Dataset Information

Medical experience as an influencing parameter in emergency medical care for psychiatric emergencies: retrospective analysis of a multicenter survey.

ABSTRACT:

Background

Prehospital care of psychiatric patients often relies on the medical experience of prehospital emergency physicians (PHEPs). The psychiatrists (PSs) involved in the further treatment of psychiatric patients also often rely on their experience. Furthermore, the interaction between PHEPs and PSs is characterized by interaction problems and different approaches in the prehospital care of the psychiatric emergency.

Objectives

To analyze the phenomenon of "medical experience" as a cause of possible interaction-related problems and assess its impact on the prehospital decision-making process between prehospital emergency physicians and psychiatrists.

Methods

The retrospective data analysis was conducted between November 2022 and March 2023. Medical experience was defined as follows, based on the demographic information collected in the questionnaires: For PHEPs, the period since obtaining the additional qualification in emergency medicine was defined as a surrogate marker of medical experience: (i) inexperienced: < 1 year, (ii) experienced: 1-5 years, (iii) very experienced: > 5 years. For PSs, age in years was used as a surrogate parameter of medical experience: (i) inexperienced: 25-35 years, (ii) experienced: 35-45 years, (iii) very experienced: > 45 years.

Results

Inexperienced PSs most frequently expressed anxiety about the psychiatric emergency referred by a PHEP (27.9%). Experienced PHEPs most frequently reported a lack of qualifications in handling the care of psychiatric emergencies (p = 0.002). Very experienced PHEPs were significantly more likely to have a referral refused by the acute psychiatric hospital if an inexperienced PS was on duty (p = 0.01). Experienced PHEPs apply an intravenous hypnotic significantly more often (almost 15%) than PSs of all experience levels (p = 0.001). In addition, very experienced PHEPs sought prehospital phone contact with acute psychiatry significantly more often (p = 0.01).

Conclusion

PHEPs should be aware that the PS on duty may be inexperienced and that treating emergency patients may cause him/her anxiety. On the other hand, PHEPs should be receptive to feedback from PS who have identified a qualification deficiency in them. Jointly developed, individualized emergency plans could lead to better prehospital care for psychiatric emergency patients. Further training in the prehospital management of psychiatric disorders is needed to minimize the existing skills gap among PHEPs in the management of psychiatric disorders.

SUBMITTER: Schick B

PROVIDER: S-EPMC10517561 | biostudies-literature | 2023 Sep

REPOSITORIES: biostudies-literature

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Medical experience as an influencing parameter in emergency medical care for psychiatric emergencies: retrospective analysis of a multicenter survey.

Schick Benedikt B Mayer Benjamin B Hensel Constanze C Schmid Sebastian S Jungwirth Bettina B Barth Eberhard E Muth Claus-Martin CM Katzenschlager Stephan S Schönfeldt-Lecuona Carlos C

BMC emergency medicine 20230923 1

<h4>Background</h4>Prehospital care of psychiatric patients often relies on the medical experience of prehospital emergency physicians (PHEPs). The psychiatrists (PSs) involved in the further treatment of psychiatric patients also often rely on their experience. Furthermore, the interaction between PHEPs and PSs is characterized by interaction problems and different approaches in the prehospital care of the psychiatric emergency.<h4>Objectives</h4>To analyze the phenomenon of "medical experience ...[more]

PMID: 37740210

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Project description:BackgroundPre-clinical psychiatric emergencies are generally treated by emergency medical staff. The subsequent clinical treatment is often conditioned by interaction problems between emergency medical staff and psychiatric clinical staff.ObjectivesTo identify problems affecting interaction between emergency medical and psychiatric care of mentally ill patients and pinpoint aspects of optimized emergency care.MethodsTo shed light on the interaction problems an anonymous, questionnaire-based, nonrepresentative survey of 98 emergency physicians (EM) and 104 psychiatrists (PS) practicing in acute psychiatry was conducted between March 1, 2021 and October 1, 2021.ResultsThe chi-square test for multiple response sets revealed consistently significant differences (p < 0.001) between EM and PS with respect to the questions analyzed. Approximately 36% of EM reported not to be adequately qualified to handle psychiatric emergencies (p = 0.0001), while around 50% of respondents were neutral in their assessment in how to deal with psychiatric emergencies. 80% of EM reported a negative interaction (rejection of patients) with PS when referring a psychiatric emergency patient to the acute psychiatric unit. The most common reasons for refusal were intoxication (EM: 78.8%, PS: 88.2%), emergency physician therapy (EM: 53.8%, PS: 63.5%), and not resident in the catchment area of the hospital (EM 68.8%, PS: 48.2%). In the casuistry presented, most respondents would choose "talk down" for de-escalation (EM: 92.1%, PS: 91.3%). With respect to drug therapy, benzodiazepine is the drug of choice (EM: 70.4%, PS: 78.8%). More EM would choose an intravenously (i.v.) or a Mucosal Atomization Device (MAD) administration as an alternative to oral medication (i.v.: EM: 38.8%, PS: 3.8%, p = 0.001, MAD: EM: 36.7%, PS: 10.6%, p = 0.006). Significantly more EM would seek phone contact with the acute psychiatric hospital (EM: 84.7%, PS: 52.9%, p = 0.0107). A psychiatric emergency plan was considered useful in this context by more than 90% of respondents. The need for further training for EM with regard to treating psychiatric clinical syndromes was considered important by all respondents. In particular, the topics of "psychogenic seizure," "intoxication," and "legal aspects of psychiatric emergencies" were considered important (Mann-Whitney U test, p < 0.001).ConclusionThe interaction-related problems identified in the emergency medical care of pre-clinical psychiatric patients relate to non-modifiable, structural problems, such as insufficient admission capacity and non-existent or inadequate monitoring capabilities in acute psychiatric hospitals. However, factors such as the education and training of EM and communication between EM and PS can be improved. Developing personalized emergency care plans for psychiatric patients could help to optimize their care.

