Advanced Life Support Group
EDITED BY
Kevin Mackway‐Jones
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| Roger Alcock | MB ChB, BSc(hons), FRCP Edin, DCH, FRCEM, Consultant in Emergency Medicine and Paediatric Emergency Medicine, Forth Valley Royal Hospital, Larbert |
| Helen Bradford | MA, DClinPsy, CPsychol, AFBPsS, Consultant Clinical Psychologist, Bradford Psychology |
| Mark Buchanan | Consultant in Adult and Paediatric Emergency Medicine, Arrowe Park Hospital |
| Vanessa Craig | MBBCh, BAO, MRCPsych, Consultant Liaison Psychiatrist, Greater Manchester Mental Health NHS Foundation Trust, Manchester Royal Infirmary |
| Sandrine Dénéréaz | Paramedic – Paramedics School Director, École Supérieure d’Ambulancier et Soins d’Urgence Romande, Lausanne, Switzerland; President, Commission for Emergencies Health Measures, Lausanne |
| Fiona Donnelly | BSc, MBChB, MRCPsych, PgDip Psychiatry, PGDip Health and Public Leadership, Consultant Psychiatrist, Mental Health and Home Treatment Team, Wythenshawe Hospital |
| James Ferguson | MBChB, FRCSEd, FRCS(A&E), FRCEM, FRCPE, Professor in Remote Medicine, Robert Gordon University; Reader in Emergency Medicine, Aberdeen University; Clinical Lead, Scottish Centre for Telehealth and Telecare and Digital Health and Care Institute |
| Sarah Gaskell | DClinPsy, PGDip, Consultant Clinical Psychologist, Head of Paediatric Psychosocial Services, Royal Manchester Children’s Hospital |
| Elspeth Guthrie | MBChB, MSc, MD, FRCPsych, Professor of Psychological Medicine, Leeds Institute of Health Sciences, University of Leeds |
| Damien Longson | PhD, FRCPsych, Consultant Liaison Psychiatrist, Greater Manchester Foundation Trust; Associate Dean, Royal College of Psychiatrists |
| Kevin Mackway‐Jones | MA, DH, FRCP, FRCS, FRCEM, Professor of Emergency Medicine, Manchester Royal Infirmary and the Royal Manchester Children’s Hospital; Director of Postgraduate Medicine, Manchester Metropolitan University |
| Laura McGregor | FRCEM, MRCP, DTMH, DIMC, Consultant in Emergency Medicine, University Hospital Monklands; Educational Coordinator, Emergency Medicine, Scottish Centre for Simulation and Clinical Human Factors |
| Aaron McMeekin | MRCPsych, Consultant Perinatal Psychiatrist, Greater Manchester Mental Health NHS Foundation Trust; Honorary Lecturer, Academic Unit of Medical Education, University of Sheffield |
| Andrew McNeill Russell | MBChB, MRCS, FRCEM, Consultant in Emergency Medicine, University Hospital Monklands |
| Rachel Thomasson | PhD, MRCPsych, Consultant Neuropsychiatrist, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust |
| Sue Wieteska | CEO, Advanced Life Support Group |
| Damian Wood | MBChB, DCH, MRCPCH, Consultant Paediatrician, Nottingham Children’s Hospital, Queen’s Medical Centre |
| Helen Bradford | MA, DClinPsy, CPsychol, AFBPsS, Consultant Clinical Psychologist, Bradford Psychology |
| Fiona Donnelly | BSc, MBChB, MRCPsych, PGDip Psychiatry, PGDip Health and Public Leadership, Consultant Psychiatrist, Mental Health and Home Treatment Team, Wythenshawe Hospital |
| Richard J. Drake | BSc, MBChB, MRCPsych, PhD, Clinical Lead for Mental Health, Health Innovation Manchester; Honorary Consultant, Greater Manchester Mental Health NHS Foundation Trust; Senior Lecturer, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester |
| Peter‐Marc Fortune | FRCPCH, FFICM, FAcadMEd, Consultant Paediatric Intensivist, Associate Medical Director, Royal Manchester Children’s Hospital |
| Elspeth Guthrie | MBChB, MSc, MD, FRCPsych, Professor of Psychological Medicine, Leeds Institute of Health Services, University of Leeds |
| Mark Hellaby | MSc, Med, PG Cert, BSc(Hons) RODP, FHEA, North West Simulation Education Network Manager, NHS Health Education England |
| Damien Longson | PhD, FRCPsych, Consultant Liaison Psychiatrist, Greater Manchester Foundation Trust; Associate Dean, Royal College of Psychiatrists |
| Kevin Mackway‐Jones | MA, DH, FRCP, FRCS, FRCEM, Professor of Emergency Medicine, Manchester Royal Infirmary and the Royal Manchester Children’s Hospital; Director of Postgraduate Medicine, Manchester Metropolitan University |
