Education and Training in the Psychiatric Emergency Service



Education and Training in the Psychiatric Emergency Service


Jennifer S. Brasch



Psychiatric emergency services (PESs) are well-established educational sites for many training programs (1,2). Programs need to capitalize on the numerous educational opportunities provided within a PES by providing a supportive and enriching educational experience for trainees. Inadequate training or poor supervision can lead to continued anxiety and insecurity in students, resulting in the perception of emergency duty as an unwelcome service responsibility for the duration of their careers (3). PESs need to promote quality educational experiences to encourage interest in psychiatry and emergency psychiatry as a career choice.

Using a PES as a clinical teaching unit has many advantages (3, 4, 5). The PES offers the best place to observe acute psychopathology, the effects of acute pharmacologic intervention, and the effects of crisis intervention counseling. It is an excellent setting for trainees to observe and perform numerous assessments to develop rapid assessment skills, and to learn to provide multiple treatment modalities in a crisis setting. A PES provides frequent opportunities to be exposed to the medicolegal aspects of psychiatry, including consent, capacity, and laws involving involuntary assessment and treatment. Trainees observe firsthand the effects of the psychosocial determinants of health when assessing PES patients and see the hardest-to-treat patients, a group that highlights the limits of our science and our health care system. Trainees learn to use collateral sources of information, to work within the financial restraints of the system, to become familiar with community resources, and to make rapid treatment decisions with limited information. In addition, the PES is an excellent setting for trainees to learn to work as members of multidisciplinary teams.

There are also challenges to using the PES as an educational site. The PES can be a potentially intimidating environment with a fast pace, unpredictable patient load and service demands, and an unclear role for trainees. This can potentially lead to considerable stress for trainees, especially with night call duties in a busy PES. In a PES, the risk of violence may be a greater danger for inexperienced trainees. Frequent expressions of anger or suicidal and homicidal ideation by patients may be difficult for trainees to handle, or patients may be intolerant of trainees’ limited skills. Trainees must cope with patients who harm themselves or engage in violence toward others and face the potential for liability. Seeing primarily hard-to-treat cases can be discouraging and skew a new trainee’s impression of psychiatry. Trainees may find disposition decisions difficult, or excess time dealing with third-party insurers frustrating (6). Finally, trainees may not be accepted by tightly knit teams, or they may encounter inadequate supervision and mentoring.

No other environment offers trainees the fast-paced excitement and clinical challenges of the PES. This chapter reviews educational activities within the PES, rotations for residents and medical students, clinical placements for allied health care professionals, and continuing PES education. In the PES, everyone has something to learn and something to teach.


PSYCHIATRY RESIDENT TRAINING

All psychiatry residents can expect to perform assessments within emergency settings during their training (1,2). Although patients with agitation, suicidal ideation, and other crises are most commonly seen within PESs, they can present in
any psychiatric setting. Therefore, all psychiatrists-in-training should become competent and comfortable in crisis situations (7). Residency training programs need to provide training in emergency psychiatry that promotes the care of patients in crisis as valuable and educational, not as simply a necessary service obligation.

The Accreditation Council for Graduate Medical Education (ACGME) includes training in emergency psychiatry as a requirement for psychiatry residents (8):


Emergency Psychiatry: This experience must be conducted in an organized, 24-hour psychiatric emergency service, a portion of which may occur in ambulatory urgent-care settings, but not as part of the 12-month outpatient requirement. Residents must be provided experiences in evaluation, crisis evaluation and management, and triage of psychiatric patients. On-call experiences may be a part of this experience (but no more than 50%). Programs must have organized PES services. These requirements are effective July 2007.

The American Association for Emergency Psychiatry (AAEP) has developed detailed training objectives (7) that expand on the ACGME requirements just described. These have been adapted to the ACGME competencies (9) format and are listed in Table 42.1.








