Emergency - Quality, Education and Safety

Teleconference

Dr Nicholas Lelos | Advanced Trainee | Emergency Care Institute

18th April 2018

Thanks for joining

House rules

Confidentiality

Respect

AGENDA

• Case reviews

• Underlying causes

• Clinical context

• NSW Health guidance

Participation encouraged throughout

(But please turn off camera & mute mic when not talking)

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

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

Case 1

RN TL intervened – need to run tests

Patient refused.

Placed in WR by 03:38 am

Patient gone by 04:48 am

THOUGHTS ON THE CASE?

Confidentiality

Respect

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

•What went well?

•What could have gone wrong?

•How can this help local

management?

DISCUSS

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

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

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

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

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

Case 2 -aftermath

Day 2 follow up – declined

Day 7 went to hotel for alcohol, kicked out.

Found next morning in garden by father

Comments?

RCA issues

Engagement of patient

Alcohol as a masking agent ASSESSED WHILST INEBRIATED

Follow up and structures available

Patient perspective

Therapeutic intervention

Not ‘assessment’ but ‘assistance’

Less history taking

Approach considerations

• De-escalation

• Stance and body language

• Explanations

• Environment

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

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

Thoughts?

How common are patient journey delays transferring care between ED and

psych?

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?

Case 3 - developments

Reviewed by clinician that knew him in the café

Either forcibly return to ED +/- police;

Or discharge from café

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

Metamphetamine Management

Mental Health for Emergency Departments – A Reference Guide. NSW Ministry of Health.

Amended March 2015.

Body brought back in ED at 21:00 – jumped off a building

RCA did not find any issues with ED management

Final outcome

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

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

Local protocols?

Discuss what you would do in your facility

Mental Health for Emergency Departments: A

reference Guide March 2015

Case resolution

Drug induced psychosis

Review in the morning by MH team – symptom resolution

Back to police custody

CLINICAL TOOLS AND GUIDELINES

From ECI Website

• 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

Classification of resources

for ages 0 - 17

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

SUMMARY

Determine physical issues on presentation

Various methods available for management

Know what is available in area

Online resources

Documentation

Discussion/ Questions?

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

Looking to next month, please…

•Share your cases

•Share your patient safety actions

•Spread the word with your colleagues

(or send me their email: Nicholas.lelos@health.nsw.gov.au)

What would you like to see / hear about?

Level 4, 67 Albert Avenue

Chatswood NSW 2067

PO Box 699

Chatswood NSW 2057

T + 61 2 9464 4666

F + 61 2 9464 4728

aci-info@health.nsw.gov.au

www.aci.health.nsw.gov.au

Many thanks!

Next E-QuEST

Thursday 17th May 08:00 am

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