| Aaron McMeekin | MRCPsych, Consultant Perinatal Psychiatrist, Greater Manchester Mental Health NHS Foundation Trust; Honorary Lecturer, Academic Unit of Medical Education, University of Sheffield |
| Rachel Thomasson | PhD, MRCPsych, Consultant Neuropsychiatrist, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust |
This text and the associated course are very valuable at many levels. Emergency mental health presentations in the UK have increased out of proportion to other presentations, and care of these patients in crisis has become an essential core skill for an emergency clinician.
Mental health and emergency clinicians may work in silos due to organisational structure and lack of experience of each other’s fields. The APEx course teaches both emergency and mental health clinicians together, bridging the gaps in experience and knowledge and allowing the professionals to learn from each other.
The unified approach of: A, agitation; E, environment; I, intent; O, objects; alongside the traditional ABCD approach gives confidence to both sets of professionals to ensure safety. It uses a common language which has the potential to become a universal language. It supports the important principle of assessing and managing a patient’s physical and mental health problems alongside each other with equal parity.
A great strength of this course is high‐fidelity simulation in a safe environment and this is supported by the excellent material in this book.
Emergency departments offer open access healthcare 24 hours a day, 7 days a week, 365 days a year. The number of patients attending these departments in England increased by 7.4% between 2010–11 and 2016–17 and is currently at an all‐time high. It is unsurprising that a significant proportion of the patients attending emergency departments present with mental health problems, and the number of patients in crisis is increasing at 10% per year and now make up more than 5% (one in 20) of all attenders.
Despite the high numbers of patients attending in mental health crisis (more attend with this presentation than attend with chest pain), the vast majority of emergency department staff are not trained specifically to deal with patients with mental health emergencies or, indeed, to deal with mental illness at all. A value clarification exercise that looked into emergency mental healthcare in one emergency department in London established that the work most valued by the staff was trauma ‘because of the excitement and drama it provided’. The environmental values for good mental healthcare (privacy, quietness, safety, calmness and having time) were noted to be the ‘antithesis’ of the environment found in the emergency department. Experienced emergency department nurses noted a ‘deficit in mental health knowledge’ but were unable to further identify the deficits. A key theme emerged of ‘a perceived conflict between two cultures’ which gives mental health a low status.
The course that this book supports (APEx) is designed to fill some of the gap and more closely align the cultures of care. The content has been designed jointly by psychiatrists and emergency physicians and is presented in a structured manner. Recognisable presentations (such as ‘overdose and poisoning’, ‘aggression’ and ‘behaving strangely’) are dealt with rather than focusing on diagnoses. Primary assessment is achieved with a new bespoke structured approach (ABCD AEIO U) that is similar to the more familiar ABCD emergency care approach to physical emergencies. Secondary assessment consists of parallel physical and psychosocial history and examinations. Throughout the text close co‐operation between emergency and mental health teams is emphasised as is the value of joint working.
Patients in mental health crisis clearly deserve better than they currently get. This book, and the APEx course it supports, is for them.
We acknowledge the contribution of Satveer Nijjar, Independent Trainer with Lived Experience, ‘Attention Seekers Training’, who provided her personal account to inform Chapter 11: The patient experience.