TABLE 42.1 Training Objectives






















































    By the completion of a residency program, a psychiatric resident will be able to demonstrate the
    following competencies.
      Patient Care
    Residents must be able to provide patient care that is compassionate, appropriate and effective for
    the assessment and management of patients seen within a psychiatric emergency service (PES).
    This includes the following skills:

  1.     Prioritization Skills
        Given the responsibility of running a psychiatric emergency service, residents will:

    1. Triage patients presenting to the PES with acute psychiatric illness, symptoms, or distress,
      recognizing patients whose needs take priority
    2. Attend to the most distressed patients first
    3. For each patient, recognize and attend to emergent needs for medication, seclusion,
      restraint, searches, or monitoring
    4. Refer patients whose psychiatric symptoms are due to a medical illness promptly for
      appropriate medical care

  2.     Patient Assessment and Management Skills
        Within the limitations of time and resources in the PES, given a patient with acute psychiatric
        illness, symptoms, or distress

    1.     Perform an assessment including:

      1. A rapid, focused psychiatric interview to obtain all necessary data
      2. An appropriately detailed mental status exam
      3. A physical exam, as appropriate
      4. A risk assessment for suicidal and homicidal ideation
      5. Establishing a therapeutic alliance
      6. Demonstrating respect and empathy for the patient
      7. Adjusting the detail of the assessment to the needs of the patient and situation
      8. Obtaining collateral information (from family, other caregivers, old charts, etc.) when
        necessary (i.e., almost always)
      9. Ordering laboratory investigations and medical consultation, when appropriate
      10. Documenting the assessment accurately and legibly

    2.   Once an emergency psychiatric assessment has been completed, integrate the information by:

      1. Stating a differential diagnosis (using DSM-IV)
      2. Stating a preferred diagnosis
      3. Describing a brief biopsychosocial understanding of the patient and the current situation
      4. Using this brief biopsychosocial understanding to develop a treatment plan
      5. Explaining the factors used to reach the decisions that guide the treatment plan
      6. Documenting the proposed treatment plan

    3.     Using the assessment, diagnosis, and biopsychosocial understanding of an emergency
          psychiatric patient, initiate emergency management and treatment by:

      1. Providing appropriate feedback, counseling, and information to the patient and support
        persons
      2. Giving further instructions to staff to ensure the safety of the patient and staff (e.g., use
        of seclusion, restraint, searches, observation, etc.)
      3. Ordering appropriate emergency medications
      4. Ordering appropriate monitoring of the patient
      5. Demonstrating compassion and respect for the patient’s dignity
      6. Demonstrating verbal and nonverbal skills to de-escalate high-tension situations

    4.     Given a completed emergency psychiatric assessment, diagnosis, and biopsychosocial under
          standing, make recommendations for further treatment as appropriate by:

      1. Justifying the need for inpatient treatment
      2. Selecting appropriate outpatient treatment
      3. Explaining treatment recommendations to third-party payers
      4. Communicating (verbally and/or in writing) the assessment findings and patient’s needs
        to inpatient and outpatient treatment facilities
      5. Including social and family supports in treatment plans
      6. Recommending relevant community resources to patient
      7. Performing short-term crisis-oriented therapy when appropriate
      8. Initiating psychopharmacologic treatments, when appropriate

  3.     Crisis Telephone Call Skills
        Given a crisis phone call, respond appropriately by:


    1. Listening carefully
    2. Remaining calm
    3. Counseling the caller appropriately
    4. Notifying community resources (police, outpatient therapist, etc.) as needed

  4.    Child and Adolescent Emergency Psychiatric Skills
       Given a child or adolescent with a psychiatric emergency, perform an assessment, integrate the
        information, and manage the patient appropriately by:


    1. Utilizing a developmental approach
    2. Including a review of the child’s intellectual and emotional functioning and his or her social,
      interpersonal, educational, and physical functioning
    3. Obtaining a history of recent events, trauma, drug use, and maladaptive behavior
    4. Assessing family structure and relationships, and the supports and capacities of the family
      or agency who protects and cares for the child
    5. Demonstrating all the skills and competencies listed for adult patients
      Medical Knowledge