Project description:BackgroundNeurological emergencies are one of the major diagnosis groups in the Emergency Medical Services (EMS) with the highest rate of misdiagnosis. Despite the knowledge of time sensitivity and the importance of prehospital factors, prehospital delay is common. Although several stroke triage scales have been developed, a gold standard in the prehospital setting is lacking.ObjectivesOur aim was to evaluate the perception of neurological emergencies by EMS personnel and to identify current problems, difficulties and opportunities for improvement in the prehospital management of stroke, seizure, non-specific neurological symptoms, and paediatric neurological emergencies.MethodsThe study was conducted as an online survey through SoSci Survey and was made available from March 1st to June 30th 2023 to all personnel working in emergency medical services. The access link was distributed through snowballing, social media, and through a QR code on a promotional poster. The survey was completed anonymously. The final survey consisted of 30 questions in German on the topics of neurological emergencies, general neurological assessment, specific neurological examination including paediatric assessment, stroke, and seizures, and finally suggestions for improvement.ResultsThe largest group of participants were paramedics, who estimated to encounter neurological emergencies at a general rate of 20-60%. When unease was felt, the main reasons were ambiguity of symptoms and insufficient admission capacity of hospitals. The biggest challenges were highly varied. Almost 80% of participants assumed that the neurological assessment would be omitted in difficult patient groups such as demented, intoxicated or children. 75% felt uncomfortable making a paediatric assessment, 50% were unfamiliar with the Paediatric Glasgow Coma Scale.ConclusionsSupport through more standardized practical training and defined, uniform guidelines is needed. There was also a clear need for peer collaboration, feedback and case sharing. Digitalization, the usage of telemedicine and updated versions of the documentation protocols including paediatric adaptations to current guidelines could further improve current neurological assessment in the prehospital setting.

Project description:ObjectiveThe objective was to describe characteristics of civil monetary penalties levied by the Office of the Inspector General (OIG) related to violations of the Emergency Medical Treatment and Labor Act (EMTALA) involving psychiatric emergencies.MethodsDescriptions of EMTALA-related civil monetary penalty settlements from 2002 to 2018 were obtained from the OIG. Cases related to psychiatric emergencies were identified by inclusion of key words in settlement descriptions. Characteristics of settlements involving EMTALA violations related to psychiatric emergencies including date, amount, and nature of the allegation were described and compared with settlements not involving psychiatric emergencies.ResultsOf 230 civil monetary penalty settlements related to EMTALA during the study period, 44 (19%) were related to psychiatric emergencies. The average settlement for psychiatric-related cases was $85,488, compared with $32,004 for non-psychiatric-related cases (p < 0.001). Five (83%) of the six largest settlements during the study period were related to cases involving psychiatric emergencies. The most commonly cited deficiencies for settlements involving psychiatric patients were failure to provide appropriate medical screening examination (84%) or stabilizing treatment (68%) or arrange appropriate transfer (30%). Failure to provide stabilizing treatment was more common among cases involving psychiatric emergencies (68% vs. 51%, p = 0.041). Among psychiatric-related settlements, 18 (41%) occurred in CMS Region IV (Southeast) and nine (20%) in Region VII (Central).ConclusionsNearly one in five civil monetary penalty settlements related to EMTALA violations involved psychiatric emergencies. Settlements related to psychiatric emergencies were more costly and more often associated with failure to stabilize than for nonpsychiatric emergencies. Administrators should evaluate and strengthen policies and procedures related to psychiatric screening examinations, stabilizing care of psychiatric patients boarding in EDs, and transfer policies. Recent large, notable settlements related to EMTALA violations suggest that there is considerable room to improve access to and quality of care for patients with psychiatric emergencies.

