Emergency psychiatry encompasses the urgent evaluation and management of patients with active symptoms. The definition of emergency is determined by the ability of the patient or the patient's social environment to tolerate these symptoms. Although these emergency evaluations are most commonly performed in hospital settings, mobile crisis teams permit completion of emergency assessment in community settings.
GOALS OF EMERGENCY PSYCHIATRY
The goals of emergency psychiatric care are similar to those of emergency medical–surgical care: (1) triage, (2) expeditious, pertinent assessment, (3) accurate differential diagnosis, (4) management of acute symptoms, and (5) appropriate disposition planning.
The triage function determines the degree of urgency of the patient's presentation and the initial pathway for evaluation of the patient. In many settings, the person responsible for the triage function is not a mental health specialist. The triage clinician must first distinguish between situations that constitute a genuine emergency and those that, although perceived as such by the patient or others, can safely await later assessment.
Next, the triage clinician must correctly identify, among a variety of emergency situations, those that reflect a need for psychiatric evaluation as a first step. This is a critical decision as patients may have both medical and psychiatric complaints or exhibit behavioral problems that may originate from a medical, neurological, or substance-induced disorder. A medical evaluation, including a brief history of the presenting complaint, and physical assessment including vital signs are critical components of this triage function.
Last, the triage clinician must ensure the safety of patients until they can be evaluated by a psychiatrist or other mental health professional. In emergency room (ER) settings where priority is often given to patients presenting with severe injuries or acute medical signs and symptoms, the needs of a well-appearing patient arriving with no obvious disorder may be overlooked. However, this patient may have suicidal or homicidal ideation that can be as life threatening as any other medical emergency and requires immediate attention to ensure the safety of the patient and others.
Although initial triage is most commonly undertaken by nursing personnel, the psychiatrist must assume an active role in the training and supervision of those clinicians and in the formulation of standards and clinical criteria applied during the triage "sorting" function. Triage is only as effective as the quality of the standards and the rigor with which they are applied.
Assessment of psychiatric patients under emergency circumstances focuses on the need to quickly evaluate the pertinent aspect(s) of the patient's presentation, with special attention paid to potential life-threatening issues. Although the patient may have had an initial brief medical evaluation and triage to psychiatry, the clinician should continue to be alert to the possibility that the patient has a medical disorder or substance-induced disorder underlying his/her presentation.