Pediatric emergency medicine trisk 1038

SECTION VII
Behavioral Health Emergencies


CHAPTER 126 ■ BEHAVIORAL AND
PSYCHIATRIC EMERGENCIES
EMILY R. KATZ, ANIK JHONSA, ERON FRIEDLAENDER, JOEL A. FEIN, THOMAS H.
CHUN, LAURA L. CHAPMAN

INTRODUCTION
The emergency department (ED) is frequently the setting for the initial
evaluation of emotional and psychiatric difficulties of children and their
families. As such, ED physicians must be proficient in psychiatric
evaluation, crisis intervention, and disposition planning, regardless of
whether a mental health professional is consulted. Even when a consultant is
involved, the ED physician still shares responsibility for the patient’s care
and disposition. As in any other situation involving a consultant, it is critical
that the ED physician and the consultant agree on a treatment plan, both
from a patient care perspective and from a medicolegal standpoint.

GOALS OF EMERGENCY MENTAL HEALTH
ASSESSMENT AND CRISIS INTERVENTION
First and foremost, the assessment and management of psychiatric
emergencies requires that the ED establish and maintain a safe environment
for the patient, family members, and staff. Systems/protocols must be in
place to enable early identification of patients at high risk of violence toward
self and/or others, to provide adequate observation, to immediately intervene
for unsafe behaviors, and to prevent further harm. ED physicians must be
facile in evaluating for underlying causes of emotional/behavioral
disturbances, including potential medical etiologies for the patient’s
symptoms, assessing the risk for further decompensation and future harm,

and developing adequate disposition and aftercare plans. Additional goals
include providing support and stabilization for the patient’s family and
offering adequate guidance around prevention/management of any future
unsafe behaviors, means restriction, and indications for return to care.
KEY POINTS


ED physicians must be competent at assessing and managing
psychiatric emergencies and have systems in place to safely
manage acutely suicidal or aggressive patients.
All patients with mental health complaints should receive a medical
evaluation to identify significant underlying or comorbid illnesses.
Verbal de-escalation and trauma-informed care are key
components to managing agitation. Specific techniques are
available to help limit the distress of children with autism and other
developmental disabilities.
All suicidal comments and acts should be taken seriously. Means
restriction is an essential component of disposition planning.
ED physicians are typically best served using their usual “pretest
probability threshold” for ordering testing/interventions on children
with suspected somatization/conversion disorder.
The Children’s Hospital of Philadelphia Clinical Pathway
ED Pathway for Evaluation/Treatment of Children With
Behavioral Health Issues
URL: />Authors: J. Lavelle, MD; M. M’Farrej, MD; J. Esposito, MD; A.
Jhonsa, MD; E. Perry, MSW; K. White, MSW; E. Steinmiller, RN; A.
Felix, CRNP; K. Crescenzo, RN; M. K. Abbadessa, RN; A. Fu, MD;
C. Jacobstein, MD; K. Osterhoudt, MD; E. Friedlaender, MD
Posted: February 2013, last revised October 2018

REQUIREMENTS OF THE EMERGENCY DEPARTMENT
The ability to respond effectively to psychiatric emergencies of children and
families requires special capacities of the ED and its staff. Ensuring safety
includes not only the physical characteristics of the patient room but also the
access to medical and hospital security personnel, as well as appropriate
safety procedures and policies.


It is vitally important to ensure patients do not bring weapons or other
dangerous objects into the ED. Procedures to achieve this end may include
use of metal detectors or a physical search of the patient and their
belongings. Some EDs use a protocol whereby all patients must wear a
hospital gown and slippers while in the ED. This separates the patient from
their belongings and can facilitate a search for harmful objects. Such a
policy may also theoretically reduce the risk of patient elopement.
A safe and adequate physical space is an absolute requirement of the ED.
Patients with high risk of harm to self/others need to be under constant
supervision by either ED medical or security staff via direct visualization of
the patient or by continuous video monitoring. At a minimum, the patient
room should be free of objects that could cause harm including objects used
for strangulation (e.g., medical tubing, electrical or equipment cords). Such
objects should be either inaccessible to the patient (e.g., in locked cabinets)
or physically removed from the room.
The optimal setting for a psychiatric evaluation is a quiet and lowstimulus environment in which interruptions are infrequent, and privacy and
confidentiality are assured; ideally this environment would be a separate,
distinct area from the main ED with direct access to medical and security
staff and capacity for using restraints.
Clinicians in the ED should have a pre-existing relationship with a mental
health team that is committed to providing child psychiatric consultation at
all times. The ED should also have relationships with (a) psychiatric

inpatient unit(s), for efficient transfers and hospitalizations when needed.
The staff should be thoroughly familiar with the procedures for psychiatric
hospitalization, including the specific legal requirements for involuntary
commitment. The hospital should have specific guidelines or protocols for
the management of psychiatric patients requiring admission for treatment of
medical conditions.
Finally, the ED should have relationships with other social agencies and
an awareness of relevant laws. The police should be aware of which children
to bring to the ED for psychiatric assessment and should be prepared to
remain in the ED until adequate security has been arranged. Relationships
should be developed with community mental health resources, temporary
shelters, and other crisis intervention centers, ensuring effective referrals