- Email: [email protected]
Quality of care in Emergency Psychiatry: Developing an international network
Available online at www.sciencedirect.com
European Psychiatry 22 (2007) 411e412 http://france.elsevier.com/direct/EURPSY/
Quality of care in Emergency Psychiatry: Developing an international network Cristian Damsa MD a,b, Antonio Andreoli MD a, Daniele Zullino MD a, Eric Adam MSc c, Adriana Mihai MD d, Susanne Maris MSc a, Lionel Cailhol MD e, Coralie Lazignac MD a, Michael H. Allen MD b a
Cantonal Universitary Hospital Geneva, 24, rue Micheli-du-Crest, 1211 Geneva, Switzerland Department of Psychiatry, Clinical Investigation Program, University of Colorado Health Sciences Center. 4455 East 12th Avenue, Denver, Colorado 80220, US c Service d’urgences psychiatriques, Centre Hospitalier Re´gional "La Citadelle". Boulevard du Douzie`me de Ligne, 1. 4000 Lie`ge, Belgique d Psychiatric Clinic II, University of Medicine Tg Mures, Gh. Marinescu 38, 540139 Tg Mures, Romania e Service de psychiatrie et de psychologie me´dicale, Hoˆpital Universitaire de Purpan-Casselardit, 170, avenue de Casselardit, 31059 Toulouse Cedex, France. 1211 Geneva, Switzerland b
Quality of care in Emergency Psychiatry: Developing an international network Between 2000 and 2007, a growing interest for guidelines on the management of psychiatric emergencies can be observed in Europe, as well as in the United States. The most frequently used clinical guidelines in emergency psychiatry are derived from expert opinions [1]. In spite of continuous efforts to build evidence-based consensus guidelines for the treatment of behavioral emergencies, clinicians continue to resist to the development and the use of such guidelines. Clinicians tend to be skeptical regarding evidence-based guidelines and standardized measuring scales, often venting regarding the practical application of such tools or guidelines [4]. This contributes to the relative imbalance between abundant expert opinions regarding the management of agitation and suicidal behavior and the small amount of empirically validated data in the emergency settings [1-4, 6]. Even less frequent are the studies that incorporate a systematic and consecutive recruitment of patients, or specific patient-groups, e.g. borderline personality disorder, in emergency [2]. Based on those observations, we try to develop an international network in Emergency Psychiatry, by connecting several European countries (Switzerland, France, Belgium, Romania) and United States. The aims of our collaboration are: 1. Measure and ameliorate the quality of care in Emergency Psychiatry. E-mail address: [email protected] (C. Damsa).
2. Develop European clinical guidelines for the assessment and management of agitation, suicidal behavior and addictions in Emergency Psychiatry. 3. Provide a structured educational program for residents and students. 4. Conduct multicenter international studies that focus on Emergency Psychiatry. Since the start of our international research collaboration in 2003, our group published 49 papers (29 original papers), cumulating 46 points of Impact factor (Figure 1). Interestingly, this seems related to the observation that the use of clinical standardized scales for the psychiatric assessment in emergency appears to be an original way to improve the quality of care in emergency psychiatry [4, 5]. We observed that the Observer Effect (Heisenberg) is a powerful tool for improving care in emergency, at least for the management of the agitation. Introducing some clinical standardized scales appears to be as an ‘effective medication’ administered to the entire emergency staff [4]. Furthermore, the systematical use of standardized clinical scales stimulates some clinicians to question their ‘‘clinical convictions’’ and to improve the helping alliance, mainly by spending more time with patients [4]. Moreover, introducing new psychotherapeutic models in emergency psychiatry could avoid unnecessary hospitalizations and increase the compliance of the patients to ambulatory followup care, which has a positive significant economic impact on the health systems [5]. In spite of many efforts to create guidelines concerning the management of violent behavior in emergency departments,
C. Damsa et al. / European Psychiatry 22 (2007) 411e412
412 50
50 46
45
Original papers
40
Total
45 37
49
35
40 35
43
30
30
30 29
36
25
24
20
20
20
15
15
11
10 5 5 4
9
25
Impact Factor
Nombre articles
Impact Factor
10
11
5
5
0
0 2002
2003
2004
2005
2006
2007
Figure 1. Evolution of the number of publications of an international research group focusing on emergency psychiatry. Clinical researches in emergency psychiatry, by the Heisenberg Effect, appears to be a powerful tool for improving quality of care in emergency, at least for the management of agitation.