Project description:INTRODUCTION:The Emergency Medical Treatment and Labor Act (EMTALA) was intended to prevent inadequate, delayed, or denied treatment of emergent conditions by emergency departments (ED). While controversies exist regarding the scope of the law, there is no question that EMTALA applies to active labor, a key tenet of the statute and the only medical condition - labor - specifically included in the title of the law. In light of rising maternal mortality rates in the United States, further exploration into the state of emergency obstetrical (OB) care is warranted. Understanding civil monetary penalty settlements levied by the Office of the Inspector General (OIG) related to EMTALA violations involving labor and other OB emergencies will help to inform the current state of access to and quality of OB emergency care. METHODS:We reviewed descriptions of all EMTALA-related OIG civil monetary penalty settlements from 2002-2018. OB-related cases were identified using keywords in settlement descriptions. We described characteristics of settlements including the nature of the allegation and compared them with non-OB settlements. RESULTS:Of 232 EMTALA-related OIG settlements during the study period, 39 (17%) involved active labor and other OB emergencies. Between 2002 and 2018 the proportion of settlements involving OB emergencies increased from 17% to 40%. Seven (18%) of these settlements involved a pregnant minor. Most OB cases involved failure to provide screening exam (82%) and/or stabilizing treatment (51%). Failure to arrange appropriate transfer was more common for OB (36%) compared with non-OB settlements (21%) (p = 0.041). Fifteen (38%) involved a provider specifically directing a pregnant woman to proceed to another hospital, typically by private vehicle. CONCLUSION:Despite inclusion of the term "labor" in the law's title, one in six settlements related to EMTALA violations involved OB emergencies. One in five settlements involved a pregnant minor, indicating that providers may benefit from education regarding obligations to evaluate and stabilize minors absent parental consent. Failure to arrange appropriate transfer was more common among OB settlements. Findings suggesting need for providers to understand EMTALA-specific requirements for appropriate transfer and for EDs at hospitals without dedicated OB services to implement policies for evaluation of active labor and protocols for transfer when indicated.

Project description:BackgroundCritically ill patients need to be immediately identified, properly managed, and rapidly transported to definitive care. Extensive prehospital times may increase mortality in selected patient groups. The on-scene time is a part of the prehospital interval that can be decreased, as transport times are determined mostly by the distance to the hospital. Identifying factors that affect on-scene time can improve training, protocols, and decision making. Our objectives were to assess on-scene time in the Helicopter Emergency Medical Service (HEMS) in our region and selected factors that may affect it in specific and severe conditions.MethodsThis retrospective cohort study evaluated on-scene time and factors that may affect it for 9757 emergency primary missions by the three HEMSs in western Norway between 2009 and 2013, using graphics and descriptive statistics.ResultsThe overall median on-scene time was 10 minutes (IQR 5-16). The median on-scene time in patients with penetrating torso injuries was 5 minutes (IQR 3-10), whereas in cardiac arrest patients it was 20 minutes (IQR 13-28). Based on multivariate linear regression analysis, the severity of the patient's condition, advanced interventions performed, mode of transport, and trauma missions increased the on-scene time. Endotracheal intubation increased the OST by almost 10 minutes. Treatment prior to HEMS arrival reduced the on-scene time in patients suffering from acute myocardial infarction.DiscussionWe found a short OST in preselected conditions compared to other studies. For the various patient subgroups, the strength of association between factors and OST varied. The time spent on-scene and its influencing factors were dependent on the patient's condition. Our results provide a basis for efforts to improve decision making and reduce OST for selected patient groups.ConclusionsThe most important factors associated with increased on-scene time were the severity of the patient's condition, the need for intubation or intravenous analgesic, helicopter transport, and trauma missions.

Project description:ObjectiveEmergency medical services (EMS) professionals infrequently transport children leading to difficulty in recognition and management of pediatric critical illness. Simulation provides an opportunity to train EMS professionals on pediatric emergencies. The objective of this study was to examine the effect of serial simulation training over 6 months on EMS psychomotor and cognitive performance during team-based care.MethodsThis was a longitudinal prospective study of a simulation curriculum enrolling EMS professionals over a 6-month period during which they performed three high-fidelity simulations at 3-month intervals. The simulation scenarios included a 15-month-old seizure (T0), 1-month-old with hypoglycemia (T1), and 4-year-old clonidine ingestion (T2). All scenarios were standardized and required recognition and management of respiratory failure and decompensated shock. Scenarios were videotaped and two investigators scored EMS team interventions during simulations using a standardized scoring tool. Inter-rater reliability was assessed on 30% of videos using kappa analysis. Volumes of administered intravenous fluid (IVF) and medications were measured to assess for errors in administration. The primary outcome was the change in scenario score from T0 to T2.ResultsA total of 135 team-based simulations were conducted over the study period (48, 40, and 47 at T0, T1, and T2, respectively). Inter-rater reliability between reviewers was very good (κ = 0.7). Median simulation score improved from T0 to T2 (24 vs 31, p < 0.001, maximum score possible = 42). The proportion of completed tasks increased across multiple categories including improved recognition of respiratory decompensation (19% vs. 56%), management of the pediatric airway (44% vs. 88%), and timeliness of vascular access (10% vs. 38%). Correct IVF administration varied by scenario (25% vs. 52% vs. 30%, p = 0.02).ConclusionSerial simulation improved EMS team-based care in both recognition and management of pediatric emergencies. A standardized pediatric simulation curriculum can be used to train EMS professionals on pediatric emergencies and improve performance.

