New psychiatric guidelines: What ED nurses must know

Many diagnostic tests are unnecessary

New guidelines from the American College of Emergency Physicians will affect the way you care for adult psychiatric patients in your ED, according to Stephen J. Wolf, MD, a member of the panel that authored the guidelines and director of the emergency medicine residency program at Denver Health Medical Center.

"The implications of this policy are pretty profound," he says. "It hopefully will change the culture of EDs across the country." (To access the guidelines, go to www.acep.org. Under "Practice Resources," click on "Clinical Policies," "Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department.")

When patients present to an ED with a psychiatric complaint, many diagnostic tests usually are ordered up front, including a complete blood count, CHEM-7, liver function tests, and urine toxicology screen.

"ED nurses should be aware that a lot of these tests that are ordered in almost knee-jerk fashion. Our policy says they are not necessarily needed," says Wolf. "What should be ordered are only those tests driven by medical complaints that will result in a change in medical management."

Many psychiatric facilities will insist that certain tests be ordered to ensure that there are no medical issues that might arise while the patient is in their care, notes Wolf. "The thought is that extensive testing can ensure this. In fact, our review found that testing does not provided additional information over a thorough history and physical," says Wolf.

However, it is important for ED nurses to recognize that a psychiatric patient can have medical issues and that many psychiatric symptoms can be caused by medical illnesses, says Carol A. Ziolo, RN, LCPC, a mental health liaison specialist for the ED at Northwest Community Hospital at Arlington Heights, IL. "Medical clearance is crucial to a psychiatric patient’s treatment plan," she adds.

For example, Ziolo cared for one patient who complained of confusion and sadness, with a history of bipolar disorder. "We were ready to admit her to our mental health unit until her blood results showed she was in kidney failure," she recalls. "She want to a medical floor, and her mental status improved when her kidney function improved."

Another man came to the ED psychotic and disoriented with a history of a depression. "Everyone thought he was experiencing a psychiatric psychosis until a CAT scan showed he had bleeding in his brain that required surgery," says Ziolo.

At Northwest Community, the ED nursing director met with the psychiatric hospitalist and ED medical director to discuss the medical needs of psychiatric patients, and a decision was made to give psychiatric patients a "mental health panel" consisting of a complete blood count, comprehensive metabolic panel, urine drug screen, blood alcohol levels for patients with a history of alcohol abuse, and pregnancy test for all women of childbearing age.

Intoxicated patients are seen by a psychiatrist on a medical unit if they have taken a supratherapeutic ingestion of medication or harmful substance, says Ziolo. "We will also ask that a CAT scan of the brain be done in the ED if the patient has an altered mental status and no history of mental health issues," she adds.

Drug screens are important to determine if you need to watch for any type of withdrawal or the patient is in a substance-induced psychosis, says Ziolo. "Also, the drug screen can help determine disposition, mental health vs. substance abuse treatment, especially in adolescents," she says.

Agitated patients usually are medicated with haloperidol and lorazepam IM, says Ziolo.

"We offer PO [lorazepam] to people who are anxious, agitated, but cooperative," says Ziolo. They haven’t been using ziprasidone as often because it is not as effective as haloperidol in chronic patients, she adds.

To keep staff current on pharmacological management of agitated patients, Ziolo and other mental health liaisons attend inservices from drug companies and educate ED nurses. "Also, we suggest the drug company representatives talk with the medical director of the ED so she can educate the ED physicians during their monthly meetings," she says.

Sources

For more information on care of psychiatric patients in the ED, contact:

  • Stephen J. Wolf, MD, Director, Residency in Emergency Medicine, Denver Health Medical Center, 777 Bannock St., MC 0108, Denver, CO 80204. E-mail: Stephen.Wolf@dhha.org.
  • Carol A. Ziolo, RN, MA, LCPC, Northwest Community Hospital, 800 W. Central Road, Arlington Heights, IL 60005. Telephone: (847) 618-4145. Fax: (847) 618-3996. E-mail: CZiolo@NCH.org.