little is known about the impact of such guidelines on an emergency environment in real life. A current initiative of our research group is the development of an educational program for nurses, psychiatrists, residents and security staff, on crisis intervention for a better management of violent behavior in patients following a suicidal attempt [2]. The program includes: 1. An educational program for physicians, nurses and security staff focused on restraint and violent behavior: early screening of potential violent behavior, team procedures, diagnosis and awareness of written guidelines. 2. Emphasis on dialogue between intervening staff by common reunions including a journal club, discussing the interest of guidelines about restraint. 3. Medical presence during all security intervention for restraint. 4. Debriefing after each intervention including patient restraint. In an effort to acquire a more representative, medically and psychiatrically unselected sample of patients consulting the emergency, our international research group recommends that data from international observational studies should be compared to randomized studies done in the emergency. We
hope to develop new links with other emergency psychiatric teams, through our Emergency Psychiatry Section from the AEP. References [1] Allen MH, Currier GW, Carpenter D, Ross RW, Docherty JP. Expert Consensus Panel for Behavioral Emergencies 2005. The Expert Consensus Guideline Series Treatment of Behavioral Emergencies 2005. J Psych Practice 2005;11: 5-108; quiz 110e2. [2] Cailhol L, Allen MH, Moncany AH, Cicotti A, Virgillito S, Barbe R, et al. Violent behavior of patients admitted in emergency following a drug suicidal attempt: A specific behavioral crisis intervention. Gen Hosp Psychiatry 2007;29:42e4. [3] Damsa C, Adam E, De Gregorio F, Cailhol L, Lejeune J, Lazignac C, et al. Intramuscular olanzapine in patients with borderline personality disorder: an observational study in an emergency room. Gen Hosp Psychiatry 2007;29:51e3. [4] Damsa C, Ikelheimer D, Adam E, Maris S, Andreoli A, Lazignac C, et al. Heisenberg in the ER: observation appears to reduce involuntary intramuscular injections in a psychiatric emergency service. Gen Hosp Psychiatry 2006;28:431e3. [5] Damsa C, Hummel C, Sar V, Di Clemente T, Maris S, Lazignac C, et al. Economic impact of crisis intervention in emergency psychiatry: a naturalistic study. Eur Psychiatry 2005;20:562e26. [6] Kapur S, Arenovich T, Agid O, Zipursky R, Lindborg S, Jones B. Evidence for onset of antipsychotic effects within the first 24 hours of treatment. Am J Psychiatry 2005;162:939e46.
European Psychiatry 22 (2007) 411e412 http://france.elsevier.com/direct/EURPSY/
Quality of care in Emergency Psychiatry: Developing an international network Cristian Damsa MD a,b, Antonio Andreoli MD a, Daniele Zullino MD a, Eric Adam MSc c, Adriana Mihai MD d, Susanne Maris MSc a, Lionel Cailhol MD e, Coralie Lazignac MD a, Michael H. Allen MD b a
Cantonal Universitary Hospital Geneva, 24, rue Micheli-du-Crest, 1211 Geneva, Switzerland Department of Psychiatry, Clinical Investigation Program, University of Colorado Health Sciences Center. 4455 East 12th Avenue, Denver, Colorado 80220, US c Service d’urgences psychiatriques, Centre Hospitalier Re´gional "La Citadelle". Boulevard du Douzie`me de Ligne, 1. 4000 Lie`ge, Belgique d Psychiatric Clinic II, University of Medicine Tg Mures, Gh. Marinescu 38, 540139 Tg Mures, Romania e Service de psychiatrie et de psychologie me´dicale, Hoˆpital Universitaire de Purpan-Casselardit, 170, avenue de Casselardit, 31059 Toulouse Cedex, France. 1211 Geneva, Switzerland b
Quality of care in Emergency Psychiatry: Developing an international network Between 2000 and 2007, a growing interest for guidelines on the management of psychiatric emergencies can be observed in Europe, as well as in the United States. The most frequently used clinical guidelines in emergency psychiatry are derived from expert opinions [1]. In spite of continuous efforts to build evidence-based consensus guidelines for the treatment of behavioral emergencies, clinicians continue to resist to the development and the use of such guidelines. Clinicians tend to be skeptical regarding evidence-based guidelines and standardized measuring scales, often venting regarding the practical application of such tools or guidelines [4]. This contributes to the relative imbalance between abundant expert opinions regarding the management of agitation and suicidal behavior and the small amount of empirically validated data in the emergency settings [1-4, 6]. Even less frequent are the studies that incorporate a systematic and consecutive recruitment of patients, or specific patient-groups, e.g. borderline personality disorder, in emergency [2]. Based on those observations, we try to develop an international network in Emergency Psychiatry, by connecting several European countries (Switzerland, France, Belgium, Romania) and United States. The aims of our collaboration are: 1. Measure and ameliorate the quality of care in Emergency Psychiatry. E-mail address: [email protected] (C. Damsa).
