Acute Psychiatric Emergencies in the ED. The APEx course. • St Emlyn's

This month we have a podcast on how we approach patients with mental health needs in the ED. It outlines the rationale and delivery of a change in how we manage some of the most vulnerable patients in the ED. We hope you find it interesting and I suspect you will also find it quite challenging. We are aiming to improve the care of patients with Mental Health needs, but in doing so we must face our own prejudices and practices, which are not always healthy.

Editorial note on language – as you listen to the podcast you might be surprised to hear us use words like ‘insane’ in relation to decisions and systems. In some ways it seems incongruous to use such terms in a podcast that promotes a better understanding of mental health issues. We considered taking them out, but after consideration we left them in an attempt to illustrate the false dichotomy between medical and psychiatric needs that is embedded in much of our work. Perhaps the use of language reflects this and makes the point that we can do better.

Why do we need to rethink our approach to Psychiatric emergencies in the ED?

There are a group of life threatening conditions that present to your ED that you don’t deal with, or at least you don’t deal with very well. This group of conditions has a significant mortality and an incredibly high morbidity, but if you are a typical emergency physician you probably don’t think you own the problem. This group of conditions is at least as common as chest pain and yet it’s unlikely that you feel the same level of ownership of the problem.

The issue is of course that of psychiatric illness. In Virchester it accounts for about 1 in 20 patients through the door, and that number is much, much higher if we were to include substance abuse and its related outcomes.

In general, the approach in many UK units is to divide the patient up on arrival into physical and mental health needs. We feel responsible for the physical problem and then we try and offload any psychiatric problems onto the psychiatrists and mental health teams. You can visit this page to learn more about the division. At the centre of this is the patient who really does not see or feel this dichotomy and we really need to challenge our approach to this.

Such dichotomies are embedded in our systems. I’m sure that many readers will be familiar with the request to ‘medically clear’ a patient in order that they can then be assessed by the mental health team. Bizareer customs and practice take place around these assessments, for example in Virchester the rule that a patient with a heart rate of more than 100 cannot be medically fit for assessment is sometimes used to decline psychiatric assessment. Such informal rules (none are actually written down or appear in any agreed protocol) result in delayed assessments, patient distress and long waits in the ED. I could go on, and whilst there is good and practice amongst all teams and specialities (we are just as bad at the mental health teams in promoting this dichotomy), the point is that we really don’t act in the patient’s best interests by dividing mental and physical health.

This clear difficulty was one of the starting points for the APEX course, which aims to bring psychiatry and emergency medicine together for the benefit of patients, services and staff.

The interview on the podcast is recorded with Prof. Kevin Mackway-Jones who many of you will know through his work with the Advanced Life Support Group. He was the instigator of APLS at a time when there was a clear need for emergency physicians to improve their approach and knowledge of paediatric emergencies. APEx feels the same. A common condition in our EDs for which we are not currently doing the best that we can for our patients and where a joint teaching and learning approach is needed between the ‘tribes’ of medicine.

This could be a game changer to how we manage a very common and very vulnerable group of patients in the ED.

So what’s on the course?

I can’t give you the whole courses here but there are a few principles that underpin the content and approach.

Key points.

It’s co-written and developed between psychiatry and emergency medicine
It’s a symptom based approach (just like APLS) and so it deals with how we deal with the presenting complaint first and not the underlying diagnosis (as you may not know what this is when you are dealing with the patient).
The approach will be familiar to many Eps.
Primary Survey
Resuscitation
Secondary Survey
Definitive management
There is a unified approach. The patient needs an ABC approach for physical health, but in addition and concurrently they also need the AEIOU approach.
1. A – Assessment of Aggression and Agitation
2. E – The Environment in which you are assessing the patient
3. I – The Intent of the patient
4. O – The Objects the patient has to carry out the intent
5. U – The Unified assessment (as you will also be carrying out an ABC assessment alongside AEIOU)
Rapid tranquilisation is a key conern for EPs and so there is lots on this that does not automatically default to restraint, a needle and syringe and a significant risk.
1. Oral tranquilisation works
2. Ketamine is not the answer to every patient
3. It’s a risk based approach as every intervention (including no intervention) has a risk

Find out more

You can find out more on the ALSG website here.

What has APEx got to do with St Emlyn’s?

At St Emlyn’s we are letting you know about the course for several reasons. Many of us teach and support the work of the ALSG charity (for free and because we believe in it), but also that we all believe that the care of patients with mental health needs can be improved. They are a vulnerable group who generally get a bad deal when they present in crisis to emergency departments. We know we can do better and we believe that this course will help us achieve our goal to do the best that we can for our patients.

APEX Course information.

@EMManchester