American Association for Emergency Psychiatry Recommendations to Address Psychiatric Staff Shortages in Emergency Settings

The PEC must perform independent psychiatric and substance abuse evaluations, with a focus on triage, stabilization, and safety assessments. Strong skills in triage, assessment, differential diagnosis, treatment planning, and documentation are required. The PEC should be able to perform evaluations independently and recommend necessary treatments for a variety of behavioral health conditions. Although some presentations of psychiatric or behavioral disturbances may be clear cut, others may be more nuanced or the result of underlying medical illnesses. Clinicians must quickly determine whether someone needs medical observation or workup even before additional mental health intervention can proceed. The core competency in psychiatric assessment is a developed skill set unique to psychiatric clinicians—one that involves rapid establishment of rapport concurrent with diagnostic interviewing.

The PEC must be able to perform a comprehensive mental status examination, including but not limited to assessment of mood, anxiety, psychosis, cognition, insight, and judgment. Some training will likely be required for clinicians to recognize general medical comorbidities or toxic conditions and when medical consultation is necessary. The PEC must have a basic, practical understanding of medical issues and the effects of substances, including but not limited to physical illness and intoxication syndromes and, for more experienced clinicians, adverse drug effects and interactions.

In addition to eliciting the chief complaint, the PEC must have the acumen to ascertain an underlying need or request, especially regarding reluctant patients, malingering patients, or patients who have been brought to the ES against their will (9, 10). In some cases, a more detailed evaluation may need to be deferred in the interest of safety for the patient, other patients in the ES, or caregiving staff. Instead, a brief assessment resulting in a focused differential diagnosis is conducted.

The ability to gather collateral information from sources other than the patient is required to make an accurate clinical appraisal and to identify care needs. This process often begins when a patient is first brought to the ES (with important input from first responders and law enforcement officers) and continues throughout an episode of care in discussion with family members, friends, guardians, case managers, psychotherapists, outpatient physicians, and other invested parties. Central to the process is risk assessment, requiring attention to imminent potential for suicide, homicide, or impaired judgment that could result in unsafe behavior. The PEC must then be able to document the assessment and the corresponding treatment plan clearly and concisely.

The patient presenting with suicidal ideation is a common example of a clinical scenario where strong evaluation skills are needed. A PEC with knowledge of psychiatric assessment and therapeutic interventions can make a professional determination that discharge may be a better option for some of these patients. Work of this kind requires the PEC to have advanced training to carry out targeted and systematic safety assessments. Ideally, the PEC provides leadership and consultation to medical and nursing staff. In turn, the emergency physician receives expert opinions on a variety of high-stress situations. This scenario would include patients for whom hospitalization may be expedient or appear safer but would not necessarily offer the best clinical pathway.

In the role of expert consultant, the PEC not only collaborates with staff but also serves as teaching faculty for medical students, residents, and other trainees. The PEC takes leadership in providing clinical opinions, collaborating with individuals from other disciplines, and sharing expertise between and among members of the clinical team.

The PEC must manage behavioral emergencies (using verbal de-escalation to obviate the need for restraint). The PEC must be skilled at verbally de-escalating the agitated patient and working collaboratively with nursing staff, security, and police. There is evidence that effective verbal de-escalation can reduce the need for restraints and forced medications (13). Psychiatric literature and experiential training programs, such as the Crisis Prevention Institute (CPI), can assist clinicians in developing this competency (6). Supervision by a more senior clinician can provide an added layer of expertise.

The PEC must assist in the recognition of general medical illnesses, states of intoxication and withdrawal, and adverse drug reactions presenting as behavioral health emergencies. An essential competency is the ability to recognize that medical illness, intoxication and withdrawal states, and adverse drug reactions can all give rise to behavioral emergencies. The PEC must have a high index of suspicion for undetected medical illness (14, 15) and be able to assess the need for medical evaluation—or, in some cases, reevaluation—when further information is elicited or obtained. The PEC must be effective in engaging emergency doctors in persuasive but respectful conversation when negotiations are necessary to revisit medical clearance decisions that have already been made.

A basic understanding of vital signs, medications, and general medical conditions and their potential impact on a patient’s mental status and physical presentation is essential. The PEC is not expected to diagnose medical illness but rather to recognize when a behavioral health presentation may have nonpsychiatric contributing factors and to request medical evaluation. PECs have a unique advantage: they can spend longer periods with the patient and engage collateral resources. This ability not only aids an emergency physician in treatment planning but also can reveal more nuanced elements of the patient’s history and help physicians identify possible medical issues manifesting as psychiatric disturbance.

