept transfers. A receiving hospital must accept the patient if it is an appropriate facility and has capacity. What if, for example, a nursing home-type patient from an out-of-state hospital ED shows up by ambulance at your doorstep? There was no transfer call and no paperwork. You’re working in a hospital that by state statute exists solely to serve persons in your county. What do you do? Answer: Obey EMTALA. Screen the patient for emergency medical and psychiatric conditions. Once you’ve done that, you can explore your options, focusing first on what is in the patient’s best interest. Medical safety: (“Don’t get burned”). There are different ways to get burned, but the most common way is accepting a patient whose medical condition is more serious than you were aware of and more difficult than you can reasonably handle. ED docs generally treat you as a comrade of the trenches, but by and large hospitalists don’t, if for no other reason than they are under even more pressure discharge patients. ED docs can always admit, but hospitalists can only discharge. Medicine and surgical teams usually relegate the job of calling you to someone low on the totem pole. Never take report from a medical student, and if the resident’s report isn’t perfect, speak to the attending. In our experience, fielding these calls is one of the very hardest core competencies in a PES. It takes a while to develop a nose for medical dumps, but clues are that the patient is elderly or has been on a medical service for three days or more. A picture is worth a thousand words. We have a low threshold for sending out a nurse or doctor mobile team to see the patient before accepting, and we recently adopted a new policy of seeing all patients in person who have been on a medical service three days or more, as well as reviewing a faxed discharge summary first. On the phone, the most important questions for you to get answers to are: Why did the ER hospitalize him? (Med teams often aren’t sure.) Is the patient walking, talking, eating, and drinking? Does he have any special ports, equipment, or special care needs? Does he have any other medical conditions that were not a focus of care? I once asked the ED physician this question and was told, yes, diabetes. When I asked, I was told the serum glucose was in the high 400’s. The ED doc said the patient ran chronically high, but our hospital’s limit is 315. It’s very rare for referring doctors to lie, but they are under a lot of pressure to move patients out, and they aren’t above leaving some things out. Safety for discharge: I think what your director is referring to when she says “not to get behind” is, among other things, the need for you to work efficiently. This requires always having the desired outcome in mind and working toward it from the moment a patient comes to you. Patients are brought in because they’re unsafe. So the desired result is that they become safe for discharge. That’s the bottom line, and whether a patient is admitted to an inpatient unit or is treated and released, the goal is to turn an acute patient into an outpatient. If you’re not so busy that you have to revert to the triage mode, this goal can often be accomplished in the emergency setting. When patients ask you when they can go, have your answer ready. Tell them, “When it’s safe to go.” Keep it simple. True, being safe to go entails 3 or 4 key ingredients, but you want patients working on them from the moment they arrive. For example, if they’re

“Federal law trumps all other law: city, county and state. Period.”

AAEP Job Board Be sure to visit the AAEP Job Board at: www.emergencypsychiatry.org/ jobs

Member of the AAEP receive a discount for posting positions. Contact the AAEP Office at AAEP@EmergencyPsychiatry.org to receive the coupon code.

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AAEP Board Roster

Consult Corner (continued)

President

not acting safe, help them begin by changing their behavior in the here and now, and changing their perspective. You’re not their enemy; you’re their advocate. Motivate them to work with you. If they want to go, they must give you and the team something to go on. Model how you want security and nursing staff to treat them. A person perceives the sum total of how he is treated during his stay as all a part of his treatment. Minimize how long he has to wait to see you. Catch high acuity early and intervene before it escalates. If people have to wait too long, they tend to act up or shut down. Whether people are overtly acute or not, you want to engage them quickly, help them open up, identify and treat the reason they’re here today. Help them get to the point. Discover the acute precipitant, the ‘why now?’ What made the person unsafe before he came to you? This is usually the most sensitive and closely guarded part of the history, and it requires you, the examiner, to be sensitive while you’re probing, but if he can figure out ‘why now’, he can develop a plan to deal with it better. If he can engage with you, he’s more likely to engage with outpatient therapy, which is usually needed for a safe discharge. If he can reengage social supports, he’s more ready for outpatient therapy. If he can defuse some of his acuity with talking about what hurts and, as needed, taking some medicine, this reduces his acuity and makes him more ready for outpatient therapy. Keep it moving. Don’t get behind. Your goal is safety for discharge.

Scott Zeller, MD SZellerMD@gmail.com

President-Elect Seth Powsner, MD Seth.powsner@aya.yale.edu Immediate Past President Anthony Ng, MD atng@emh.org Board of Directors: Leslie Zun, MD, MBA zunl@sinai.org Jagoda Pasic, MD, PhD jpasic@u.washington.edu Daryl Knox, MD Daryl.knox@mhmraharris.org Rachel Glick, MD rglick@umich.edu Social Work Liaison: Janet Richmond, MSW janetrichmond@att.net Past President - 2006-2008:

This is a quick orientation to your first day. The first four types of safety— personal, medicolegal, statutory, and medical—are concepts to be in your toolkit when you walk in the door. It will take time to appreciate their nuances and integrate them into working knowledge. The fifth type, efficiently achieving safety for discharge, takes years of practice, but at least you know what you’re working on. It is a lot to think about, but you can begin to think clearly if you— and your understandably concerned husband—are not worried about your safety.

Avrim Fishkind, MD afishkind@jsahealthmd.com Past President - 2004-2006: Jon Berlin, MD jberlinmd@gmail.com AAEP Executive Office Staff: Executive Director Jacquelyn Coleman, CAE AAEP@EmergencyPsychiatry.org Administrative Assistant Jacquilyn Davis AAEP@EmergencyPsychiatry.org

AAEP Member Announcements What’s going on with your Emergency Psychiatry facility, with you and your staff? We’d like to know and share it with other AAEP members in our informal newsletter. We invite you to share any news relevant to Emergency Psychiatry with your fellow members. Please send your announcements to us either by email or see the attached Announcement Form and send your news to: AAEP@EmergencyPsychiatry.org. American Association for Emergency Psychiatry One Regency Drive P.O. Box 30 Bloomfield, CT 06002 Phone: 888-945-5430 Fax: 860-286-0787 Email: AAEP@EmergencyPsychiatry.org Website: www.EmergencyPsychiatry.org


AAEP December Newsletter