2. Develop European clinical guidelines for the assessment and management of agitation, suicidal behavior and addictions in Emergency Psychiatry. 3. Provide a structured educational program for residents and students. 4. Conduct multicenter international studies that focus on Emergency Psychiatry. Since the start of our international research collaboration in 2003, our group published 49 papers (29 original papers), cumulating 46 points of Impact factor (Figure 1). Interestingly, this seems related to the observation that the use of clinical standardized scales for the psychiatric assessment in emergency appears to be an original way to improve the quality of care in emergency psychiatry [4, 5]. We observed that the Observer Effect (Heisenberg) is a powerful tool for improving care in emergency, at least for the management of the agitation. Introducing some clinical standardized scales appears to be as an ‘effective medication’ administered to the entire emergency staff [4]. Furthermore, the systematical use of standardized clinical scales stimulates some clinicians to question their ‘‘clinical convictions’’ and to improve the helping alliance, mainly by spending more time with patients [4]. Moreover, introducing new psychotherapeutic models in emergency psychiatry could avoid unnecessary hospitalizations and increase the compliance of the patients to ambulatory followup care, which has a positive significant economic impact on the health systems [5]. In spite of many efforts to create guidelines concerning the management of violent behavior in emergency departments,
C. Damsa et al. / European Psychiatry 22 (2007) 411e412
412 50
50 46
45
Original papers
40
Total
45 37
49
35
40 35
43
30
30
30 29
36
25
24
20
20
20
15
15
11
10 5 5 4
9
25
Impact Factor
Nombre articles
Impact Factor
10
11
5
5
0
0 2002
2003
2004
2005
2006
2007
Figure 1. Evolution of the number of publications of an international research group focusing on emergency psychiatry. Clinical researches in emergency psychiatry, by the Heisenberg Effect, appears to be a powerful tool for improving quality of care in emergency, at least for the management of agitation.
little is known about the impact of such guidelines on an emergency environment in real life. A current initiative of our research group is the development of an educational program for nurses, psychiatrists, residents and security staff, on crisis intervention for a better management of violent behavior in patients following a suicidal attempt [2]. The program includes: 1. An educational program for physicians, nurses and security staff focused on restraint and violent behavior: early screening of potential violent behavior, team procedures, diagnosis and awareness of written guidelines. 2. Emphasis on dialogue between intervening staff by common reunions including a journal club, discussing the interest of guidelines about restraint. 3. Medical presence during all security intervention for restraint. 4. Debriefing after each intervention including patient restraint. In an effort to acquire a more representative, medically and psychiatrically unselected sample of patients consulting the emergency, our international research group recommends that data from international observational studies should be compared to randomized studies done in the emergency. We
hope to develop new links with other emergency psychiatric teams, through our Emergency Psychiatry Section from the AEP. References [1] Allen MH, Currier GW, Carpenter D, Ross RW, Docherty JP. Expert Consensus Panel for Behavioral Emergencies 2005. The Expert Consensus Guideline Series Treatment of Behavioral Emergencies 2005. J Psych Practice 2005;11: 5-108; quiz 110e2. [2] Cailhol L, Allen MH, Moncany AH, Cicotti A, Virgillito S, Barbe R, et al. Violent behavior of patients admitted in emergency following a drug suicidal attempt: A specific behavioral crisis intervention. Gen Hosp Psychiatry 2007;29:42e4. [3] Damsa C, Adam E, De Gregorio F, Cailhol L, Lejeune J, Lazignac C, et al. Intramuscular olanzapine in patients with borderline personality disorder: an observational study in an emergency room. Gen Hosp Psychiatry 2007;29:51e3. [4] Damsa C, Ikelheimer D, Adam E, Maris S, Andreoli A, Lazignac C, et al. Heisenberg in the ER: observation appears to reduce involuntary intramuscular injections in a psychiatric emergency service. Gen Hosp Psychiatry 2006;28:431e3. [5] Damsa C, Hummel C, Sar V, Di Clemente T, Maris S, Lazignac C, et al. Economic impact of crisis intervention in emergency psychiatry: a naturalistic study. Eur Psychiatry 2005;20:562e26. [6] Kapur S, Arenovich T, Agid O, Zipursky R, Lindborg S, Jones B. Evidence for onset of antipsychotic effects within the first 24 hours of treatment. Am J Psychiatry 2005;162:939e46.