ALSG: www.alsg.org
For details on ALSG courses visit the website or contact:
Advanced Life Support Group
ALSG Centre for Training and Development
29–31 Ellesmere Street
Swinton, Manchester
M27 0LA
Tel: +44 (0) 161 794 1999
Fax: +44 (0) 161 794 9111
Email: enquiries@alsg.org
The material contained within this book is updated on approximately a 4‐yearly cycle. However, practice may change in the interim period. We will post any changes on the ALSG website, so we advise you to visit the website regularly to check for updates (www.alsg.org).
To access references, visit the ALSG website www.alsg.org – references are on the course pages.
It is important to ALSG that the contact with our providers continues after a course is completed. We now contact everyone 6 months after his or her course has taken place asking for on‐line feedback on the course. This information is then used whenever the course is updated to ensure that the course provides optimum training to its participants.
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Psychiatric and behavioural presentations to emergency departments are common – if substance abuse is included in these figures then some 35–40% of presentations (6–8 million each year in England) are defined as such.
Systematic assessment and management of a person with acute mental health problems in the emergency department or other acute hospital setting can present major challenges. Key considerations include:
This text seeks to provide a safe, practical system for practitioners.
Before starting any assessment for a patient with possible mental health problems:
There must be a safe area where people who are acutely disturbed can be assessed and managed appropriately.
The safe and successful management of people with acute mental health problems requires close working between emergency/acute hospital teams with liaison mental health teams. Each team needs to carry out their own tasks, be aware of each other’s skills, and work collaboratively to ensure the best possible outcome.
Good communication and basic rapport building with a person with acute mental illness are essential. Communication is no less important with families of patients and with clinical colleagues – especially between those of different disciplines. Detailed records of current clinical findings, the patient’s history, prior mental health records, physical test results and management plans must be completed, and communicated to staff who will be taking over the care of the patient when he/she leaves the emergency department.
In an emergency, if it is deemed in the patient’s best interests, hospital staff have a duty of care to treat the patient, provided treatment is limited to that which is reasonably required in that emergency situation.
As consent legislation and practice are complex areas with different practices in different countries and jurisdictions, we will highlight the medicolegal aspects of patient care in relevant chapters, by detailing the principle of what they achieve. Chapter 9 summarises legal aspects in more detail and maps the principle of the relevant laws. The details will differ depending on the jurisdictions where the Acute Psychiatric Emergencies (APEx) course is available.
A structured approach will enable all clinicians (whether mental health trained or not) to manage psychiatric emergencies optimally, so that patients receive high‐quality care. It will also ensure that important steps in the care process are not forgotten. As it is common for mental and physical health problems to occur at the same time, both require consideration.
A structured approach focuses initially on a primary assessment designed to identify and manage any immediate threats to safety, either for the patient or for others. This involves a rapid assessment of ABCD physical risk and an AEIO psychiatric risk assessment. These then inform the Unified assessment.
After a primary assessment has been completed and relevant steps have been taken to ensure safety, a secondary assessment needs to be undertaken. This includes establishing the key features of the presentation. In particular, it is important to establish whether the presentation is predominantly a physical health or a mental health problem (or a combination of both). This process involves being able to interact with the patient in a manner which conveys understanding and empathy, builds rapport, reduces anxiety and enables information gathering in an effective and efficient manner. Secondary mental health assessment includes a focused conversational psychosocial history and examination of the mental state, while secondary physical health assessment involves a focused physical history and full top‐to‐toe examination. Following on from this, an appropriate emergency treatment and management plan can be identified.
The final phase of the structured approach is to stabilise the patient so that transfer to an appropriate care environment can occur.
Throughout this text the same structure will be used so the clinician will become familiar with the approach and be able to apply it to any clinical emergency situation.
Figure 1.1 shows the structured approach in diagrammatic form.
Figure 1.1 The structured approach
This book will introduce the structured approach in more detail and then explore its use in the common psychosocial presentations to the emergency department.