The PEC must develop appropriate treatment plans, including disposition planning, determination of potential need for medications, and subsequent impact of such treatment. The PEC conducts an assessment that includes both an understanding of the underlying biopsychosocial issues and a working differential diagnosis. The PEC may provide immediate crisis intervention and interact with family and other collaterals to assist with discharge disposition and outpatient follow-up. If admission is indicated, the emergency physician and PEC can even begin treatment, in consultation with a backup psychiatrist, while a bed search is conducted. In these situations, the PEC can follow the patient while the patient is in the ES. The PEC can observe the patient for both symptom reduction and side effects in collaboration with the medical and nursing staff. Initiation of treatment in the ES can alleviate acute symptoms of distress and may improve a patient’s well-being to the point of stabilization and discharge. When treatment is begun in the ES, staff morale improves because they can directly observe a move toward recovery, instead of providing only custodial care while boarding the patient. Mutual trust among the PEC, emergency physician, and ES staff is crucial to design such treatment plans. An experienced PEC can have enormous impact on individual patient care and, by extension, on the local mental health system.

The PEC must recognize circumstances in which specialized consultation from a psychiatrist is indicated. Knowing one’s limits and determining when to call for consultation is essential. The type and the timeliness of supervision will vary depending on whether a PEC is working directly with a psychiatrist or with an emergency physician as backup. Although, ideally, the PEC would have a psychiatrist for clinical backup and supervision for patients with complex presentations, this arrangement may not always be possible if local resources are limited. If the psychiatrist is the supervising physician, a PEC’s scope of practice may encompass broader aspects of psychiatric evaluation and treatment. In either case, it is recommended that the PEC’s institution clearly determine the level of supervision and liability of both the PEC and supervising physicians.

The PEC must possess self-awareness and recognize clinician-patient dynamics that may complicate medical and psychiatric examinations. Temperament is key. A PEC who is comfortable working in a fast-paced and sometimes chaotic environment, where decisions need to be made quickly and often with limited data, would do well. Those with experience in inpatient psychiatry or suicide prevention are particularly well suited to this role because of their familiarity with acute psychiatric presentations. A successful PEC is someone flexible enough to move out of the role of traditional psychotherapist (13). He or she must be comfortable with a biopsychosocial model of practice and be willing to learn the basics of general medical illness, pharmacology, and laboratory and radiological findings.

Self-awareness is important for effective management of psychiatric emergencies. When severe agitation, character pathology, or family dysfunction are encountered, the ability to recognize one’s own countertransference reactions to such situations can be of clinical benefit. The ability to help the ES staff acknowledge their own reactions to psychiatric patients is another valuable tool for effective communication and optimal treatment. Countertransference and stigma are powerful factors with clinical relevance in the ES.

The PEC should demonstrate knowledge of medicolegal issues, such as involuntary holds and decision-making capacity. The ability to assess and then clearly document a rationale for involuntary psychiatric hospitalization is crucial. The initial assessment leading to treatment against a patient’s expressed wishes is medicolegally essential in the justification of subsequent interventions that impose upon a patient’s autonomy. The PEC may be asked to comment on the decisional capacity of patients who refuse medical treatment, admission, or a necessary procedure. A working knowledge of the concept of capacity is essential to properly advocate for patients. Also necessary is knowledge of how legal determinations (i.e., decision making and involuntary treatment) are made in the jurisdiction both where the patient resides and where treatment is proposed (16).

The PEC must collaborate with ES clinical teams across disciplines and specialties. Working in the ED requires an ability to collaborate with medical professionals from multiple disciplines, including emergency physicians, P.A.s, N.P.s, registered nurses, and a host of ancillary staff. All emergency personnel work at a fast pace, and their workflow is designed for urgency.

However, many clinicians have previous training and expertise in clinical care settings that place value on slowing down and focusing on fine details to fully evaluate the patient. This is not always possible in the ES. It is important for the PEC to balance the benefits of slowing down with the need for efficiency in the ES.

A focused examination is preferred over a detailed diagnostic workup or intake usually done in a traditional outpatient clinic setting. Even before meeting with a patient, the clinician should have a sense of the patient’s or emergency physician’s request and of what symptoms to look for and should be able to form hypotheses regarding the differential diagnosis, potential treatment, and disposition options. The PEC must be comfortable making decisions based on the limited data and resources available in the ES, especially during evening and weekend hours when community connections are difficult to obtain. Otherwise, patients will remain in the ES well past what can be tolerated by the demands of patient flow.

The PEC can help emergency providers manage their own expectations about what is necessary for high-quality and efficient emergency psychiatric care. The PEC can assist the ES staff in recognizing that speaking with and understanding psychiatric patients simply takes more time and depends on measures that do not provide definitive results (e.g., lab tests) to guide decision making. Psychiatric patients may still have longer stays, but they can also get better care when a PEC is present.

Often, the assessment of a patient is interrupted by other tasks, such as the arrival of an agitated patient or a call from collateral sources or an insurance company. The ability to multitask is crucial, with one case often impinging upon another. Finally, PECs doing this demanding work must be given resources to manage their own job stress as well as a schedule that allows for collegial interactions, ongoing learning, and time between shifts to sustain interdisciplinary relationships and personal well-being. Boxes 2 and 3 are schematics of the above recommendations.