Introduction: Adult Emergency Departments (EDs) in Calgary are facing a crisis of boarded patients admitted to psychiatric in-patient units. In psychiatric emergency care, “boarding” describes the holding of patients in the ED after the decision to admit has been made by a staff psychiatrist and a bed request has been submitted. Literature review suggests psychiatric patients face exorbitantly higher boarding times than any other service in the hospital however little is published on the nature of these adverse events. Examples of adverse patient events from a psychiatric perspective could include: the need to initiate mechanical and/or chemical restraints after admission and while still in the ED, attempts to self-harm, and verbal and physical assault on ED staff. Methods: This study quantifies the incidence of adverse events experienced by psychiatric patients while boarded in the ED. It uses a retrospective chart review of all adult psychiatric patients, age 18 - 55yo, who presented to one of four adult EDs and who were admitted to a psychiatric in-patient unit in the Calgary Zone between January 1, 2019 and May 15, 2019. A randomly generated convenience sample identified 200 patients, 50 from each site, for in-depth review. Results: During the study time period, 1862 adult patients were admitted from emergency departments to the psychiatry service across all four sites. Of the 200 charts reviewed, patients ranged in age from 26-41 (average 34). 52.5% were male with the majority being admitted to a non-high observation bed. The average boarding time was 23.5 hours with an average total ED length of stay of 31 hours for all comers. Those who experienced an adverse event while boarded in the ED experienced a significantly prolonged average boarding time (35 hours) compared to those who did not experience an adverse event (6.5 hours) (p = 0.005). Significant adverse events were associated with the specific hospital site and the type of admission bed needed (high observation versus normal versus short stay) (p < 0.05). Conclusion: Psychiatric patients boarded in Calgary EDs experience a number of significant adverse events. The importance of understanding the reality of the conditions that psychiatric ED patients face while waiting for in-patient placement cannot be overstated. This study is important to emergency medicine as it will allow for deeper understanding of the patient experience while in the ED and identifies areas that may require further advocacy amongst ED staff and our psychiatry colleagues.

Clinical researchers in acute emergency settings are commonly faced with the difficulty of satisfying the conventional ethical requirement of obtaining informed consent, whilst ensuring a representative group of patients is recruited into studies. We discuss our own experience in addressing institutional ethical requirements to obtain informed consent in a multi-centre trial, recruiting highly agitated patients in the emergency setting in Melbourne, Australia. We suggest that, through the application of existing ethical and legal frameworks and pre-emptive communication with the key stakeholders in ethics committees, hospital insurers and legal representatives, a balance can be struck between ethical and legal requirements on the one hand, and the integrity of the research question, on the other.

Rapid tranquilization (RT) is a procedure used in an inpatient setting to deal with acute behavioural disturbance not manageable by other means. The 2gether NHS Foundation Trust has an RT policy which incorporates the National Institute of Clinical Excellence (NICE) guidance on best practice which breaks down into eight domains.

The aim of this audit was to scrutinize practice in relation to this policy.

The audit team sampled 50 Prevention and Management of Violence and Aggression (PMVA) incidents that occurred over a four month period at Wotton Lawn Hospital and the Montpellier Low Secure Unit in Gloucester. PMVA is a method of organized restraint involving a team of three staff used to administer parenteral RT as well as managing disturbance. Data was collected using an audit proforma.

This audit demonstrated adherence to the majority of standards in the RT policy in most incidents. However, there was a significant non-compliance in two areas: appropriate physical observations being carried out after an RT incident and administration of RT in a private area. It may be that standards were in fact met but that there was no evidence for this in the documents examined.

The authors believe that clinical practice can be improved by effective training of staff that emphasizes the need to meet standards and the importance of contemporaneous documentation following an RT incident. They have disseminated the results of this audit to appropriate clinical leads and trainers.

The audit will be repeated in 12 months’ time.

Agitation is a common and serious problem presenting a conflict of values: the need for safety temporarily outweighing the emphasis on dignity, autonomy and privacy that should characterize usual care. Given the difficulty of experimenting with this population, a group of experts in emergency psychiatry met to discuss the management of behavioural emergencies. This was conceptualised as occurring in phases including the first 2 hours, 2–24 hours, and after 24 hours. A number of general principles were recognised, including initial efforts devoted to less coercive strategies that appear as part of a graded hierarchy of choices, awareness of potential organic causes, and an endpoint of calming and patient participation rather than sleep. Anticipation of various contingencies in standard procedures is encouraged. Nonpharmacological methods should always be emphasised. Pharmacological treatment may target symptoms non-specifically in the first phase until the syndrome responsible can be identified and definitive treatment tailored to individual needs in later phases can be started. Benzodiazepines are recommended for their non-specific effects. Second-??generation antipsychotics are preferred for their lower side-effect burden initially and advantages in the domain of hostility as well as relapse prevention. Oral treatment with an orodispersible formulation is preferred to parenteral treatment if possible. Moderate doses of antipsychotics are recommended in contrast to rapid neuroleptisation. Combinations of benzodiazepines and antipsychotics may enhance calming and reduce total antipsychotic dose required for calming but caution is warranted with some agents. Frequent monitoring and reassessment of initial interventions is critical. In later phases, the focus shifts from managing behaviour to treating acute symptoms and finally to education and recovery. The ultimate goal is the return of autonomy, formation of an alliance and development of a durable, mutually agreeable plan of care that considers both tolerability and efficacy in multiple domains. Every effort should be made to prevent undesirable outcomes in the early stages from compromising care in the much longer periods following the behavioural emergency.

The National Institute for Clinical Excellence (2005) published guidance on the management of disturbed behaviour in mental health settings and emergency departments. The guidance included some of the recommendations made in the Independent Inquiry into the death of David Bennett (2003). One important recommendation requires that staff implementing physical interventions (restraint) and/or parenteral rapid tranquilisation are able to effectively manage the physical health of the patient including any immediate complications that may arise.

This article provides background and a syllabus for training for staff to be able to meet the physical assessment skills and interventions required by recent UK national guidance. Also reported is the creation, role and deployment of a 24-hour Medical Emergency Response Team in an in-patient mental health setting to ensure responses to both medical and psychiatric emergencies offer improved safety and adhere to the new guidance. The article describes the provision of a person with the sole responsibility monitoring a patients physical safety during restriant, 24 hour a day, 7 days a week.

The article will be of interest to those working in in-patient mental health and learning disability services, especially those where they are not served by a resuscitation team as part of a District General Hospital and where there is no resident Duty Medical Officer.