Emergency - Quality, Education and Safety Teleconference€¦ · Emergency - Quality, Education and...
Transcript of Emergency - Quality, Education and Safety Teleconference€¦ · Emergency - Quality, Education and...
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Emergency - Quality, Education and Safety
Teleconference
Dr Nicholas Lelos | Advanced Trainee | Emergency Care Institute
18th April 2018
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Thanks for joining
House rules
Confidentiality
Respect
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AGENDA
• Case reviews
• Underlying causes
• Clinical context
• NSW Health guidance
Participation encouraged throughout
(But please turn off camera & mute mic when not talking)
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Case 1 – Night visits
54 yr old male, homeless, alcohol dependence polysubstance abuse
Mental health problems erratic med compliance
Multiple visits, no GP, refuses social services, lost to follow up
Sunday 01:00 am – BIBA assaulted and kicked in head multiple times
Smell of alcohol
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Case 1 Continued
01:48 am – Cat 3 Soft collar on took off
R posterior heamatoma and jaw pain, EtOH +++
Vital signs stable GCS 15
03:00 am – vitals stable GCS 14; sats 88% refused O2
For iv cannula struck out and swore at RN
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Case 1
RN TL intervened – need to run tests
Patient refused.
Placed in WR by 03:38 am
Patient gone by 04:48 am
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THOUGHTS ON THE CASE?
Confidentiality
Respect
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Case 1 - aftermath
Member of public reported him at 13:40 at a nearby park bench
14:15 no signs of life
Deceased
Acute subdural haematoma at autopsy
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•What went well?
•What could have gone wrong?
•How can this help local
management?
DISCUSS
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Types of ED Presentations
• Anxiety and panic
• Self harm
• Suicidal ideation and suicide attempts
• Depression
• Psychosis
• Pain
• Physical issues – co-morbidities
• Situational crisis
• Stress
• Drug and alcohol
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Role of ED assessment and the aggressive/MH patient
Cause for presentation
Clinical issue that requires acute management
Minimum exam: gastro, cardio, resp, neuro, abdo with obs
To ensure that disposition is appropriate (ie the presentation is
primarily psychiatric and the patient is physiologically stable)
New presentations/ Elderly/
Abnormal Vital signs
Atypical symptoms
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However….
• NOT an “insurance exam”
• NOT a guarantee that the person has no intercurrent illness
• NOT a guarantee that there is no risk of subsequent illness
• LOOK for: - ingestion/side effects
• excessive drowsiness or confusion (not same as psychosis)
• - physical causes
• - issues for psychiatry to follow up
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Case 2: Rivers and tributaries
40 year old indigenous male
BIB Parents concerned about safety with GP letter
Alcohol and cannabis ?admission
Low mood alcohol problems, poor sleep, relationship breakdown, employment
issues, 1/7 suicidal ideation
Obs 36.4 141/76 HR 86 RR 22 Sats 97%
Cat 3
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Case 2 - cont
Agitation – given diazepam 15 mg po and thiamine
Distressed mood, slurred speech, denied perceptual or added stimuli
Denied self harm or planning.
Deemed low suicidal risk note concerns from others
Depression + alcohol; refused detox, self discharged from ED
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Case 2 -aftermath
Day 2 follow up – declined
Day 7 went to hotel for alcohol, kicked out.
Found next morning in garden by father
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Comments?
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RCA issues
Engagement of patient
Alcohol as a masking agent ASSESSED WHILST INEBRIATED
Follow up and structures available
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Patient perspective
Therapeutic intervention
Not ‘assessment’ but ‘assistance’
Less history taking
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Approach considerations
• De-escalation
• Stance and body language
• Explanations
• Environment
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Case 3 – Coffee time
43 year old male BIBA 08:00 am
Known iv metamphetamine user with chronic suicidal ideation and
schizophrenia – paranoid thinking
Recurrent visits in ED
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Case 3 - continued
Given droperidol iv – slept
Reviewed by mental health, to stay in ED until psych bed available and
reassess post substance
1:1 special assigned – several periods of leave for cigarettes
Stayed in ED overnight
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Thoughts?
How common are patient journey delays transferring care between ED and
psych?
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08:30 am left ED and went to an outdoor café, refusing to leave
No behavioural disturbances, no expressions of suicidal or self-harm intent
Paranoid thinking improved considerably
Options?
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Case 3 - developments
Reviewed by clinician that knew him in the café
Either forcibly return to ED +/- police;
Or discharge from café
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Use of force and restraints – chemical
and physical
Recurrence of certain presentations
Importance of staff safety
Therapeutic relationships
Drug overlay on MH conditions
DISCUSSION POINTS
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Metamphetamine Management
Mental Health for Emergency Departments – A Reference Guide. NSW Ministry of Health.
Amended March 2015.
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Body brought back in ED at 21:00 – jumped off a building
RCA did not find any issues with ED management
Final outcome
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Case 4: Friday Night Fever
51 year old male 00:30
Brought in by 6 policemen from a reinforced patrol car.
Found having fights outside pub – no obvious injuries, ?alcohol consumption
Police section 22
Observations – unable to record, agitation and violence
Spitting, aggressive, attempting to punch staff
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Case 4 - continued
00:35 – Droperiol and midazolam im, no ivc 10 mg and 10 mg
00:45 – minimal effect – another 10 mg of droperidol
00:53 Observations 38 HR 110 BP 130/70 RR 20 Sats 99% on air – started
rousing up
In total: 10 mg of midazolam im, 40 mg droperidol im 20 mg droperidol iv
Urine drug screen metamphetamines, THC
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Local protocols?
Discuss what you would do in your facility
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Mental Health for Emergency Departments: A
reference Guide March 2015
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Case resolution
Drug induced psychosis
Review in the morning by MH team – symptom resolution
Back to police custody
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CLINICAL TOOLS AND GUIDELINES
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From ECI Website
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• Least restrictive alternative, and must consider their safety and that of others;
• closest available to home and usual supports wherever possible, especially for
younger children and Aboriginal families;
• most developmentally and clinically appropriate care given available resources.
Policy 08/11/2011
Key Principles for Pediatric /adolescent Patients
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Classification of resources
for ages 0 - 17
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Resources available• Telephone: The Mental Health Line 1800 011 511 has been established for
these patients, family and car
• Websites: https://headtohealth.gov.au/
• https://headspace.org.au
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SUMMARY
Determine physical issues on presentation
Various methods available for management
Know what is available in area
Online resources
Documentation
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Discussion/ Questions?
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E-QuESTs so far•Atypical Chest Pain - ACS
•Sepsis in the elderly
•Abdominal pain in the elderly - AAA & Ischaemic gut
•Scrotal emergencies
•Deadly headaches
•Paediatric deterioration
•Head injuries
•Opthalmological emergencies
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Looking to next month, please…
•Share your cases
•Share your patient safety actions
•Spread the word with your colleagues
(or send me their email: [email protected])
What would you like to see / hear about?
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Level 4, 67 Albert Avenue
Chatswood NSW 2067
PO Box 699
Chatswood NSW 2057
T + 61 2 9464 4666
F + 61 2 9464 4728
www.aci.health.nsw.gov.au
Many thanks!
Next E-QuEST
Thursday 17th May 08:00 am
Look out for our email survey
We need your responses to guide future
work