  1.    Knowledge areas essential to the PES include the following problems and diagnoses:

    1. Suicidal ideation
    2. Homicidal ideation
    3. Acute psychosis
    4. Acute intoxication and withdrawal
    5. Substance abuse and dependence
    6. Concurrent disorders (substance abuse and an axis I or II disorder)
    7. Psychiatric illness with medical symptoms
    8. Medical illness with psychiatric symptoms
    9. Depression
    10. Anxiety
    11. Acute exacerbation of chronic psychosis
    12. Personality disorders (especially borderline and antisocial)
    13. Side effects of psychopharmacologic agents
    14. Acute bereavement
    15. Acute psychic trauma
    16. Drug seeking
    17. Malingering or factitious disorder
    18. Victims of domestic abuse
    19. Situational problems, especially family, vocational, or scholastic

  2.     Residents must have and demonstrate knowledge of medicolegal issues relevant to emergency
        psychiatry by:

    1. Stating local laws on involuntary commitment
    2. Describing the process of finding a patient incompetent to consent/refuse treatment
    3. Stating local laws regarding public intoxication
    4. Stating local laws on confidentiality in emergency psychiatry describing specific exceptions to
      confidentiality, including the reporting of child abuse/neglect, elder abuse, domestic violence,
      and unsafe driving
      Practice-Based Learning and Improvement
    Residents must be able to investigate and evaluate their patient care practices, and appraise and
    assimilate scientific evidence to improve their patient care practices. Residents are expected to:
         A. Exhibit the ability to critically self-evaluate their psychiatric emergency skills and demon
              strate improvement as a result of such evaluations
         B. Incorporate material discussed in supervision within the psychiatric emergency service into
             clinical work
      Interpersonal and Communication Skills
   Residents must be able to demonstrate interpersonal and communication skills that result in effective
   information exchange by teaming with patients, their patients’ families, and professional associates.

  1.    Within an emergency setting, residents are expected to communicate effectively by:

    1. Obtaining the background and reasons for all consultation requests
    2. Providing timely, helpful recommendations to the referring physician after completing a
      consultation, as requested
    3. Communicating recommendations (written and/or verbal) to other clinics and agencies
      clearly and specifically
    4. Completing required documentation accurately, coherently, legibly, and on time

  2.    Given the responsibility of running a psychiatric emergency service, the resident will manage
       the patients, staff, and trainees by:

    1. Obtaining a summary of patients currently in the PES at the beginning of each shift
    2. Providing a summary of patients currently in the PES for the incoming staff at the end
      of each shift
    3. Collaborating appropriately with staff
    4. Delegating tasks appropriately to staff and trainees
    5. Supervising and teaching trainees and staff as appropriate
    6. Contacting physician backup when indicated
    Professionalism
   Residents must demonstrate a commitment to carrying out professional responsibilities, adherence
   to ethical principles, and sensitivity to a diverse patient population. Within a PES, residents are
   expected to:
        A. Demonstrate professional attitudes to colleagues, supervisors, team members, and trainees,
             including respect
        B. Honor professional obligations and responsibilities
        C. Perform and complete assessments and other responsibilities within the limitations of time,
             energy, space, and resources of the psychiatric emergency service
        D. Maintain a positive attitude
        E. Demonstrate flexibility in managing a heavy workload
        F. Remain calm in stressful situations
        G. Demonstrate an awareness of one’s own reactions to crisis situations and to specific types
             of patients
    Systems-Based Practice
Residents must demonstrate an awareness of and responsiveness to their community’s system of
mental health care. Residents are expected to:
        A. Describe the role of the local emergency psychiatric services within the community’s mental
             health care network
        B. Describe community- and hospital-based services that psychiatric emergency service
             patients may need and utilize
Adapted from Brasch J, Glick RL, Cobb TG, et al. Residency training in emergency psychiatry: a model curriculum devel
oped by the Education Committee of the American Association for Emergency Psychiatry. Acad Psychiatry. 2004;28:95–103.
Reprinted with permission from Academic Psychiatry (© 2004). American Psychiatric Association.

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