Improving the Patient Experience and Reducing Coercive Care in Emergency Psychiatry

Welcome to CER +, the podcast of the Cowichan ER + guests! 

In this episode, we present a focused summary of the management of agitation and ways to reduce the use of coercive care in emergency psychiatry with our guest expert — Dr. Rachel Grimminck, a Clinical Assistant Professor at the University of Calgary and a Clinical Instructor at the University of British Columbia.   Dr. Grimminck was the the Clinical Medical Director for Psychiatric Emergency Services at Foothills Medical Center in Calgary, developed a simulation program at the University of Calgary for psychiatry residents largely focused on emergency psychiatry presentations, and is currently working on the latest revision of the Canadian Psychiatric Association guideline on Clinical Training Approaches for emergency psychiatry for psychiatry residents.  She is also an Island Health Physician Quality Improvement (PQI) participant with a project focused on improving care for psychiatric patients in the Emergency Department at the Cowichan District Hospital (CDH).

The learning objectives for this episode are as follows:

1Describe how seclusion impacts patients and the risks of seclusion

2List 3 principles of effective verbal de-escalation and describe one skill to help patients regulate emotions in the ED

3Understand how to approach pharmacology in the management of agitation in psychiatric populations

Produced, audio edited and show notes by: Dr. Rachel Grimminck 

Hosted by: Dr. Ava Butler, Staff Emergency Medicine doctor at Cowichan District Hospital

Interview Content:

1:20 - Background and context to ED/MHSU committee at CDH and PQI project

4:35 - Working with Patient Voices Network Patient Partners and Patient Experiences in Seclusion

6:30 - Systemic factors contributing to increased MHSU presentations  and prolonged ED boarding

9:10 - Patient partner suggestions for improved care

9:55 - Verbal de-escalation principles: Validation, offering choices, working with emotional dysregulation, short simple sentences, role of clear behavioral expectations

12:55 - Skills including: Mammalian Dive Reflex Using Ice, Paced Breathing and Progressive Muscle Relaxation (PMR)

15:15 - HALTS - Hungry/Hormonal, Angry, Lonely, Tired, Sick/Scared (and Pain)

16:00 - Role of Compassion

16:30 - Role of medications

17:30 - Imminent risk situations - involving security, involuntary measures if needed

18:10 - Risks of physical restraints

18:30 - IM medications principles

22:00 - Risks of seclusion and  mitigating risks including addressing medical issues 

References

• Consensus Statements of the American Association for Emergency Psychiatry Project BETA Psychiatric Evaluation Workgroup from 2012
  • Stowell KR et al. Psychiatric evaluation of the agitated patient. West J Emerg Med. 2012 Feb; 13(1):11-6. 
  • Nordstrom K et al. Medical evaluation and triage of the agitated patient. West J Emerg Med. 2012 Feb; 13(1):3-10.
  • Richmond JS et al. Verbal De-escalation of the Agitated Patient. West J Emerg Med. 2012 Feb; 13(1):17-25.
  • Wilson MP et al. The psychopharmacology of agitation. West J Emerg Med. 2012 Feb; 13(1):26-34.
  • Knox DK et al. Use and Avoidance of Seclusion and Restraint. West J Emerg Med. 2012 Feb; 13(1):17-25. 
• Emergency Medicine Cases Ep 115 Emergency Management of the Agitated Patient with Dr. Reuben Strayer and Dr. Margaret Thompson https://emergencymedicinecases.com/emergency-management-agitated-patient/

CPA Note: The views expressed in this podcast do not necessarily reflect those of the Canadian Psychiatric Association.