Project description:Abstract Objectives Substance abuse is common in patients with psychiatric emergencies. To further understand the connection between substance abuse and psychiatric disorders, a retrospective chart review was done that included positive drug screens among patients with psychiatric emergencies and to determine whether there was an association between substances used and the psychiatric diagnosis. Methods A retrospective chart review of patients seen in an emergency department with psychiatric emergencies was conducted. The review comprised 1000 charts with diagnoses of anxiety, depression, schizophrenia, attention‐deficit/hyperactivity disorder (ADHD), bipolar disorder, alcohol abuse, or schizoaffective disorder. Data collected included patient demographics, tobacco abuse, chief complaint, arrival mode, voluntary versus involuntary status, suicide attempt on presentation, psychiatric diagnoses, urine drug screen, and ethanol results. Chi‐square statistical analysis was conducted to examine the relationship between substances of abuse and psychiatric diagnoses. Results Approximately 58% of patients with a history of psychiatric illness had a positive urine drug screen. Of 245 patients with schizoaffective disorder, 69 (28%) were positive for tetrahydrocannabinol (THC) and 48 (20%) were positive for cocaine. Of 225 patients with depression, 59 (29%) were positive for THC and 33 (15%) were positive for cocaine. Cannabis was the most commonly reported substance used among patients with depression, schizophrenia, anxiety, schizoaffective disorder, and bipolar disorder, and ethanol was most common in patients with ADHD. No significant correlations were found between psychiatric diagnosis and positive drug screens. A statistically significant secondary end point was found that White people using cannabinoids were more likely to attempt suicide than were African American people (P = 0.02). Conclusions Positive drug screens were common among patients presenting to an ED with psychiatric emergencies. Cannabis was the most commonly reported substance used among patients independent of diagnosis. Ethanol was the most common in patients with ADHD. Urine drug screens are unlikely to provide insights into relationships between specific substance use and psychiatric emergencies.

Project description:ObjectiveDentists must be prepared to manage medical emergencies, which are arisen during dental practice together with the increase of age population and medically compromised patients. This study aims at assessing the occurrence of medical emergencies in a cohort of Italian dentists, to ascertain their level of confidence in the management of these conditions, also based on their educational training and type of medical graduation, and, finally, to know their educational needs, in order to plan appropriate institutional interventions for specific training.MethodsA national-based cross-sectional study was carried out by means of an online survey sent to all dentists working in Italy.ResultsThe survey included 6818 questionnaires. Most of the respondents (n = 4443; 65.2%) reported the occurrence of at least one medical emergency during their professional life. The events rarely resulted in death as declared by only 62 (0.9%) of respondents. The commonest medical emergency was the vasovagal syndrome. Most medical emergencies occurred during the dental procedure (n = 4883; 71.6%). An average degree of satisfaction about the ability to diagnose and manage medical emergencies was reported by most of respondents, with high level of confidence in treating vasovagal syndrome, while a lack in preparedness about the management of myocardial infarction or transient ischemic attack (TIA) and stroke. Medical doctors were more confident in managing the emergencies than dentistry graduates (p < .01). Considering the educational needs, almost all of participants (n = 6721; 98.6%) declared the need to improve their training and expressed their interest in theoretical-practical institutional courses as well as in the establishment of an official national register for medical emergencies occurred in dental practice.ConclusionsMedical emergencies are not negligible and the dentist should receive adequate training and continuing education to be updated and ready for their correct management.Clinical significanceThe dentist should be ready to deal with medical emergencies and provide first aid to the patient. The dentist is not always prepared to manage the most complex emergencies; therefore, there is the need to organize post-graduate courses and to set up an emergency register.

Dataset Information

Medical experience as an influencing parameter in emergency medical care for psychiatric emergencies: retrospective analysis of a multicenter survey.

Background

Objectives

Methods

Results

Conclusion

Publications

Medical experience as an influencing parameter in emergency medical care for psychiatric emergencies: retrospective analysis of a multicenter survey.

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